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Protecting EMSPublic Safety Providers in a World with a Potential Pandemic

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Title: Protecting EMSPublic Safety Providers in a World with a Potential Pandemic


1
Protecting EMS/Public Safety Providers in a World
with a Potential Pandemic
  • Daniel T. OLaughlin, MD, FACEP
  • Brian D. Mahoney, MD, FACEP

2
Protecting EMS/Public Safety Providers in a World
with a Potential Pandemic
  • Daniel T. OLaughlin, MD, FACEP
  • Brian D. Mahoney, MD, FACEP

3
Why worry now?
  • China
  • Vietnam
  • Indonesia
  • Myanmar
  • Pakistan
  • 61 mortality

4
Its Not If, But When
5
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6
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7
Seasonal Influenza
  • Respiratory infection
  • Spread through coughing, sneezing
  • 1 to 5 days from exposure to onset of symptoms
  • Contagious 1 day before feeling ill up to 7 days
    after
  • Seasonal influenza traditionally occurs October
    through April

8
Influenza Symptoms
  • Rapid onset of
  • Fever
  • Chills
  • Body aches
  • Sore throat
  • Non-productive cough
  • Runny nose
  • Headache

9
Its Just the Flu! Annual Influenza Impact
  • Average of 38,000 deaths in US related to
    seasonal influenza each year
  • 800-1000 in MN
  • 200,000 influenza related hospitalizations

10
Influenza Basics
  • Type A Influenza
  • RNA Virus
  • 16 different hemagglutinin antigens (HA)
  • 9 different neuraminidase antigens (NA)
  • Historically human disease is caused by mixtures
    of H1, H2, H3 and N1, N2
  • All known subtypes are also found in birds, but
    only H5 and H7 have caused severe bird outbreaks

11
How rapidly can this spread?
12
US Flu Picture October 28, 2006
13
US Flu Picture November 25, 2006
14
US Flu Picture December 30, 2006
15
US Flu Picture January 27, 2007
16
US Flu Picture February 24, 2007
17
Influenza Transmission
  • Droplet
  • Contact
  • Possible Aerosol

Image Source Human Biology, Starr and McMillan
18
Because you werent born in a barn… and even if
you were…
19
Protecting Yourself and Others
  • The single best way to protect against the flu is
    to get vaccinated each fall.

20
Standard Precautions
  • Wear gloves and gown if contact with patient's
    respiratory secretions is anticipated.
  • Change gloves and gowns after each patient
    encounter and perform hand hygiene.
  • Decontaminate hands before and after touching the
    patient and after touching the patient's
    environment or the patient's respiratory
    secretions, whether or not gloves are worn.

21
Standard Precautions
  • When hands are visibly soiled or contaminated
    with respiratory secretions, wash hands with soap
    (either plain or antimicrobial) and water.
  • If hands are not visibly soiled, use an
    alcohol-based hand rub.

22
Droplet Precautions
  • Wear a surgical or procedure mask when entering
    the patients room or when working within 3 feet
    of the patient. Remove the mask when leaving the
    patients room and dispose of the mask in a waste
    container.
  • If patient movement or transport is necessary,
    have the patient wear a surgical or procedure
    mask, if possible.

23
Fomites
  • Surface lifespan is variable
  • 2-8 hours

24
Influenza Epidemics vs. Pandemics
  • Seasonal outbreaks (epidemics)
  • Caused by subtypes of influenza viruses that
    already circulate among people
  • An influenza pandemic is a global outbreak of
    disease
  • Occurs when a new influenza A virus appears or
    emerges in the human population, causes serious
    illness, and then spreads easily from person to
    person worldwide.
  • Does not have to be seasonal
  • A Novel Virus in a Naïve Population
  • Pandemic flu tends to affect the young and
    healthy in addition to those older patients or
    with co-morbidities

25
Pandemic Influenza
  • The good news - current bird flu passes from
    human to human only poorly
  • Pandemic occurs when reassortment of RNA
  • Two flu strains swap RNA
  • A human with seasonal flu gets bird flu at the
    same time
  • The two strains of flu trade RNA and a new virus
    is born it now has ability to go human to human
    readily
  • A Shift or mutation occurs that allows the
    transmission from Avian to Human populations

26
Influenza Pandemics
  • At least 10 pandemics recorded in last 300 years
  • 3 Human Pandemics in the last 100 years
  • 1918 (Deaths 700,00 US/50-100 million
    worldwide)
  • 1957 (Deaths 60,000 US/1 million worldwide)
  • 1968 (Deaths 34-40,000 US)

27
H5N1 Avian Influenza
  • First isolated in 1961 in South Africa from terns
  • Major outbreaks identified in 1983, 1997,
    2003-present
  • Changes in virus structure in 2003 (Z strain)
  • Able to infect larger number of animal species
  • More resistant to current antiviral medications

28
  Projected Pandemic Impact Based on 2004 Metro
Region Population Estimate of 2.8 Million (53.8
of Minnesota Population)
29
Current Realities
  • Hospitals currently routinely operate at or near
    full capacity with limited ability to increase
    services
  • National shortage of multiple categories of
    Health Care Workers

30
Hospital Resources Mpls/SP Metro Area
  • Routinely staffed beds 4857
  • Avg. daily census 4143
  • Surge Capacity
  • Census vs. staffed variance 714
  • Unstaffed but available beds 1068
  • 15 of total beds staffed 728
  • PACU/procedure rooms 536
  • Convertible rooms single to double 473
  • Total average overall surge capacity is around
    3000 - remember we would have 92,000 admissions
    to care for!

31
Hospital Resources Mpls/SP Metro Area
  • Stepdown beds 501 (surge 190 addtl)
  • ICU beds 416 (surge 192 addtl)
  • PICU beds 64 (surge 20-39 addtl)
  • ED beds 460
  • OR suites 295
  • Ventilators 533
  • Remember we would have 6,930 ventilator cases to
    manage!

32
Community Mitigation Strategies
  • Social distancing
  • Cancel public events
  • Concerts, sports, movies, plays, church services
  • Close schools and work places
  • Malls, office buildings
  • Close recreation facilities
  • Pools, gymnasiums, youth programs

33
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34
Duty to Plan
  • "Any community that fails to prepare with the
    expectation that the federal government will come
    to the rescue will be tragically wrong,"

Health and Human Services Secretary Mike Leavitt
February 24, 2006
Image from NPR website
35
EMS / Public Safety Planning - Workforce
  • Potential of reduced workforce by 30-40 during
    peak of each pandemic wave
  • Anticipate multiple waves, with each wave lasting
    up to 90 days
  • Pre-train and certify cross-sector employees and
    volunteers
  • Establish policy to address payroll/benefits of
    employees
  • Screen Employees before shift
  • Ill staff should stay at home

36
EMS Public Safety Planning Vaccination /
Prophylaxis
  • Vaccination
  • Develop internal plan to immunize all direct
    patient care providers and essential staff in a
    short period of time.
  • May be months before have vaccine!
  • Prioritizing prophylaxis for essential workforce
  • Pre-identify essential workforce positions
  • Levels of priority staff needs to be established
    as anti-virals may be limited.
  • Antivirals may not work!

37
On The Street In The Rig
  • Utilize standard and droplet precautions when
    transporting symptomatic patients.
  • Consider the routine use of masks for all patient
    transports when pandemic flu is in the community.
  • Unless medically necessary to support life,
    aerosol-generating procedures (nebs, mechanical
    ventilation) should be avoided.

38
On The Street In The Rig
  • Optimize vehicles ventilation to increase volume
    of air exchanges during transport.
  • Notify the receiving facility that a patient with
    possible pandemic flu is being transported
  • Perform routine cleaning of your vehicle and any
    reusable patient care equipment.

39
Staff
  • ALL job categories will have significant
    absenteeism remember 30-40 during peak
  • From NYC Healthcare Worker Survey
  • gt50 had childcare issues
  • 27 had eldercare issues
  • 30 had a spouse expected to respond
  • Creative use of volunteers may be needed
  • Rapid credentialing process for volunteers

40
Staff and Patient Mental Health Family Needs
41
EMS / Public Safety Continuity Planning
  • Isolation of Incident Command Post, Emergency
    Operations Center, Dispatch Communications Center
  • Establish standardized medical surveillance
    system for entry
  • Stock masks and hand sanitizers at the door
  • Maintain NIMS-NRP compliance for command-control

42
EMS / Public Safety Continuity Planning
  • Develop succession plans for leadership if they
    were to succumb to illness
  • Plans should be 3 deep
  • Identify essential staffing and critical staffing
    thresholds in order to maintain operations
  • Discuss plans with key suppliers and customers
    and maintain those lines of communication during
    an event

43
EMS / Public Safety Planning Business Continuity
  • Interruption in supply chain for food, fuel, PPE,
    and other essential items
  • Establish stockpiles to maintain operations for
    90 days per wave
  • Establish guidelines for using/changing/ reusing?
    PPE
  • Depleted response resources due to mechanical
    failure/lack of personnel
  • Enhance preventive maintenance programs for
    fleets
  • Establish supplemental contracts/MOUs with local
    repair businesses

44
Stuff
45
Pharmaceuticals
46
Respiratory Care Supplies
47
Space
48
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49
Single 50 Patient Pods
50
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51
Sample Dispatching Triage
52
Adjusting Standards of Care
53
Overarching Goal
  • Do the greatest good for the greatest number of
    persons you can based upon the resources available

54
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55
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56
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57
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58
In preparing for battle, I have always found
that plans are useless, but the planning is
indispensable. Dwight D. Eisenhower
59
Questions ?
60
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61
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62
Economic Realities
  • Just In Time economy affects healthcare as well
  • Hospitals, if profitable, only have a thin profit
    margin (avg 1.9)
  • 30 of US hospitals are currently losing money
  • Average US hospital has 41 days of cash on hand
  • A hospitals ability to offset typical lost
    revenue from illness related hospitalizations
    with elective procedures will be greatly reduced
    or eliminated altogether

63
Fear is Worse than the Disease, and Fear Drives
Fear
  • The real enemy during the SARS emergency in
    Toronto was fear of the unknown.
  • It was this fear that encouraged stigmatization
    of businesses, ethnic groups, and geographic
    locations where SARS appeared.
  • The best remedy for fear of the unknown is
    timely, accurate, and practical information
    provided in a coordinated fashion by both the
    government and private sector leadership.

64
Ethical Issues of Mass Medical Care With Scarce
Resources
65
Values to Consider in Developing Ethical Decision
Making Process
  • Individual liberty
  • Protection of the public from harm
  • Proportionality
  • Privacy
  • Duty to provide care
  • Reciprocity
  • Equity
  • Trust
  • Solidarity
  • Stewardship

Adapted from Stand On Guard For Thee, University
of Toronto Joint Centre for Bioethics
66
Procedural Values in Ethical Decision Making
Process
  • Reasonable
  • Open and Transparent
  • Inclusive
  • Responsive
  • Accountable

Adapted from Stand On Guard For Thee, University
of Toronto Joint Centre for Bioethics 2005 and
Daniels N. Accountability for reasonableness. BMJ
2000.
67
Why The Concern About Pandemic Influenza?
  • Influenza pandemics are inevitable naturally
    recur at more-or-less cyclical intervals
  • Can cause
  • High levels of sickness and death
  • Drastic disruption of critical services
  • Severe economic losses
  • There will be little warning time between the
    onset of spread of a pandemic and its arrival in
    the U.S.

68
Why The Concern About Pandemic Influenza?
  • Outbreaks occur simultaneously in many areas
  • Impacts will last for weeks to months
  • Pandemics disproportionately affect younger,
    working-age people
  • Current avian influenza outbreak spread to much
    of the world

69
Projected Pandemic Impact Based on 2004 Minnesota
Population Estimate of 5.1 Million (1.75 of
U.S. Population)
70
Current Realities
  • Emergency Department overcrowding and EMS
    diversions is a national crisis (June 2006 IOM
    Report)
  • Numbers of Hospitals, Hospital beds and Emergency
    Departments have seen significant declines in the
    past several years

71
Hospital Resources Mpls/SP Metro Area
  • About 265 isolation rooms
  • Surge capacity of additional 289 isolation
    patients with cohorting

72
Minnesota EMS Resources
  • 78 of Minnesota EMS personnel are volunteer
  • lt40 of EMS personnel rated EMS as their 1st
    priority in a disaster

73
Lots of Checklists…But…
  • Generally lack specifics
  • Generally not prioritized
  • Generally do not include any metrics
  • Often not harmonized across organizations
    agencies

74
Potential Planning Roadblocks
  • Healthcare surge capacity is low
  • Personal preparedness is poor
  • Hospital administration buy-in is variable
  • Financial support is poor
  • Staff absenteeism
  • Union concerns
  • Insufficient PPE/Meds/Vaccine for HCWs
  • Workforce licensing restrictions rapid
    credentialing
  • Specialization / Compartmentalization of
    healthcare

75
EMS Planning Workforce Working Quarantine
  • During SARS, over 400 paramedics on working
    quarantine
  • N95 mask on all the time at work
  • exception if gt 3 meters from others in station
  • Full PPE for all patient contact
  • Full isolation at home
  • Very stressful on paramedics families

76
EMS Planning Workforce Working Quarantine
  • Ensure staff get paid while on quarantine
  • If people suffer financial loss, they wont stay
    isolated
  • Dont forget the families

77
EMS Continuity Planning
  • Pandemic Event would likely last months
  • Typical flu season is Dec-Apr
  • Continuity plans for a pandemic should include,
    short, medium and long-term planning
  • Planning should include identifying triggers for
    plan activation and lines of authority to carry
    out the plan
  • Develop succession plans for leadership if they
    were to succumb to illness
  • Plans should be 3 deep

78
EMS Medical Dispatch
  • Manage the 9-1-1 Call Center during the pandemic
    wave
  • Engage supplemental support to relieve regular
    employees
  • Enforce shared workstation disinfection practice
  • Coordinate infrastructure management with other
    sectors

79
Objectives
  • Discuss the potential impact of an influenza
    pandemic on EMS/Public Safety
  • Identify resources that may be significantly
    limited during a pandemic
  • Review EMS planning considerations to manage
    workforce and equipment shortages.
  • Discuss some of the ethical issues that will
    likely occur during a pandemic
  • Discuss your personal preparations for you and
    your family

80
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81
Its Not If, But When
Dilbert, By Scott Adams
82
Community Mitigation Strategies
  • Social distancing
  • Snow days, voluntary self-shielding
  • Cancellation of public events
  • concerts, sports events, movies, plays
  • Closure of schools and workplaces
  • office buildings, shopping malls
  • Closure of recreational facilities
  • community swimming pools, youth clubs, gymnasiums

83
EMS Planning - Workforce
  • Labor relations adjustments/variances during
    pandemic outbreak
  • Establish MOU with employees/unions
  • Maintain Human Resources/Payroll/Benefits for
    workforce
  • Establish alternative absenteeism policy during a
    pandemic outbreak
  • Screen Employees before shift
  • Ill staff should stay at home

84
Resource Issues
  • Staff
  • Stuff
  • Space

85
Personnel Augmentation
  • Hospital personnel
  • Clinic personnel
  • Medical Reserve Corps
  • Non-clinical practice professionals
  • Retired professionals (eg HC Medical Society)
  • Trainees in health professions
  • Ski patrol, civil air patrol, other service
    organizations
  • Lay public (CERT teams, etc)
  • Federal / interstate personnel

86
www.pandemicflu.gov
www.codeready.org
www.operationhope.org
87
EMS / Public Safety Continuity Planning
  • Isolated regional outbreaks could trigger
    self-quarantine orders
  • Disruption in Critical Infrastructure
  • Public Works
  • Power
  • Public Transit

88
EMS Medical Dispatch
  • Manage the 9-1-1 Call Center during the pandemic
    wave
  • Assign staffing for each operational period
  • Equip Call Center to maintain essential
    supplies/resources
  • Coordinate activities among the Public Safety
    Answering Points (PSAPs)

89
EMS Public Communication
  • Develop scripts that can be modified to
    facilitate a clear message regarding current EMS
    resource triage
  • Work within a Joint Information Center (JIC)
    structure within the community

90
Hospital C
Hospital B
Clinic coord
Hospital A
Healthsystem
RHRC
Multi-Agency Coordination Center
EM
PH
A
A
EMS
B
B
C
C
Jurisdiction Emergency Management
B
Public Health Agencies
C
A
EMS Agencies
91
Trends in Infectious Disease Mortality in the
United States During the 20th Century
Armstrong, GL. JAMA. 1999 Jan 6281(1)61-6.
92
PPE - IT WORKS!
  • Four Toronto EMS paramedics were hospitalized
    with SARS
  • Paramedics got sick before mandatory use of PPE
  • After full PPE, no more SARS in medics
  • PPE is not designed for EMS environment
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