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Not Just Decisions, the Right Decisions; Not Just Stuff but the Right Stuff Sally Phillips, RN, PhD March 6, 2009 Emergency Management Summit Tiered Response Individual Hospital planning and response Health care system planning and response Regional health care system planning and response State level planning and response Intrastate and Interstate planning and response Federal Response Decisions and Stuff Capabilities and Capacities( EXAMPLES) – Workforce equipment, training, increase numbers, administrative changes – Supplies- Caches (ventilators, medications, and associated space, resupply and receiving augmented support) – Beds and space expansions – Labs Requirements to respond – Planning Scenarios System wide expansions and policies – Home care, primary care, ambulatory services – Other facilities in system Partners in individual hospital mission – EMS AHRQ Emergency Preparedness Resource Inventory (EPRI) EPRI Goals Enable regions to compile an inventory of critical resources via a public domain database tool Provide flexible access to inventory data via a web site Provide ability to make emergency requests and tabulate responses – What resources do you need? – What resources can you share? EPRI Inventory Structure • Resource Types, Resources Resource Type (Examples) Hospital Beds Physicians Antibiotics Facility Capabilities Resources (Examples) ICU Beds Trauma Surgeons Oral Cipro 500 Mg Doses Food Preparation Capability • Location Types, Locations Location Type (Examples) Hospitals Nursing Homes EMS Agencies Locations (Examples) Hospital ABC Nursing Home XYZ EMS Agency ABC • Resources are “Assigned” to Location Types EPRI Home Page Inventory Data Entry and Data Quality Resource Requirement Models AHRQ Surge Model – Estimates hospital resources needed to treat casualties from nine different WMD scenarios Mass Evacuation Transportation Model – Estimates transportation resources needed to evacuate patients from healthcare facilities Models and Tools for Mass Casualty Surge Requirements Resources for WMD response Surge Model Scenarios Biological – Anthrax – Smallpox – Flu Pandemic – Food Contamination – Plague Chemical – Chlorine – Mustard – Sarin Nuclear / Radiological – 1 KT or 10 KT nuclear device – Radiological dispersion device (“Dirty bomb”) – Radiological point source Conventional explosive Surge Model Components Event Surge Model Casualty Module Pre-hospital management Surge arrivals Hospital or network capacity Surge Model Hospital Module Treated Died Factors Considered Attack location characteristics (e.g., population density) Time delay between attack and when symptoms present (biological and radiological scenarios) Optional mass prophylaxis (biological and radiological scenarios) Condition of casualties upon arrival at the ED (e.g., mild vs. severe symptoms) Hospital Resources in the Surge Model Durable equipment Human resources Pharmacy Consumable supplies Personal protective equipment Psychological Support Housekeeping Lab / Radiology Mortuary Nutrition Casualty Arrivals at Hospitals (Prophylaxis reduces hospitalizations from 5,000 to 1,048) Hospitalized Patients by Day and Unit Resource Requirements for this Scenario Category Name Units Day of Peak Need Amount Needed on Peak Day Ancillary: Psychologist Psychological support FTE 4 21 Capacity: Floor Med/Surg Bed Unit of Use 10 588 Capacity: Ventilator Mechanical ventilator Machine Time 4 94 Engineering: Facility Engineering FTE 4 33 Epidemiology: Infection Control Patient infection control FTE 4 51 Equipment:O2 Monitoring Oxygenation monitoring equipment Machine Time 4 164 Equipment: Vent Tubing Ventilator equipment Unit of Use 4 94 Housekeeping: Janitorial Janitorial/Housekeeping FTE 4 69 Housekeeping: Laundry Sheet change Unit of Use 4 732 Lab/Radiology: Laboratory Laboratory machines Machine Time 4 15 Pharmacy: Antibiotics Cirprofloxacin or Doxycycline 400mg/100 mg bid 4 732 Pharmacy: Antibiotics Rifampin or other 2nd line agent 600mg po bid 4 199 Resource Requirements for this Scenario Category Name Units Day of Peak Need Amount Needed on Peak Day PPE: Universal Universal Precautions PPE Unit of Use 4 732 Radiology: CXR Radiology machines EA (Each) 3 8 Staff: CCM Intensivists (CCM) FTE 4 16 Staff: MD Non-intensivists (MD) FTE 3 28 Staff: Pharmacist Pharmacists (PharmD/RPh) FTE 5 29 Staff: Rad Tech Radiologic Technicians FTE 3 8 Staff: RN Non-critical care nurses (RN/LPN) FTE 3 126 Staff: RT Respiratory Therapists (RT) FTE 4 33 Supplies: IV set Antibiotics intravenous infusion set Unit of Use 4 465 Supplies: IV Set Intravenous infusions set Unit of Use 4 543 Supplies: Laboratory Laboratory supplies Unit of Use 4 349 Supplies: Oxygen Oxygen (O2) Unit of Use 4 283 Comparison of Required and Available Resources Display of staffing levels from HHS Area Resource File Adult Med/Surg Bed Adult Mechanical ventilator Adult ICU Bed Pediatric Mechanical ventilator Pediatric Med/Surg Bed Adult Ventilator Circuit Pediatric ICU Bed Pediatric Ventilator Circuit Burn Bed Closed circuit suction catheter 14F Operating Room Closed circuit suction catheter 8-12F Airborne Isolation Room Humidification and Flitration Unit (HMEF) Intensivists (CCM) Endotracheal tube, 3mm ID Critical care nurses (CCN) Endotracheal tube, 4mm ID Surgeons Endotracheal tube, 5mm ID Non-intensivists (MD) Endotracheal tube, 6mm ID Non-critical care nurses (RN/LPN) Endotracheal tube, 7mm ID Pharmacists (PharmD/RPh) Endotracheal tube, 8mm ID Respiratory Therapists (RT) Laryngoscope blades, adult Mortuary Laryngoscope blades, pediatric Ventilator Oxygen (O2) Laryngoscope handles NC Oxygen (O2) Endotracheal stylette Pulse oximeter Resuscitation Bag, adult Finger pulse oximeter strip Resuscitation Bag, pediatric End tidal CO2 detector, adult Radiology machines End tidal CO2 detector, pediatric Radiology supplies Temperature monitoring equipment Chemistry Laboratory machines Urine output--Foley catheter 8F-12F Chemistry Lab supplies Urine output--monitor bag Hematology Laboratory machines BP cuffs, adult Hematology Lab supplies BP cuffs, pediatric Micro/Virology Laboratory machines Microbiology/Virology Lab supplies Surge Model Treatment Paths Arriving Casualty Emergency Department Dead Or Discharged Patients Floor x1 ICU LoS value Mean Path Probabilities ED ED ED Floor Floor ED ED Floor ICU ICU ED ED ED Floor Floor ICU Floor Floor ICU Disch Death Disch Death Death Disch Death Death 0% 0% 89% 5% 1% 4% 0% 0% 0% 0% 4% 0% 0% 1% 0% 21% Mortality rate Low Calculate SCENARIO Flu Moderate Hospitalized Flu Severe ICU STREAM moderate severe Path Probabilities ED ED ED Floor Floor ED ED Floor ICU ICU ED ED ED Floor Floor ICU Floor Floor ICU Disch Death Disch Death Death Disch Death Death 0% 0% 89% 5% 1% 4% 0% 0% 0% 0% 4% 0% 0% 1% 0% 21% Overall probabilities ED ICU Floor Disch 1% 71% Expected Length of Stay ED ICU Floor E[LoS] E[LoS] E[LoS] Death P(Disch) P(Death) Sum Disch Dead Overall 0% 94% 6% 100% 6.48 5.10 6.39 4% 75% 25% 100% 13.64 6.35 11.84 Surge Model uses NIGMS MIDAS (Epicast) Flu Model Output Example of Surge Model Output: Ventilator Requirement over Time Calculating Patient Type-Specific Resource Consumption First define average resource requirements per unit, per patient type, and per time interval Calculate, based on LOS and death/transfer rates, the number of patients in any resource consumption category at any given time Hospital Bed Availability and Patient Tracking System (HAvBED) Prototype “real-time” standardized data reporting tool – Enhance system/region’s ability to care for surge of patients from public health emergency (e.g., flu) – Provides timely reporting of bed status data in an emergency (includes GIS) Nationwide scope: prototype participants (Dec, 2005) Standard Bed Reporting categories http://ahrq.gov/research/havbed/definitions.htm Sustainable Bed Availability Reporting System (HAvBED2) Delivered to DHHS 12/07 Discharge Criteria for Creation of Hospital Surge Capacity The Grant focus was the development of: an easy-to-apply method for pre-designating hospitalized patients suitable for early discharge in the event of a disaster. a tool tested and evaluated in comparison with the current ad hoc method of identification of such patients. Kelen, G. Johns Hopkins University Current development of a decision support tool underway with the Disaster Alternative Care Site Project with ASPR on this topic Project Xtreme Cross Training Video Model for Health Professional’s Cross Training for Mass Casualty Respiratory Needs Tool for assisting with mechanical ventilator staff surge Curriculum developed for ‘just in time’ training for SNS Identifies appropriate health care professionals to be trained and used in a surge situation http://ahrq.gov/prep/projxtreme/ Mass Evacuation Transportation Model A planning tool for estimating the transportation resources required to evacuate healthcare facilities – Estimate evacuation time, given transportation constraints – Or, estimate transportation assets needed to evacuate within a time constraint The Model Considers Location of evacuating and receiving facilities Patient transportation requirements Availability of transport vehicles Surge capacity of receiving facilities Traffic congestion Illustrative Hospital Evacuation Illustrative Hospital Evacuation Model Pilot Tests New York City (April 2006) – Category 4 hurricane – Evacuation of 24 hospitals and 61 nursing homes in coastal areas (approximately 24,000 patients) – Planned evacuation (72 hours notice) Los Angeles (May 2007) – Major earthquake – Evacuation of 3 hospitals (900 patients) Evacuation Time (days) Changes to ALS Availability (Los Angeles) 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 0 10 20 30 40 Number of ALS units 50 60 70 Changes to Standard of Care (Los Angeles) 120 100 Hours 80 ALS 60 BLS 40 20 0 Standard 50% ALS->BLS ALS<->BLS Mass Medical Care with Scarce Resources: Community Planning Guide Provides community planners, as well as planners at the institutional, State, and Federal levels, with information to help plan for and respond to a mass casualty event Guide is written by leading experts in 6 areas related to mass casualty care: prehospital care, hospital and acute care, alternative care sites, palliative care, ethical issues, and legal considerations. http://www.ahrq.gov/research/mce/ Mass Medical Care with Scarce Resources: A Community Planning Guide Collaboration between AHRQ and ASPR Ethical Considerations in Community Disaster Planning Assessing the Legal Environment Prehospital Care Hospital/Acute Care Alternative Care Sites Palliative Care Influenza Pandemic Case Study Ethical Principles Greatest good for greatest number Ethical process requires – Openness – Explicit decisions – Transparent reporting – Political accountability Difficult choices will have to be made; the better we plan the more ethically sound the choices will be Legal Issues Advance planning and issue identification are essential, but not sufficient Legal Triage – planners should partner with legal community for planning and during disasters Questions and Discussion http://www.ahrq.gov/prep/ Publications & Tools To order a copy of reports, tools, or resources: – contact the AHRQ Publications Clearinghouse at 800-358-9295 – Send an E-mail to [email protected]. For More Information Contact: Sally Phillips, RN, PhD Email: [email protected]