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Evidence-Based Approach to Hospital Preparedness

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Title: Evidence-Based Approach to Hospital Preparedness


1
Evidence-Based Approach to Hospital Preparedness
  • Robert Powers RN, BSN, EMT-P
  • Emergency Preparedness Coordinator
  • WakeMed Health and Hospitals
  • Raleigh, NC

2
Objectives
  • Describe the impact disasters can create in a
    community and on a healthcare system
  • Discuss research findings from recent disasters
  • Identify overall lessons learned from past
    disaster events and their specific application to
    hospital planning

3
Evidence-Based Medicine
  • The Center for Evidence-Based Medicine explains
    that EBM is the conscientious, explicit, and
    judicious use of current best evidence in making
    decisions about the care of individual patients.
  • It relies on research findings to support
    treatment methods


  • www.cebm.net/glossary.asp

4
Disaster Research
  • Application of available disaster research to
    clinical treatment
  • Strongest EBM method is the randomized,
    double-blind, placebo-controlled trial
  • Look to guidance from clinical reports of
    disaster events and apply it to our disaster
    planning

5
Applied EBM
  • Rather than purely using opinions, we want the
    research incorporated into expert opinions
  • Either validating or revealing possible errors in
    those opinions

6
Application Difficulties
  • No standard terminology
  • No standard method of collection
  • Records lost or incomplete
  • Gaps in research
  • Retrospective in nature

7
Disaster Planning Issues
  • Contamination/Exposure issues
  • Chemical
  • Emerging Infectious Diseases
  • Surge
  • Immediate impact
  • Gradual impact
  • Communication
  • Evacuation

8
Contamination-Tokyo Subway
  • 0755- Attack occurs
  • 0816- Notification of a gas explosion
  • 0828- First patients arrives at St.Lukes
  • 0900-TMFD identifies chemical as acetonitrile
  • 0940- University MD calls advises to suspect
    sarin
  • 0940- Found low cholinesterase levels
  • Started using 2-PAM
  • 1100- Police analysis identifies chemical as
    sarin. Hospital learns this from TV news.

  • Okumura AEM 1998

9
Contamination-Tokyo Subway
  • St Lukes Hospital
  • In chapel, 45.8 workers there developed
    signs/symptoms of exposure (38/83)
  • In ICU, 38.7 workers (12/31)
  • 23 of 472 reporting staff members developed
    signs/symptoms of exposure
  • 1 nurse admitted (with nausea/headache)
  • 135 EMS workers out of 1364 developed acute
    symptoms (9.9)

  • Okumura AEM 1998

10
Contamination-Tokyo Subway
  • Keio University Hospital
  • 40 minutes in resuscitation room
  • 11 of 15 MDs symptomatic
  • Dim vision, rhinorrhea


  • Nozaki ICM 1995

11
Contamination-SARS
  • Toronto-
  • During first wave, 73 of those contracting SARS
    were healthcare workers (51)
  • During second wave, 29 were healthcare workers
    (39)
  • Taiwan-
  • 33 cases were healthcare workers

  • MMWR Taiwan 2003

  • www.sars.ca

12
Contamination-U.S.
  • ATSDR Hazardous Substances Emergency Events
    Surveillance (HSEES)
  • Study of US events from 16 reporting states
  • When hospital decon was needed
  • 10 events with 52 patients total in rural
    settings
  • 82 events with 889 patients total in urban
    settings

  • Berkowitz PDM 2004

13
Contamination-U.S.
  • Urban events
  • 377 patients from public
  • 170 patients were first responders
  • 342 patients were healthcare workers

  • Berkowitz PDM 2004

14
Contamination-U.S.
  • Rural events
  • 11 patients from public
  • 29 patients were first responders
  • 12 patients were healthcare workers
  • Berkowitz PDM 2004

15
Contamination-U.S.
  • HCWs
  • 23 rural
  • 38 urban
  • First responders
  • 56 rural
  • 19 urban

  • Berkowitz PDM 2004

16
Contamination-HCWs
17
Contamination-Hospital Planning
  • Whether the event is small or large, the hospital
    stands to have a quarter of its ED staff exposed.
  • Not only is the hospital now operating with
    decreased staffing numbers, but the staff have
    become patients and increased the patient load

18
Contamination-Hospital Planning
  • Staff education on procedures for dealing with
    potentially contaminated patients
  • Proper removal of patient to decon area
  • Proper PPE education for staff
  • Proper assessment of patient in need of isolation
    or decontamination

19
Contamination-Hospital Planning
  • Staff must have rapid access to decontamination
    equipment
  • Decontamination must be able to occur rapidly
    (Scaleable)

20
Contamination-Hospital Planning
  • Staff must have rapid access to the PPE they need
  • Staff must have adequate amounts of PPE
  • The Japanese government budgeted for 4 PPE suits
    per hospital after the Tokyo Subway event
  • Lack of N95 compliance in Toronto

21
Contamination-Hospital Planning
  • Staff must be aware of on-going events worldwide
    and aware of any changes that need to take place
    at triage
  • Toronto-SARS
  • Medical staff were originally unaware of events
    taking place in Hong Kong and China
  • Lack of health alerts concerning SARS
  • Didnt know to ask pertinent questions at triage,
    e.g. travel history

22
Contamination-Hospital Planning
  • Staff education on WMD signs and symptoms
  • Cant wait on lab results or reports from the
    scene
  • Staff should not feel any repercussions for
    jumping the gun when there are suspicions of
    contamination

23
Surge
  • Immediate impact on hospitals
  • Explosive and Chemical events
  • Gradual impact on hospitals
  • Infectious disease events

24
Surge
  • Istanbul bombing
  • Single hospital study TERSH hospital
  • 418 patients total/16 hospitals
  • 184 patients in first hour at TERSH
  • 88 (48) by EMS
  • 28 (15) admitted
  • 18 (10) to OR
  • 7 (4) critically injured

  • Rodoplu PDM 2004

25
Surge-Oklahoma City Bombing
  • Study of 13 hospitals
  • 388 total patients
  • 48 were pediatric patients
  • First patients arrived within 15 minutes
  • Peak at 60-90 minutes
  • Within 3 hours, 227 patients at hospitals
  • 33 arrived by EMS

  • Mallonee JAMA
    1996

  • Hogan AEM 1999

26
Surge-Oklahoma City Bombing
  • Median ED stay was 55 minutes
  • 63.6 patients went to 5 major hospitals within
    1.5 miles of the explosion site
  • 72 (18.6) admitted
  • 158 were seen by a private MD

  • Mallonee JAMA 1996

  • Hogan
    AEM 1999

27
Surge-London Bombing
  • Study of Royal London Hospital
  • Approx. 700 patients total event
  • 194 total patients at Royal London
  • First patient 120 minutes after first blast
  • 90 mins later peaked with 95 patients
  • Over in 2 hours
  • 27 admits
  • 8 ICU admissions

  • Mohammed PDM 2006

28
Surge- NYC 9/11
  • St Vincents Hospital
  • First patient 114 minutes after first plane
  • Around 300 patients in first 2 hours
  • NYU Downtown Hospital
  • 350 patients in first 2 hours
  • 448 patients total for first day
  • 24 admitted
  • 12 ICU patients
  • 5 to OR

  • Kirschenbaum CCM 2005

  • Cushman J Trauma 2003

29
Surge-Egyptian Border Bombing
  • Yoseftal Hospital
  • First patient arrived in 32 minutes
  • 168 patients total
  • 50 in first 2 hours peaks in 2 hours
  • 2 admissions
  • 1 to OR
  • 23 evacuated to trauma center


  • Leiba PDM 2004

30
Surge-Tsunami
  • Patong Hospital Thailand
  • Around 700 patients in first 2 hours
  • 59 patients over next 22 hours
  • 1.4 admission rate
  • 5.1 evacuated to secondary hospital


  • Leiba PDM 2006

31
Surge-Tokyo Subway
  • 5500 patients went to 280 medical facilities
  • 1046 admitted to 98 hospitals
  • 20 admitted to ICUs
  • 688 transported through EMS coordination
  • 452 via ambulance
  • 236 via minivans
  • 25 of patients transported by taxi
  • 2 of 3 cardiac arrests arrived via private
    vehicle

  • Okumura AEM 1998


  • Pangi BCSIA 2002

32
Surge-Tokyo subway
  • St Lukes Hospital
  • Closest hospital to half of the affected subway
    stations and the most heavily impacted hospital
  • 0755 Attack occurs
  • 0816 Notice of a gas explosion
  • 0828 First patient arrives
  • On foot
  • Has visual complaints
  • 0840 First ambulance arrives
  • 0843 First cardiac arrest arrives by pov

  • Okumura AEM 1998

33
Surge-Tokyo Subway
  • St Lukes Hospital
  • 641 total patients first 24 hours
  • 500 patients in the first 90 minutes
  • 107 with moderate symptoms admitted
  • 4 ICU admits


  • Okumura AEM 1998

34
Surge
35
Surge-Admissions
36
Surge-ICU
37
Surge Planning
  • Variance in first patient arrival time
  • 15-90 minutes after event
  • May or may not have time to begin set-up before
    patients arrive
  • May or may not have notification of an event
  • Some of this time is spent determining there has
    been an event
  • London bombings 17 minutes before notified of a
    suspected event and another 19 minutes before a
    major incident declared
  • This time while events are sorted out decreases
    chance of early notification by public safety

38
Surge Planning
  • 50 to 70 of patients arrive via other methods
    than EMS
  • The critical patients are not able to self-direct
    themselves to area hospitals so tend to be the
    ones EMS transports
  • Ones self-referring tend to be the ambulatory,
    walking wounded
  • EMS needs to plan for measures that can rapidly
    gather and transport these walking wounded
    patients to farther hospitals

39
Surge Planning
  • Supplies should be in place and ready to go for
    initial impact
  • Close storage
  • No vendors necessary to bring supplies
  • Disaster plan should be able to be implemented
    immediately
  • Existing staff is well-versed and able to
    implement disaster plan

40
Surge
  • Triage should be aimed at rapidly sorting these
    patients and relocating them to MTA away from the
    ED
  • Rapid triage system
  • Keep it simple
  • Initially surge manpower into extra triage
    stations to rapidly process incoming walking
    wounded

41
Surge Planning
  • MTA area
  • Rapid set-up
  • Staff from areas outside ED
  • Large setting

42
Surge Planning
  • Temporary Surge Admission Area or Holding Area
  • Hold these patients during peak period
  • Prioritize resources for incoming ICU or OR
    patients during peak period

43
Surge-Treatment
  • Advanced Airway Procedures
  • 2 bus bombings
  • 52 patients
  • 42 intubated
  • 2 open-air bombings
  • 190 patients
  • 7 intubated
  • Oklahoma City
  • 388 patients
  • 2 intubated
  • 1 surgical airway

  • Hogan AEM
    1999/Halpern PDM 2003

44
Surge-Intubations
45
Surge Planning-Respiratory
  • Respiratory Therapy should be incorporated into
    the plan
  • ED MDs and Anesthesia have other roles
  • Surge airway supplies should be rapidly available

46
Hospital Services- Radiography
  • Oklahoma City bombing
  • 45 of 265 patients
  • Manchester
  • 50 of 208 patients
  • Bologna bombing
  • 43 of 107 patients


  • Halpern PDM 2003

47
Hospital Services
  • Oklahoma City bombing
  • 19 of patients had CT Scan
  • Chi-Chi Earthquake- Taiwan
  • 30 of 95 patients with crush syndrome needed
    hemodialysis

  • Hogan AEM 1999

  • Chan PDM
    2006

48
Hospital Services Planning
  • Almost half of patients from an explosive or
    collapse event will need x-ray
  • Services such as CT, dialysis and the lab will be
    impacted
  • These departments need to be involved in hospital
    disaster planning

49
Hospital Services Planning
  • Utilize portable x-ray machines
  • Plan for a prioritization of all these services
    beforehand

50
Surge-Field Teams
  • Deployment of personnel from hospital to the
    scene
  • Tokyo
  • NYC
  • London

51
Surge-Field Teams
  • Tokyo- St Lukes Hospital
  • Sent 8 MDs, 3 nurses
  • No emergency procedures performed
  • London
  • Sent MD teams to various scenes
  • Arrived 30-40 minutes after bombing
  • Only Grade-I Trauma Center in London
  • Patients arriving at hospital 20 minutes after
    bombing

  • Okumura AEM 1998

  • Mohammed PDM
    2006

52
Surge-Field Teams
  • NYC
  • Chelseas Pier Triage Area
  • Group of MDs from NYU Downtown Hospital
  • No critical patients
  • Bellevue had MD teams at WTC site
  • No critical patients
  • Minor cuts and bruises

  • Cushman J Trauma 2003

53
Surge-Field Teams
  • Limited value
  • Late arrival/Leaving nearby hospitals
  • Utilize hospitals farther away if extended scenes
  • Have a developed plan not ad hoc

54
Surge-Crowds
  • Large number of non-patients at hospital
  • Seeking shelter and food
  • Seeking information about family members
  • Plan must address these arrivals

55
Surge-Gradual Impact
  • SARS
  • Toronto
  • Hong Kong
  • Taiwan

56
Surge-Toronto
  • Toronto- Scarborough Grace Hospital
  • 3/7/03 Mr. T patient seen in ED 2 other patients
    exposed (16 hours in ED in Obs bed)
  • 3/16 Mrs. M at ED 7 visitors and 1 patient
    exposed
  • 3/17 Mr. M intubated in ICU 3 nurses and 1 MD
    exposed
  • 3/21-4/1 Average 8-10 staff members sick a day
  • 3/26 Hospital closed due to staffing shortages
  • 6/5 ED re-opened


  • www.sars.ca

57
Surge-Toronto
  • Toronto
  • 3/23 Re-commissioned TB hospital with 25
    isolation beds
  • 3/26 Opened first SARS assessment center

  • www.sars.ca

58
Surge-Toronto
  • Canadas HSC
  • Study noted patient volume decreased during SARS
    outbreak
  • 133 baseline patient visits per day
  • Broke down SARS into 3 periods and found patient
    volume down an average of 36 patients per day
    (27)

  • Boutis CMAJ 2004


59
Surge-Toronto
  • SARS I (3/7-4/19)
  • 144 SARS cases
  • 128 suspected
  • 247 total admissions
  • 29 of 144 admitted to ICU (20)
  • 20 of those 29 received ventilators (14 overall)
  • SARS II (5/23-6/4)
  • 74 SARS cases


  • www.sars.ca

  • Booth
    JAMA 2003

60
Surge-Toronto
  • 375 total cases March-June 2003
  • Southern Ontario population 11 million
  • 10-20,000 quarantined in Ontario
  • Surviving patients 74 discharged by Day 14
  • Median stay 10 days
  • Peak of 8 probable cases per day


  • Booth JAMA 2003

61
Surge-Hong Kong
  • Feb-June 2003
  • 1755 probable SARS cases
  • Hong Kong area population 110 million


  • Lau EID 2004

62
Surge-Hong Kong
  • 138 SARS patients at Prince of Wales Hospital
    during period of outbreak from March 11-25
  • 32 admitted to ICU (23)
  • 19 on ventilators (14)
  • Median stay 22.1 days
  • Median stay for intubated patients 26.8 days


  • www.sarsreference.com

  • Lee NEJM
    2003

63
Surge-Taiwan
  • March-July
  • 668 total SARS admissions
  • Peak approx. 15-25 probable cases per day during
    period 4/20-5/25
  • 22 million population


  • McDonald EID 2004

64
Surge-Taiwan
  • National Taiwan University Hospital
  • 270 SARS patients
  • Maximum admits in 24 hours was 12
  • Overall bed occupancy decreased 48
  • ED visits decreased 37


  • Chen EID 2004

65
Surge-Taiwan
  • National Taiwan University Hospital
  • SARS screening unit established
  • 3/15-4/22 median 6 patients screened a day
  • 4/23-5/12 median 36 patients screened a day
  • 4/23-5/12 754 patient screened with 63 admitted


  • Chen EID 2004

66
Surge-Taiwan
  • China Medical University Hospital, Taiwan
  • ED visits 33.4 lower during outbreak
  • 15 hospitals in Taiwan studied
  • Overall bed occupancy decreased 20

  • Chen BMC 2006

  • Chen Med Care
    2005

67
Surge Planning
  • Fever clinics
  • Kept hospitals functioning by screening prior to
    entrance
  • Assessed patients while minimizing transmission
    potential
  • Prevented ED overcrowding
  • At hospitals or coordinated with public health
  • Construct or retrofit

68
Surge Planning
  • N95
  • Canada hospitals non-compliant
  • North York Hospital 2-day supply
  • 4/2/03 Staff were required to wear N95 at all
    times while at work
  • Taiwan issues with private company and individual
    hording of masks
  • Hospitals should increase par levels, lessen
    dependence on outside vendors

69
Surge Planning
  • Gradual increase of patients
  • Involves regional planning
  • Canada stopped hospital transfers from taking
    place at certain hospitals

70
Surge Planning
  • Plan on surging in place or regional planning to
    identify a location
  • Identify an area
  • Supplies
  • Staffing
  • Incorporation into planning and drills

71
Surge-ED visits
72
Surge-Hospital Occupancy
73
Surge Planning
  • Shortages of ED and ICU staff
  • Decrease in other admissions can help in finding
    additional staff and supplies
  • Plan to close general non-isolation beds and
    re-assign staff to newly created surge isolation
    co-horts

74
Communications
  • Istanbul bombings
  • Complete city phone and cell phone system failure
  • Tulane Hospital- Katrina
  • Complete failure to communicate caused an
    inability to implement their disaster plan


  • Gray Urban 2006

  • Rodoplu
    PDM 2006

75
Communications
  • London bombings
  • Mobile networks failed
  • In-coming calls blocked phone lines
  • Pager system went offline
  • St Lukes Hospital- Tokyo Subway
  • Communications were jammed
  • Yelling down halls to communicate

  • Mohammed PDM 2006

  • Okumura AEM 1998


76
Communications
  • Tokyo EMS
  • Couldnt communicate with hospitals as a result,
    couldnt get permission to intubate
  • Couldnt acquire hospital availability
    information
  • Forced to attempt communication through public
    telephone lines

  • Okumura AEM
    1998

77
Communications
  • St. Vincents Hospital- NYC 9/11
  • No public telephone services
  • No cell phone services

  • Kirschenbaum CCM 2005


78
Communications Planning
  • Hospitals have an over reliance on communication
    systems and computer-based systems
  • Relatively small events, e.g. bombings, are going
    to cause a failure in the local communication
    system

79
Communications Planning
  • Large scale events are going to disrupt the
    infrastructure that supports both civilian and
    medically-utilized communication systems
  • Emergency dispatchers will be overwhelmed with
    incoming calls
  • Surviving hospital communication systems will be
    overwhelmed with incoming calls from the
    community

80
Communications Planning
  • Must have basic back-up plans in place
  • 2-way radios not reliant on outside systems
  • Runners
  • Disaster plans that can be implemented without
    the requirement of extensive communication

81
Communications Planning
  • Plans for EMS that are not dependent on
    communication to implement
  • standing orders for MCIs
  • regional transportation pre-plan in place for
    MCIs

82
Hospital Evacuation
  • Northridge Earthquake
  • 6 hospitals evacuated within 24 hours of
    earthquake
  • 5 of which had non-structural damage only (water
    damage and loss of power)
  • 1 with suspected structural damage evacuated
    emergently clearing ambulatory patients first
  • Hospital evacuated via stairs
  • Flashlights, manual ventilations
  • Carried patients with blankets, backboards and
    mattresses
  • Schultz NEJM 2003

83
Hospital Evacuation- Katrina
  • Charity/Tulane
  • Hospitals evacuated ambulatory/stable patients
    ahead of the storm
  • Generators in basement flooded at Charity
  • Power loss, flooding, loss of communications
  • Individual hospitals working out their own
    evacuation processes

  • Gray Urban 2006

84
Hospital Evacuation
  • Tulane evacuation 4 day process
  • ICU patients evacuated first
  • Patients carried to garage then to roof landing
    pad by truck
  • Spinal boards needed for patient movement had to
    be brought up from storage in Baton Rouge
  • 2 patients with 500 lb heart pumps
  • 2 bariatric patients each over 600 lbs.

  • Gray Urban 2006

85
Hospital Evacuation
  • Houston
  • Flooding in basement caused failure of electrical
    switchgear to emergency generators
  • Over 31 hours
  • 169 patients discharged
  • 406 transferred by ground and air
  • Backboards utilized for pt movement 5 neonates
    strapped to one board




  • www.semp.us

86
Hospital Evacuation Planning
  • Hundreds of people seeking shelter
  • Evacuating critical first or last
  • Planning must be regional and involve local EM
  • Accessibility of needed supplies
  • Plans for refueling generators

87
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