Download New England Society for Health Care Material Management

New England Society for Health
Care Material Management
Preparing for Pandemic Surge
March 22, 2006
New England Society for Health Care
Material Management
Robert P. Paone, B.S., Pharm. D.
Statewide Strategic National Stockpile
Coordinator
Center for Emergency Preparedness
Massachusetts Department of Public Health
(508) 820-2011 (desk)
(617) 438-8249 (cell)
[email protected]
3/21/2006 R. Paone
Objectives
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Review current impact projections of a
Pandemic Flu in Massachusetts
Describe Pandemic Response Plans at state
and local levels
Discuss surge preparations
3/21/2006 R. Paone
Potential Impact of Next Pandemic In
Massachusetts: Planning Assumptions

Outbreaks will occur simultaneously
throughout the US
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Up to 40% absenteeism in all sectors at all
levels
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Order and security disrupted for several
months, not just hours or days
3/21/2006 R. Paone
Pandemic v. Usual Surge Event
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Likely to happen across Commonwealth and
affect all regions simultaneously
Expected to occur in at least 2 waves of
approximately 8 weeks duration each
Projected numbers are spread across the
wave, with a peak occurring mid-wave
High attack rate among healthcare workers
3/21/2006 R. Paone
Example of an Epidemic Curve
Hospital Admissions for 30% Attack Rate, 8 Week Wave
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1
3/21/2006 R. Paone
2
3
4
5
6
7
8
9
10
MDPH FLU SURGE ASSUMPTIONS
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Attack rate: 30%
Hospitalization rate: 4% of ill
Death rate: 1% of ill
Duration of epidemic wave: 8 weeks
Avg. length of non-ICU stay for flu related illness: 5 days
Avg. length of ICU stay for flu related illness: 10 days
Avg. length of vent usage for flu related illness: 10 days
Flu admissions requiring ICU care: 50%
Flu admissions requiring mechanical ventilation: 15%
Flu deaths assumed to be hospitalized: 70%
Daily increase of cases compared to previous day: 3%
3/21/2006 R. Paone
Surge Bed Definitions
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Level 1: Staffed and available
Level 2: Licensed, Staffed
 Two types
 Beds made available through patient discharge and
transfers. These beds are NOT additive – they are within
the Level 1 bed number, but are vacated and made
available for surge.
 Beds made available through canceling of elective
surgery, such as day surgery or endoscopies. Both the
beds and the staff for those beds can be redirected for
general hospital patients. These beds ADD to overall
capacity. (Redirected level 2 beds, or 2R)
Level 3: Licensed but not staffed
 Generally equipped, including wall gases
Level 4: Overflow beds in non-traditional patient care areas
 Cafeterias, lobbies, etc.
 Require purchase of equipment (including beds), supplies
and in need of staff
3/21/2006 R. Paone
Hospital Surge Capacity
Level I
Level II
Level III
Level IV
Total:
13,067
2,000*
3,568
5,071
23,706*
Current staffed beds
Re-directed
Un-staffed beds
Non-trad. space
*Adjusted number reflects omission of beds that had been double counted through transfers
out to other hospitals. This number will decrease over time as the “elective” admissions
become non-elective. All beds are ultimately dependent on available staffing, so maximum
number may not always be attainable.
3/21/2006 R. Paone
Comparison of Pandemic
Planning Numbers
1957/68-like
# Ill
MDPH
Surge
Planning*
1918-like
2 M (30%)
2M (30%)
2 M (30%)
Hospitalizations
20,000 (1%)
80,000 (4%)
220,000 (11%)
Deaths
4,600 (0.23%)
20,000 (1%)
42,000 (2.1%)
*Based on 3X 1968 projections (Trust For America’s health report: A Killer Flu, www.healthyamericans.org, June 2005)
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outbreak 30% attack rate
3/21/2006 R. Paone
Surge Bed Capacity vs. Need
Levels 1
and 2
Level 3
Level 4
*
Total Bed
Capacity
Total
Beds
Needed
Variance
1 (West.)
2,122
277
1,026
3,425
3,284
141
2
(Central)
1,948
460
579
2,987
2,867
120
3 (N.E.)
2,663
788
1,286
4,737
4,022
715
4AB
(128)
2,879
740
915
4,534
5,096
(562)
4C (Bos.)
3,013
978
748
4,739
4,014
725
5 (S.E.)
2,761
324
517
3,283
4,277
(994)
STATE
15,061
3,567
5,071
23,705
23,560
145
* 3/21/2006
Requires
Purchase of Beds & Supplies
R. Paone
State: Need 23,560
out of 23,705 Beds
3,500
3,000
Level 4
2,500
Level 3
2,000
Levels
1 and 2
1,500
1,000
500
0
1
2
3
Nonflu
3/21/2006 R. Paone
4
5
6
Flu
7
8
128 Crescent (4AB):
Need 562 more beds than available
6,000
5,000
Level 4
4,000
Level 3
3,000
Levels
1 and 2
2,000
1,000
0
1
2
3
Nonflu
3/21/2006 R. Paone
4
5
6
7
Flu
8
Southeast (5): Need 994 more level 4
beds than available
4,500
4,000
3,500
Level 4
3,000
Level 3
Level 1
and 2
2,500
2,000
1,500
1,000
500
0
1
2
3
Nonflu
3/21/2006 R. Paone
4
5
6
7
Flu
8
Gaps in Bed Capacity
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All 6 regions expected to fill 100% of level 3 beds
(licensed but unstaffed)
All regions will need to open some level 4 beds
(overflow areas)
Two regions will exceed their surge capacity
(Regions 4AB and 5)
Staffing and supplies required for ALL level 3 and 4
beds
Equipment, supplies, and staffing needed for level 4
beds
3/21/2006 R. Paone
Hospital Surge Capacity
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Despite operational changes, hospitals may
become overwhelmed depending on usage in
communities served
Alternate care spaces will need to be
identified to expand hospital capacity
Pre-hospital triage will be needed to relieve
pressure on hospital operations
3/21/2006 R. Paone
Alternate Care Sites (ACS)
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Hospitals: flu patients requiring mechanical
ventilation, or those with complex medical
management needs
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ACS: Sickest flu patients not meeting the
criteria for hospital admission but for whom
home care is not possible
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Location and number to be determined by
local hospital bed availability.
3/21/2006 R. Paone
SNS Stakeholders Conference
Federal Medical Station
Type III (Basic)
(FMS TIII)
February 21, 2006
FMS Goal
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Address the nation’s potential shortfall in allhazard mass casualty care events and create a
federal-level contingency care program as
directed in HSPD 10.
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Deploy a surge capability throughout the Nation,
pre-positioned and configured to respond rapidly
and effectively to all types of public health
emergencies, from significant incidents to largescale catastrophic disasters
3/21/2006 R. Paone
FMS Types
Standardized Capabilities Across Agencies
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Type I (Advanced): Has capability to care for severely ill or injured
patients, equivalent to conventional operating room, ICU, and basic
laboratory (Lead: DHS) (DHS uses “FMCS”)
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Type II (Specialized): Configured for specific clinical scenarios, such
as respiratory isolation and burn care. Future prototypes to be
developed. (Lead: DHHS)
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Type III (Basic): Low to mid-level acuity of care to provide platform for
DMAT teams, special needs shelters, quarantine function, alternate
care facility to augment community hospital capability (Lead: DHHS)
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Type IV (FMS): Special Needs Shelter (Lead: DHHS)
3/21/2006 R. Paone
FMS TIII (Basic)
Concept
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A Federal, deployable medical asset designed to support regional,
state, and local healthcare agencies responding to catastrophic
events. It provides two critical capabilities:
- Inpatient, non-acute treatment capability for areas where hospital bed
capacity has been exceeded.
- A quarantine capability to isolate persons suspected of being exposed
to or affected by a highly contagious disease.
Features:
- Consists of three core modules and bed expansion module
- Very few recoverable items in the FMCS kit
- Easily adapted to meet a range of mass medical care needs following
disaster
- Deploys with SNS technical team to facilitate FMCS set up and transfer to
Federal Health Care Professionals
3/21/2006 R. Paone
FMS TIII 250 Bed Module FMS TIII 250 Bed Module
Type III Basic
Configuration
e Configuration
Type III Basic
Type III Basic
Base Support
With
Quarantine
Treatment
Pharmaceutical
• Administration
• Support
• Feeding
• Quarantine
• Beds(50)
• Housekeeping
• First Aid Equipment
• Pediatric Care
• Adult Care
• Personal Protective
Equipment
• Primary Care
• Non-acute Treatment
• Special Needs
• Non-acute Treatment
• Special Needs
•Pharmaceutical
•Special Medications
• Prophylaxis
Type III Basic
Bed Aug
(50)
•Beds
• Bedding
• Bedside Equipment
Current Pack
FMS
•634 items - 3 days supply
•170 pallets (uni-pacs and pallets)
• 4 tractor trailer (53 ft) loads
3/21/2006 R. Paone
3/21/2006 R. Paone
Staffing
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Remains biggest challenge we face
Legal protections are key to recruiting personnel
Large number of non-clinical personnel also needed
Potential sources of clinical surge personnel:
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Internal Hospital Strategies
MSAR volunteers
Medical Reserve Corps that are not included in hospital staff
Retired, inactive health professionals
Students (medical, nursing, pharmacy)
Connect and Serve (www.mass.gov)
3/21/2006 R. Paone
Health Care Professionals
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Professional qualifications must be checked and
verified ahead of time
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Volunteers cannot be assigned to take care of
patients until their specific knowledge and skills are
understood
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It takes time to do this – volunteers who have not
been pre-registered and pre-credentialed may be
delayed in receiving an assignment
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3/21/2006 R. Paone
Masks v. Respirators
http://www.fda.gov/cdrh/ppe/masksrespirators.html*
•Viruses spread primarily by droplet spray
therefore surgical mask is appropriate protection if
working within three feet of infected patients.
(Upon entering the patient’s room)
•Respirators (i.e. N-95 masks, properly fitted*)
should be worn by HCWs who are involved with
patients undergoing procedures in which
aerosolized particles may be generated.
(endotracheal intubation, suctioning, nebulizer
therapy, etc.)
3/21/2006 R. Paone
WHO recommendation November 2005,
*FDA
Oxygen Needs
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Model presumes that patients in Level IV and
ACS who require oxygen will require oxygen
therapy at 4-6 liters/minute (l.p.m.) flow.
Level IV and ACS model is based on 50
patients being treated for 10 day period.
Assumption is that at any given time, 25
patients will require constant oxygen.
Cost estimates derived from preliminary
survey of local vendors.
3/21/2006 R. Paone
Delivery Systems
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Oxygen Gaseous Cylinder
Oxygen Concentrator
Liquid Oxygen
Stockpile/Cache Planning
3/21/2006 R. Paone
Gaseous Cylinder
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H tank cylinder being used at 4-6 l.p.m. will
last approximately 1 day per patient.
Therefore, each ACS will need a minimum of
250 H cylinders worth of oxygen.
Most oxygen vendors lease H cylinders to
end users and recycle the empties replacing
them with full tanks (similar to bottled water
cooler set ups used in offices)
3/21/2006 R. Paone
Oxygen Concentrators
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Different models can be used at 1 to 6 liters per
minute.
Each patient would need their own concentrator.
Primarily used for lower flow (1-2 l.p.m.)
applications, however units do exist that do 6 l.p.m.
and more expensive units could provide oxygen up
to 10 l.p.m.
Concentrators produce oxygen from room air and
therefore do not require any gaseous or liquid
oxygen to be supplied.
3/21/2006 R. Paone
Liquid Oxygen
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Based on cryogenic technology.
Most hospitals have liquid oxygen tanks on
their premises used to supply oxygen
throughout facility.
Cost is based on pounds.
It is estimated that at approx. 6 l.p.m., each
patient would probably use approx. 280
pounds for a 10 day period
3/21/2006 R. Paone
Oxygen Stockpile/Cache Planning
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MDPH representatives have started to
conduct outreach such as attending New
England Medical Equipment Dealers
quarterly meeting Dec. 8th in Boxboro, MA.
MDPH will contact major medical supply
vendors/distributors including local and
regional oxygen suppliers to explore the topic
of securing adequate oxygen supplies during
a regional, statewide and national pandemic
surge situations.
3/21/2006 R. Paone
Ventilators
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Hospital Ventilators cost approx.
$25,000/unit.
Portable ventilator contained within SNS
stock costs approx.$7,900/unit.
Looking into prices for portable ventilators.
MDPH will work with ventilator suppliers and
manufacturers to explore state and
nationwide ventilator availability.
3/21/2006 R. Paone
Ventilators
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Massachusetts Department of Public Health
is currently in the process of evaluating
ventilators and O2-concentrators.
DPH is considering purchasing 1000-2000
vents and O2-concentrators for our state wide
stockpile.
3/21/2006 R. Paone
Surge Supply Caches: Total Cost for 50
Bed ACS: $250,000
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Approx. $5000 per patient
Approx. $20,000 Oxygen and Suction
supplies
Approx. $40,500 durable medical supplies
Approx $17,600 for Intravenous related
supplies
Approx. $78,800 for
infrastructure/administrative supplies
3/21/2006 R. Paone
Alternate Care Site Costs (cont.)
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Approx $28,000 for support service costs
(laundry, food, lab-work etc.)
Approx. $46,600 Pandemic related medicines
Approx $7500 for acute/non-emergent
maintenance meds
Approx. $13,000 for stocked Crash Cart
3/21/2006 R. Paone
Maximizing the Supply Chain
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Identify items for surge
Increase par levels for on site cache
For pharmaceuticals, distributors maintain
~21 day inventory
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Work with suppliers
Place orders early in pandemic
Identify alternate sources
3/21/2006 R. Paone
Maximizing the Supply Chain (cont.)
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What else?
All suggestions are welcomed!
3/21/2006 R. Paone
3/21/2006 R. Paone
Pandemic Response Actions:
Timing and Potential Impacts
Pandemic influenza disease
Interventions to decrease transmission
Provide quality medical care
Infection control in medical & long term care settings
Maintain essential community services/emergency response activities
Antiviral treatment
& prophylaxis
Vaccination
Time
3/21/2006 R. Paone
Local Infectious Disease Emergency
Planning
Most of the impact and
most of the response
will be local.
3/21/2006 R. Paone