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Title: Emergency Management Strategies for Identifying and Integrating Community Resources to Expand Medical Surge Capacity: Alternate Care Facilities


1
Emergency Management Strategies for Identifying
and Integrating Community Resources to Expand
Medical Surge CapacityAlternate Care Facilities
The National Emergency Management Summit
  • Washington, DC
  • February 5, 2008
  • Stephen V. Cantrill, MD
  • Department of Emergency Medicine
  • Denver Health Medical Center

2
Surge Capacity
  • Ability to manage a sudden, unexpected increase
    in patient volume that would otherwise severely
    challenge or exceed the current capacity of the
    health care system
  • Intrinsic
  • Facility based
  • Community based Alternate Care Facilities
  • Extrinsic State / Federal

3
Community Based Surge Capacity
  • Requires close planning and cooperation amongst
    diverse groups who have traditionally not played
    together
  • Hospitals
  • Offices of Emergency Management
  • Regional planners
  • State Department of Health
  • MMRS may be a good organizing force

4
Where Have We Been?
5
Hospital Reserve Disaster Inventory
  • Developed in 1950s-1960s
  • Designed to deal with trauma/nuclear victims
  • Developed by US Dept of HEW
  • Hospital-based storage
  • Included rotated pharmacy stock items

6
Packaged Disaster Hospitals
  • Developed in 1950s-1960s
  • Designed to deal with trauma/nuclear victims
  • Developed by US Civil Defense Agency Dept of
    HEW
  • 2500 deployed
  • Modularized for 50, 100, 200 bed units
  • 45,000 pounds 7500 cubic feet

7
Packaged Disaster Hospitals
  • Last one assembled in 1962
  • Adapted from Mobile Army Surgical Hospital (MASH)
  • Community or hospital-based storage

8
Packaged Disaster Hospital Multiple Units
  • Pharmacy
  • Hospital supplies / equipment
  • Surgical supplies / equipment
  • IV solutions / supplies
  • Dental supplies
  • X-ray
  • Records/office supplies
  • Water supplies
  • Electrical supplies/equipment
  • Maintenance / housekeeping supplies
  • Limited oxygen support

9
Packaged Disaster Hospital
10
Packaged Disaster Hospitals
  • Congress refused to supply funds needed to
    maintain them in 1972
  • Declared surplus in 1973
  • Dismantled over the 1970s-1980s
  • Many sold for 1

11
The Re-Emergence of a ConceptThe Alternate Care
Facility
  • Planning Issues
  • Augmentation vs Alternate Facility?
  • Physical space
  • Inclusion of actual structure
  • Tents, trailers, etc
  • Cost? Storage? Ownership?
  • Structure of opportunity
  • Private vs Public sites
  • Who grants permission to use?
  • Need for decon after use to restore to original
    function?

12
Alternate Care Facility Planning Issues
  • It is not a miniature hospital
  • Ownership, command and control?
  • HICS is a good starting structure
  • Who decides to open the ACF?
  • Scope level of care to be delivered?
  • Offloaded hospital patients
  • Primary victim care
  • Nursing home replacement
  • Ambulatory chronic care / shelter

13
ACF Planning Issues
  • Staffing
  • Medical Staff
  • Ancillary Staff
  • Operational support
  • Meals
  • Sanitary needs
  • Infrastructure
  • Supplies
  • Pharmaceuticals
  • Documentation of care
  • Security

14
ACF Planning Issues
  • Communications
  • Hospitals
  • EMS
  • Emergency Management State/Local
  • Relations with EMS
  • Rules/policies for operation
  • Exit strategy
  • Exercising the plan

15
Level I CacheHospital Augmentation
  • Bare-bones approach
  • Physical increase of 50 beds
  • Would rely heavily on hospital supplies
  • Stored in a single trailer
  • About 20,000
  • Within the realm of institutional ownership
  • Readily mobile - but needs vehicle

16
Level I CacheHospital Augmentation
  • Trailer
  • Cots
  • Linens
  • IV poles
  • Glove, gowns, masks
  • BP cuffs
  • Stethoscopes

(Developed under AHRQ Task Order Rocky Mountain
Regional Care Model for Bioterrorist Events)
17
Used During Katrina Evacuee Relief
18
Level II Cache Regional Alternate Care Facility
(ACF)
  • Significantly more robust in terms of supplies
  • Designed by one of our partners, Colorado
    Department of Public Health and Environment

19
Level II Cache Regional Alternate Care Facility
  • Designed for initial support of 500 patients
  • Per HRSA recommendations of 500 patient surge per
    1,000,000 population
  • Modular packaging for units of 50-100 pts
  • Regionally located and stored
  • Trailer-based for mobility
  • Has been implemented
  • Approximate price less than 100,000 per copy

20
Level II Level I Plus
  • Ambu bags
  • Bed pans / Urinals
  • Medical ID bracelets
  • Chairs
  • Cribs
  • Emesis basins
  • Forms for documentation
  • IV sets
  • Oxygen masks
  • Ice packs
  • Pillows
  • Privacy screens
  • Soap
  • Tables
  • Duct tape
  • Adhesive tape
  • Thermometer strips
  • Tongue depressors
  • (Still No Drugs)

21
Level III CacheComprehensive Alternate Care
Facility
  • Adapted from work done by US Army Soldier and
    Biological Chemical Command
  • 50 Patient modules
  • Most robust model
  • Closest to supporting non-disaster level of care,
    but still limited
  • More extensive equipment support

22
Work at the Federal Level
  • DHHS Public Health System Contingency Station
  • Specified and demonstrated
  • 250 beds in 50 bed units
  • Quarantine or lower level of care
  • For use in existing structures
  • Multiple copies to be strategically placed
  • Owned and operated by the federal government

23

Basic Concept HHS Public Health
Service Contingency Stations (Federal Medical
Stations)
24
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25
Station Layout
Hall A
26
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27
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28
Possible Alternative Care Facilities
Hotel
Stadium
Recreation Center
School
Church
29
ACF Site Selection
  • What is the best existing infrastructure/site in
    the region for delivering care?
  • (Developed under AHRQ Task Order
  • Rocky Mountain Regional Care Model for
    Bioterrorist Events)

30
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31
ACF Site Selection Tool
  • ACF infrastructure factors listed on one axis of
    a matrix.
  • Potential ACF sites listed on the other axis of
    the matrix.
  • Relative weight scale for each factor using a
    5-point scale comparing factor to that of a
    hospital.
  • Developed as an Excel spreadsheet.

32
Potential ACF Sites (pre-selected)
  • Aircraft hangers
  • Churches
  • Community/recreation centers
  • Convalescent care facilities
  • Fairgrounds
  • Government buildings
  • Hotels/motels
  • Meeting Halls
  • Military facilities
  • National Guard armories
  • Same day surgical centers/clinics
  • Schools
  • Sports Facilities/stadiums
  • Trailers/tents (military/other)
  • Shuttered Hospitals
  • Detention Facilities

33
Factors to Weigh in Selection of an Alternate
Care Facility Site
  • Infrastructure
  • Total Space and Layout
  • Utilities
  • Communication
  • Other Services

34
Factors to Weigh in Selection of an Alternate
Care Facility Site
  • Infrastructure
  • Door sizes
  • Floor
  • Loading Dock
  • Parking for staff/visitors
  • Roof
  • Toilet facilities/showers ()
  • Ventilation
  • Walls

35
Factors to Weigh in Selection of an Alternate
Care Facility Site
  • Total Space and Layout
  • Auxiliary Spaces (Rx, counselors, chapel)
  • Equipment/Supply storage area
  • Family Areas
  • Food supply/prep area
  • Lab/specimen handling area
  • Mortuary holding area
  • Patient decon areas
  • Pharmacy areas
  • Staff areas

36
Factors to Weigh in Selection of an Alternate
Care Facility Site
  • Utilities
  • Air conditioning
  • Electrical power (backup)
  • Heating
  • Lighting
  • Refrigeration
  • Water

37
Factors to Weigh in Selection of an Alternate
Care Facility Site
  • Communication
  • Communication ( phones, local/long distance,
    intercom)
  • Two-way radio capability
  • Wired for IT and Internet Access

38
Factors to Weigh in Selection of an Alternate
Care Facility Site
  • Other Services
  • Ability to lock down facility
  • Accessibility/proximity to public transportation
  • Biohazard other waste disposal
  • Laundry
  • Ownership/other uses during disaster
  • Oxygen delivery capability
  • Proximity to main hospital
  • Security personnel

39
Weighted Scale
  • 5 Equal to or same as a hospital.
  • 4 Similar to that of a hospital, but has SOME
    limitations (i.e. quantity/condition).
  • 3 Similar to that of a hospital, but has some
    MAJOR limitations (i.e. quantity/condition).
  • 2 Not similar to that of a hospital, would take
    modifications to provide.
  • 1 Not similar to that of a hospital, would take
    MAJOR modifications to provide.
  • 0 Does not exist in this facility or is not
    applicable to this event.

40
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41
Customizing the Site Selection Matrix
  • Additional relevant factors or facility sites can
    be added to the tool based on your area or the
    type of event.

42
Issues to Consider
  • Is each factor of equal weight?
  • What if another use is already stated for the
    building in a disaster situation?
  • (i.e. a church may have a valuable community
    role)
  • Are missing, critical elements able to be brought
    in easily to site?

43
WHO needs this tool?
  • Incident commanders
  • Regional planners
  • Planning teams including fire, law, Red Cross,
    security, emergency managers, hospital personnel
  • Public works / hospital engineering should be
    involved to know what modifications are needed.

44
WHEN should you use this tool?
  • Before an actual event.
  • Choose best site for different scenarios so have
    a site in mind for each type.
  • Available from www.ahrq.gov/research/altsites.ht
    m

45
Who has used this tool?
  • Greece, in preparation for the Olympics
  • California
  • Florida
  • Other states/locations
  • Available from www.ahrq.gov/research/altsites.htm

46
The Supplemental Oxygen Dilemma
  • Supplemental oxygen need highly likely in a
    bioterrorism incident
  • Has been carefully researched by the Armed Forces
  • Most options are quite expensive with high
    cost/patient
  • Many have very high power requirements
  • Most require training/maintenance
  • All present logistical challenges
  • Remains an unresolved issue for civilian ACFs

47
And Then The Other Problems
  • Ventilators
  • Currently in US 105,000
  • In daily use 100,000
  • Projected pandemic need 742,500
  • Respiratory Therapists

48
Ventilators Surge Supply
  • Additional full units - 32,000 each
  • Smaller units for 6,000 each
  • Many Disposable Units - 65 each

49
Respiratory TherapistsJust-In-Time Training
AHRQ Project XTREME www.ahrq.gov/prep/projxtreme
/
50
ACF Ideal Staffing 33 Per 12 Hour Shift
  • Physician 1
  • Physician extenders (PA/NP) 1
  • RNs or RNs/LPNs 6
  • Health technicians 4
  • Unit secretaries 2
  • Respiratory Therapists 1
  • Case Manager 1
  • Social Worker 1
  • Housekeepers 2
  • Lab 1
  • Medical Asst/Phlebotomy 1
  • Food Service 2
  • Chaplain/Pastoral 1
  • Day care/Pet care
  • Volunteers 4
  • Engineering/Maintenance .25
  • Biomed .25
  • Security 2
  • Patient transporters 2

MEMS ACC guidelines
51
Emergency System for Advanced Registration of
Volunteer Health Professionals ESAR-VHP
  • State-based registration, verification and
    credentialing of medical volunteers
  • Should allow easier sharing of volunteers across
    states
  • Still missing
  • Liability coverage
  • Command and control

52
Medical Reserve Corps
  • Local medical volunteers
  • No corps unit uniform structure
  • 330 units of 55,000 volunteers
  • Deployments do not qualify for FEMA reimbursement
  • Liability concerns are still an issue
  • ESAR-VHP may help with credentialing

53
Development of Gubernatorial Draft Executive
Orders
  • Developed by the Colorado Governors Expert
    Emergency Epidemic Response Committee (GEEERC)
  • Multi-disciplinary
  • 20 different specialties/fields (from attorney
    general to veterinarians)
  • To address pandemics or BT incidents
  • Work started in 2000

54
Development of Gubernatorial Draft Executive
Orders
  • Declaration of Bioterrorism/Pandemic Disaster
  • Suspension of Federal Emergency Medical Treatment
    and Active Labor Act (EMTALA)
  • Allowing seizure of specific drugs from private
    sources
  • Suspension of certain Board of Pharmacy
    regulations regarding dispensing of medication

55
Development of Gubernatorial Draft Executive
Orders
  • Suspension of certain physician and nurse
    licensure statutes
  • Allows out-of-state or inactive license holders
    to provide care under proper supervision
  • Allowing physician assistants and EMTs to provide
    care under the supervision of any licensed
    physician
  • Allowing isolation and quarantine
  • Suspension of certain death and burial statutes

56
Katrina ACF Lessons Learned
  • Importance of regional planning
  • Importance of security uniforms are good
  • Advantages of manpower proximity
  • Segregating special needs populations
  • Organized facility layout
  • Importance of ICS

57
Katrina ACF Lessons Learned
  • The need for House Rules
  • Importance of public health issues
  • Safe food
  • Clean water
  • Latrine resources
  • Sanitation supplies

58
Available from AHRQwww.ahrq.gov/research/mce/mce
guide.pdf
  • Contents
  • Ethical considerations
  • Legal aspects
  • Prehospital care
  • Hospital/Acute care
  • Alternative care sites
  • Palliative care
  • Pan-flu case study

59
Disaster Alternate Care Facilities
  • Agency for Healthcare Research and Quality
  • Contract No. HHSA290200600020
  • Task Order No. 4
  • Review and Revise the Alternative Care Site
    Selection Tool

60
Task Order
  • Review AARs and Lessons Observed from
  • Response to Hurricanes Katrina and Rita
  • - Sites such as Superdome, Convention Center
  • Use of Federal Medical Stations
  • NDMS DMATs
  • Use of other mobile assets
  • State experiences in site selection

61
Task Order
  • Review, reconsider, revise site selection tool
  • Develop draft staffing and resource requirements
    for a full range of ACFs
  • Develop draft ACF conops

62
Summary
  • We are rediscovering some old concepts
  • Supplemental oxygen and respiratory support
    remain problems
  • Surge staffing facilitation requires advance
    planning at multiple levels and may still fail
  • Developing medical surge capacity requires close
    planning and cooperation amongst diverse groups
    who have traditionally not played together
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