Stephen P. Pickard MDCareer Epidemiology Field Officer

Assigned to North Dakota Department of HealthScience and Public Health Practice Office

Coordinating Office for Terrorism Preparedness and Emergency Response

State-Facilitated Pandemic Influenza Planning for Health Care

OMB Disclaimer

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention

Acknowledgement

Brenda Vossler, RNNorth Dakota Department of Health

Derek HansonSt. Alexius Medical Center, Bismarck, ND

Tim Wiedrich, MS

North Dakota Department of Health

Methods

Plans were derived using consensus of hospitals, not research methods

Limited implementation detail Lack of supporting data

Conclusions are based on a set of assumptions How the epidemic will unfold How the health care system will respond

Assumptions

Hospital bottom line: “We can provide care most efficiently for the most

patients with our own people in our own facility, even if we have to line the halls with stretchers.”

HCW, not space, will be the limiting factor 1918 lesson: nursing care matters! ND pre-event resource acquisition

Stockpile medical supplies, not vents State cannot extend tort protection to private HCF

Planning Content

Standards of care during a disaster Minimal care facilities State Medical Director Vaccine prioritization among hospital personnel Surge management (e.g., staffing, elective admits, transfer) Sheltering in place (e.g., utility loss, supply loss) Outpatient management (complicated by anti-virals) Medical supply cache use protocol Clinic management

Alternative Standards of Care

Staged Reduction in Quality of Care

Standard of Care What is the liability of facilities offering less than usual

care? What is the impact of various care reduction options and

the preferred order of introduction? How can we measure relative hospital overload and how

much overload can a hospital take? How do we time the opening of alternative inpatient care

sites to maximize hospital utilization? How do we communicate altered standards of care to the

public?

Standard of Care (SOC)

Proposal: Hospitals petition NDDoH for change of SOC Staged reduction: normal, I, II, III, and “minimum care” Each stage associated with recommended actions Transfer preferable to reduction in SOC Overload formula based on weighted critical and non-critical care

patient load and critical and non-critical nurse staffing level Usage

Control care? No Recognize change in capacity? Yes

Mandatory? No Provision of guidelines? Yes

Minimum Care Facilities

Alternative Inpatient Care

Minimum Care Facilities

Alternate inpatient, contagion facility (influenza only) MCF preparation initiated by Stage III SOC declaration Very low level of care – utter last resort

State authorized, community operated, volunteer staffed

Hydration, nutrition, hygiene for seriously ill who have: No home care available, or Dehydration, not able to take oral fluids

MCF: Concept of Operation

Hospital preferentially takes non-influenza, treatable complications, pediatrics, mentally ill

Open acute care floor (e.g., 120 patients) with assisted care in nearby rooms

No limit on illness severity accepted Co-located with palliative care One licensed HCW per 12 hour shift

MCF: Concept of Operation State medical director

Authorizes MCF under state management guidelines and tort protection

Releases supplies and PPE from cache Hospital medical director assigns patients MCF medical director identifies patients most likely

to benefit from transfer up to hospital Local ethical oversight

MCF: Concept of Operations

Rehydration fluids via nasogastric tube Can be “homemade” Save IVF for hospitals

Minimum invasion – NGT, IV, foley if needed Volunteers uncomfortable even with that

Few medications administered If needed, use patient’s own meds down NGT

No oxygen, No advanced care, No rescue care

Medical Director

Limited Health Care System Management

Medical Director Hospitals want central policy coordination CEOs have agreed, in principle, to cede

limited authority to a Medical Director Located in DOC, Ops Section of NDDoHActivated during governor-declared disasterMOU to spell out specific authorityCEOs want clinicians in role (10 identified)

Medical Director Role

Health care facility assistance Inter-hospital coordination (e.g., transfer, electives) State medical cache allocation Priority vaccine allocation Allocation of anti-virals Standard of care stage determination MCF authorization

Resources and ContactMCF concept paper and other policy documents

available at request

Stephen Pickard

Career Epidemiology Field Officer, CDC

Assigned to North Dakota

spickard@nd.gov

701.328.2365