Alternate Treatment Sites (ATS): A Guide for Development

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Alternate Treatment Sites (ATS) A Guide for
Development

• McLean County Area EMS System (MCAEMS System)

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Your speakers

• Alan Otto, MS, EFO
• Emergency Preparedness Coordinator
• OSF St. Joseph Medical Center
• Mark Lareau, RN, BSN
• Emergency Disaster Preparedness Coordinator
  Advocate BroMenn Medical Center
• Shay Simmons, MBA, USMC (Ret.)
• Emergency Preparedness and Response Coordinator
  McLean Co Health Department
• Greg Scott, RN, MS, EMT-P, CHEC
• Director
• McLean County Area EMS System

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Learning Objectives

• Upon completion of this session, attendees should
  be able to
• Identify 4 key stakeholders in the Alternate
  Treatment Sites (ATS) planning process
• Identify 5 planning assumptions inherent in
  establishing an ATS agreement
• Identify 4 benchmarks for potential ATS partners

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The McLean County ATS Experience Background

• Alan Otto, M.S., E.F.O.
• Emergency Preparedness Coordinator
• OSF St. Joseph Medical Center

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McLean County Illinois

• The largest county by land area in Illinois.
• A 2010 population of 169,572, increase of 12.7
  from 2000.
• Largest communities
• Bloomington 2010 population 76,610. Population
  change since 2000 18.2, and
• Normal 2010 population 52,497. Population
  change since 2000 15.7
• Largest employers
• State Farm Insurance Companies (14,450)
• Illinois State University (3,259)
• Country Financial (2084)
• Two Medical Centers
• Advocate Bro Menn (221 bed level II trauma
  Center)
• OSF St. Joseph (149 bed level II trauma Center

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Background Information

• MCAEMS System Hospitals
• Resource Hospitals (Designation rotates annually
  July 1 June 30)
• Advocate BroMenn Medical Center (Normal)
• OSF St. Joseph Medical Center (Bloomington)
• Associate/ Participating Hospitals
• Advocate Eureka Hospital (Eureka)
• Dr. John Warner Hospital (Clinton)
• St. Margarets Hospital (Spring Valley)
• Cooperative Planning and Response Partner
• OSF St. James Medical Center (Pontiac)

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Background Information

• Alternate Treatment Site (ATS)
• Existing patient care facility
• Resources capable of treating Minor Walking
  Wounded patients
• Green Triage Tag
• Activated for sudden MCI, typically traumatic in
  nature
• Alternate Care Site (ACS)
• Facility not typically used for patient care
• Space used by hospitals to create additional
  inpatient beds
• Activated for more long term incidents, typically
  infectious in nature (e.g. infectious outbreak,
  pandemic)

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Historical MCI Response in McLean County

• Transport Team Leader assigned patient
  destinations
• All patients to Advocate BroMenn and OSF St.
  Joseph, equally divided.
• This equal division did not always result in
  equal load on each hospital
• Both hospitals accepted whatever rolled through
  the door.
• Both probably overloaded with
  yellow/red patients.
• Both were easily overloaded with
  green patients.

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Historical MCI Response in McLean County

• Inefficient patient care
• Some Red/Yellow patients possibly transferred to
  other hospitals
• Some Green patients possibly transported to other
  areas outside of the Emergency Department
• Inside the facility
• Outside the facility
• Delayed patient care
• Green patients would wait indefinitely
• Especially dangerous for Red/Yellow patients

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Problem Recognition

• Hospitals easily overwhelmed by MCI or other
  incidents/events

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Problem Recognition

• Must find other facilities to treat victims

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Why Consider ATS in Illinois?

• Tornado-Joplin, Missouri
• 161 deaths
• 1150 injuries
• Multiple Tornados-Birmingham, Alabama
• 238 regional deaths (figures vary depending upon
  source)
• UAB hospital in Birmingham took in 134 patients
  overnight
• 1500 people seen in hospitals statewide

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Why Consider ATS in Illinois?

• January 1999 blizzard
• January 4, entire state declared disaster area
• 43 deaths in Chicago area
• ANY MCI OR PATIENT SURGE MAY INDICATE THE USE OF
  ATS!

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National Benchmarks Largely Non-Existent But

• NIMS implementation guidance for the National
  Hospital Preparedness Program's (HPP) FY12
  Funding Opportunity Announcements (Dated Dec 9,
  2011),
• Preparedness/Planning 4 Participate in
  interagency mutual aid and/or assistance
  agreements, to include agreements with public and
  private sector and nongovernmental organizations.
• TJC standard EM.02.02.11 As part of its Emergency
  Operations Plan (EOP) the hospital prepares for
  how it will manage patients during emergencies

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Benchmarks Appear Largely Non-Existent But

• A basic premise of NIMS is that all incidents
  begin and end locally!
• You are responsible for solving your problems.

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ATS Planning Participants

• MCAEMS System
• Includes Advocate BroMenn Medical Center and OSF
  St. Joseph Medical Center
• American Red Cross of the Heartland
• Illinois State University Student Health Services
• McLean County Health Department
• Bloomington Fire Department
• Normal Fire Department

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ATS Planning/Implementation Takes Time

• November 2006 - discussion of ATS by MCAEMS
  System members
• 2006-2010 - background and preparatory discussion
• August 2010 first meeting with ATS stakeholders
• August 2011 policy submittal to IDPH
• September 2011 first test of policy
• October 2011 policy approval by IDPH

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The ATS Planning Process

• Mark Lareau, R.N., BSN, CHEC
• Emergency/ Disaster Preparedness Coordinator
• Advocate BroMenn Medical Center

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Concept Development

• Realization of MCI response problems
• Additional realizations about MCI response
• Specialist could be at one hospital patients
  needing that specialist could be sent to the
  other
• Either hospital could have circumstances
  affecting its ability to take an equal number of
  patients
• Hospital plans included sending Green patients to
  other areas within the hospital or clinics
  associated with the hospital

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Concept Development

• Other realizations
• Regional preparedness planning posed the question
  of how many Red/Yellow/Green patients could we
  take
• Couldnt answer because we were accustomed to
  taking whatever rolled through the door and never
  considered what we could manage
• Preparedness efforts involve planning for sites
  for hospital surge/overflow patients
• ACS vs. ATS

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Concept Development

• What If
• hospitals determined what they could take and
  directed EMS accordingly rather than taking
  whatever rolled through the door?
• those Green patients skipped the middleman and
  went straight to the clinics?
• we included other healthcare providers not
  associated with the hospitals?

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Planning Assumptions

• Not formally stated but these were the
  assumptions from which we worked
• Planning timeline
• Policy Development
• Hospitals determine patient destinations
• Transport directly to final treatment site,
  rather than using hospital as an intermediate
• Include ATS not previously considered
• Written MOU's
• Others were developed during the process

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Planning Assumptions cont.

• Focus is on positive outcomes for patient care
• Plan should align with everyday operations to the
  maximum extent possible
• Plan must incorporate ICS principles and be in
  accordance with NIMS
• Consensus planning (stakeholder representation)
• Plan must be adaptable to all-hazards emergency
  operations

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Planning Timeline

• MCAEMS System MCI Policy Development
• ATS Policy Development
• County EMA MCI Plan Revision
• ACS Policy Development
• Slight Deviation off the Timeline
• Emergent Transfer of Medical Control
• Resource hospital directly impacted during a
  drill
• Alternate Resource Hospital can take temporary
  responsibility for Medical Control

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EMS MCI Policy Revisions

• Defined an MCI
• Early notification of hospitals, RHCC, IDPH
• MABAS box alarm cards for EMS
• Additional resources, including RMERT
• Automatic notifications
• Note EMS response may include Casualty
  Collection Point (not the same as an ATS)

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ATS Policy Development

• Continuing from/consistent with EMS MCI Policy
• Using existing structure with Resource Hospital
  as the lead
• Using existing resources that already treat these
  types of patients
• Outline responsibilities of the Resource
  Hospital, EMS system hospitals, and ATS

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ATS Policy Development

• Ideas discarded along the way
• Resource Hospital and Alternate Resource Hospital
  each communicates with half of the hospitals and
  half of the ATS
• This could lead to problems with two lines of
  communication
• Resource Hospital tracking each patient vs.
  overall numbers

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Preliminary Ideas
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Preliminary Ideas
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ATS Policy Development

• Pre-incident Responsibilities
• Resource Hospitals and ATS maintain contact
  information
• NIMS training
• Notifications
• MCI policy activated by EMS
• EMS notifies Resource Hospital with casualty
  types and numbers
• Early notifications to RHCC and IDPH

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ATS Policy Development

• Determine need for other hospitals ATS
• Resource Hospital Alternate Resource Hospital
• Resource Hospital contacts EMS system hospitals
  and ATS
• Hospitals report what they can take (Guidelines)
• ATS chooses to participate, or not, and how many
  they can take

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ATS Policy Development

• Resource Hospital directs Transport Team Leader
  on patient destinations
• How many of Red/Yellow/Green patients to each
  hospital or ATS
• Each hospital and ATS maintains log of MCI
  patients for tracking, family reunification, and
  possible reimbursement
• If a Green patient deteriorates at an ATS, 9-1-1
  is used

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Communications Interoperability

• Phone
• MERCI 155.280
• Disaster Channel Old Technology
• Disaster phone line
• StarCom
• Ham radio
• Sat phones

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Barriers to Policy Development

• Time
• Scheduling busy members from multiple agencies
• Multiple drafts (no templates or benchmarks)
• ATS buy-in
• Recruitment/ Presentation
• Acceptance of concept
• Development and legal review of MOU
• Liability
• Financial
• Training requirements

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Including Key Stakeholders

• Advocate BroMenn Medical Center
• American Red Cross of the Heartland
• Bloomington Fire Department
• Illinois State University Student Health Services
• McLean County Area EMS System Office
• McLean County Health Department
• Normal Fire Department
• OSF St. Joseph Medical Center

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Engaging Stakeholders

• Shay Simmons, MBA, USMC (Ret.)
• Emergency Preparedness Coordinator
• McLean County Health Department

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Emergency Planning and Response in McLean County

• McLean County Disaster Council (MCDC)
• Established 1969
• MCAEMS System Hospital Preparedness Work Group

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McLean County Disaster Council Members

• State Farm Insurance Companies
• Country Financial
• AFNI, Inc
• Ameren IP
• Central Illinois Regional Airport
• City of Bloomington
• Town of Normal
• Village of LeRoy

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McLean County Disaster Council Members, contd.

• McLean County Area EMS System
• McLean County EMA
• McLean County Health Department
• OSF St. Joseph Medical Center
• Advocate BroMenn Medical Center
• McLean County METCOM
• Illinois State University

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McLean County Disaster Council Members, contd.

• Illinois Wesleyan University
• Heartland Community College
• American Red Cross
• Salvation Army
• United Way/PATH 211
• Faith in Action
• ARES

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McLean County Disaster Council Members, contd.

• TSA
• FBI
• Illinois National Guard
• Illinois State Police
• And many more.

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McLean County Disaster Council Committees

• Drill
• MABAS/Mass Casualty
• Emergency Communications
• By-laws
• Incident Command Training
• Terrorism/Pandemic
• Special Needs
• LEPC

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Emergency Planning and Response in McLean County

• Drills/exercises as well as real-world
• H1N1
• Snowmageddon
• Stability and Continuity
• Leverages long-standing relationships
• Emphasizes established MOU's

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Identifying Stakeholders

• EMS and fire departments
• County EMA/ESDA offices
• Hospitals and other healthcare facilities
• Local and State Public Health Departments
• NGOs such as the American Red Cross

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Identifying Potential ATS Sites

• Considerations
• Facility capabilities
• Time constraints
• Legal and financial barriers
• Lack of benchmarks

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ATS Site Benchmarks

• Ability to deploy trained, credentialed personnel
  in support of surge capacity
• Accommodations and capability
• Supply and re-supply capability
• Communications capability

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ATS Selection

• Facilities already established within the
  community
• Acute care walk-in clinics
• Advocate BroMenn Medical Group
• ISU Health Services
• OSF Prompt Cares
• Existing workforce
• Need for ICS training

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MOU Process

• EMS System is host organization for MOUs
• Identification of responsibilities
• Resource Hospitals
• ATS

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Resource Hospital Responsibilities

• Maintain contact information/hours of operation
• Upon notification of an MCI, notify affected
  hospitals, Alternate Resource Hospital, and
  MCAEMS System office
• If need for ATS is determined, notify ATS
  primary/backup contact
• Obtain numbers of Green patients ATS can accept
• Coordinate transportation of patients to
  hospitals and ATS
• Maintain log of numbers/types of patients
• Demobilization inform all participating
  hospitals and ATS of All Clear

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ATS Responsibilities

• Provide appropriate NIMS training to responding
  staff and maintain NIMS forms to be used for an
  MCI
• Upon MCI notification, activate disaster calling
  tree
• Notify Resource hospital of approximate number of
  Green patients that can be accepted, based on
  available space
• Receive and treat patients transported directly
  from disaster site
• Collect triage tags and maintain patient logs
• Maintain record of expenses (using NIMS)
• Use 9-1-1 to transfer deteriorating Green
  patients

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Wrap Up

• Gregory Scott, R.N., M.S., EMT-P, CHEC
• Director
• McLean County Area EMS System

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The McLean County Experience

• Completion of the multi-phase planning approach
• MCAEMS System MCI policy development
• Update McLean County MCI Annex to EOP
• Develop ATS policies and MOUs
• Exercise ATS activation
• On-going training of ATS staff
• Develop ACS policies and MOUs

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ATS Types of Incidents
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ATS Types of Incidents
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ATS Types of Incidents
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McLean County ISU Fall 2011 Exercise

• October 08, 2011 (0900)
• IED scenario
• ISU Center for the Performing Arts facility
• Approximately 75 victims
• Hospital Medical Surge
• Alternate Treatment Sites (ATS) opened
• JIC instituted

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Realistic Scenario with Medical Surge
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Participating Organizations

• Advocate BroMenn Medical Center
• American Red Cross of the Heartland
• Amateur Radio ARES
• Bloomington FD
• Bloomington Township FD
• Carlock FD
• Central Illinois Regional Airport
• Danvers FD
• Downs Community FD
• G4S Security
• HCC Threat Assessment
• Heartland Community College
• Hudson FD
• Illinois State Police
• ISU Environmental Health and Safety
• ISU Grounds
• ISU Media Relations
• ISU Office of Parking and Enforcement
• ISU Police

• ISU Police Dispatch
• ISU Faculty Staff Threat Assessment Team (FSTAT)
• ISU Health Services
• ISU Student Behavioral Intervention Team (SBIT)
• LeRoy EMS
• McLean County Area EMS System
• McLean County EMA
• McLean County Health Department
• McLean County MRC
• McLean County 911
• Mennonite College of Nursing
• Normal FD
• OSF St. Joseph Medical Center
• State Farm Insurance
• OSF Prompt Cares
• Advocate Healthpoint
• Towanda FD

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Total Participants

• 345 People!!!

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County Wide Collaboration
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Lessons Learned

• Establish Medical Branch/Group Officer
• A FD Chief Officer was assigned to oversee this
  function, a Branch Director would have been more
  efficient
• Ensure effective, reliable interoperable
  communications between providers, medical
  command, public health, and health care
  facilities
• Utilize Unified Command Post to facilitate
  interoperable communication on-scene

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Lessons Learned

• Coordinate and transport patient to the
  appropriate treatment facility
• Medical Control should provide destination
  determinations on-scene personnel should await
  direction from Medical Control for transport of
  Green patients

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Lessons Learned

• Organize and distribute medical resources
• An EMS treatment equipment staging area should be
  located near the identified treatment area
• Provide medical support and safety considerations
• Full integration of EMS into the ICS structure
  all MCI identifying title vests should be utilized

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Building Capabilities

• Medical Surge trailers
• Six hospitals in MCAEMS System Hospital
  Preparedness work group each have medical surge
  trailers
• MOUs are updated annually
• MCAEMS System, ARC, Advocate BroMenn Medical
  Center, and OSF St. Joseph have a stocked surge
  trailer
• McLean County EMA MCI Trailer
• Putnam County EMS MCI Trailer

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The Future

• Have identified four local ACS sites
• Verbal commitments/working on securing MOUs
• Working on securing grant funding
• Purchase mobile POD containers full of supplies
• Enhancing McLean County MRC
• Develop a McLean County CERT
• Exercise the ACS
• Eventually exercise ATS and ACS in same incident
• Expand the ATS to the six hospitals within the
  MCAEMS System

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Alternate Care Site (ACS) Selection
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ACS Selection
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ACS Selection
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ACS Selection
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ACS Selection
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ACS Selection
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ACS Types of Incidents
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What Can Your Community Do?

• Identify readily available healthcare resources
• Available and credentialed workforce
• Willing Participant in planning process
• Comfortable with caring for walk-in patients
• Ease of access
• Geographically convenient
• Does not need to be an Acute Walk-In Clinic
• Be a change agent
• Refuse to accept the norm

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Summary

• Communities must plan for short and long duration
  medical surge incidents
• Be a leader and not a follower
• Use already existing local planning groups
• Establish a plan of action and implement
• Develop and/or enhance policies
• Identify existing untapped resources
• Establish written MOUs
• Exercise and address lessons learned

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• Mark Lareau
• mark.lareau_at_advocatehealth.com
• Alan Otto
• Alan.R.Otto_at_osfhealthcare.org
• Greg Scott
• gscott_at_mcleancountyems.org
• Shay Simmons
• shay.simmons_at_mcleancountyil.gov

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Questions