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No Vacancy: Healthcare Surge Capacity in Disasters John L. Hick, MD MDH/HCMC July 22, 2004 Capacity vs. Capability Surge Capacity – ‘the ability to manage increased patient care volume that otherwise would severely challenge or exceed the existing medical infrastructure’ Surge Capability – ‘the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions’ Barbera and Macintyre Different types of ‘surge’ Unexpected vs. expected Timeline and potential for secondary cases (anthrax vs. plague) Static vs. dynamic Triage / field treatment Healthcare facility-based Community-based Concepts and Principles Standardization Incident Management System Multiagency Coordination System Public Information Systems Interoperability (eg: personnel and resource typing) Scalability Flexibility Tiers of capacity (spillover to next level) Tiers of Response – Patient Care Federal Response (Regional & National) State A Jurisdiction I (PH/EM/Public Safety) State B Jurisdiction II (PH/EM/Public Safety) Federal Response 6th Tier State / Interstate Coordination (MDH) 5th Tier Coordination of Intrastate Regions (MDH) Jurisdiction Incident Management (County) Medical Support 4th Tier 3rd Tier nd Tier 2 Healthcare “Coalition” (Compact) HCF A HCF B HCF C Non-HCF Providers Healthcare Facility 1st Tier HRSA Grant Minnesota Local Public Health Regions Minnesota Hospital Resources 140 acute care hospitals State total 16,414 licensed beds Less than 50% of these operating Loss of 36 hospitals, 3000 beds in past 20 yrs Nearly half of MN hospitals are either ‘critical access’ or considering such designation Staff shortages, particularly nursing staff Metropolitan Hospital Compact Since April 9, 2002 27 hospitals, approximately 4800 operating beds 7 counties Agreement provides for: Staff and supply sharing Staffing off-site facilities for first 48h Communications, JPIC Regional Hospital Resource Center (HCMC) Regional Coordination Regional Hospital Resource Center (RHRC) Acts as ‘broker’ for patient transfers Coordinates hospital response and requests within region Represents hospital needs and issues to RCC Regional Coordination Center (RCC or MAC) Multi-agency coordination center for policy and strategic guidance NO jurisdictional authority Functions and scope determined by incident Hospital Response At least 50% arrive self-referred On average, 67% of patients in any given disaster are cared for at the hospital nearest the event (range 41-97%) Redistribution from the hospital closest to the incident scene to other facilities may be as (or more) important than transport from the scene Facility-based Surge Usually can free up 15% of beds at a given facility Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home) Board patients in halls Cancel elective procedures Convert procedure/PACU areas to patient care Accommodate vents on floor (or BVM or austere O2 flow powered ventilators) Supply and staffing issues (72h ahead) Per 1000 patients injured 250 dead at scene 750 seek medical care 188 admitted 47 to ICU ‘Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11 CommunityBased Surge Clinics Homecare Nursing homes Procedure centers Family-based care Off-site hospitals (Acute Care Center) Off-site clinics (Neighborhood Emergency Help Centers) (assessment and clinic level care) Local / Regional referral / NDMS Potential Alternative Care Sites Aircraft hangers Military facilities Churches National Guard armories Community/recreation centers Surgical centers / medical clinics Convalescent care facilities Sports facilities / stadiums Fairgrounds Trailers Government buildings Tents Hotels/motels Warehouses Meeting halls Factors to consider Ability to lock down/Security HVAC Lab/specimen handling Lighting Laundry Loading Dock Equipment storage Oxygen delivery capability Waste disposal Parking Communications capability Patient decon Door size Pharmacy areas Electrical power with backup Proximity to hospital Family areas Toilets/showers/waste Food supply / prep area Water supply Wired for IT/Internet access Off-site hospital Triage / admission criteria Level of care – basic nursing, drip meds, IVs, NG feeds Medications Documentation / order management Laboratory Food / water / sanitary Linen and medical waste handling Oxygen? 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 Sample Site Sample Site Food Restrooms Staff rehab areas Secure HVAC system specs Paging /messaging /radio Power Phone, T1 lines, etc. City owned! Resources Off-site matrix: www.denverhealth.org/bioterror/tools MaHIM: www.gwu.edu/~icdrm Model hospital planning: www.er1.org Off-site facilities and community planning: www2.sbccom.army.mil/hld/bwirp/ Annals of Emergency Medicine www.mosby.com/aem ‘articles in press’ (left side)