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Emergency Management Strategies for Identifying and Integrating Community Resources to Expand Medical Surge Capacity: Alternate Care Facilities The National Emergency Management Summit Washington, DC February 5, 2008 Stephen V. Cantrill, MD Department of Emergency Medicine Denver Health Medical Center 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 Cantrill 2 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 Cantrill 3 Where Have We Been? Cantrill 4 Hospital Reserve Disaster Inventory Developed in 1950’s-1960’s Designed to deal with trauma/nuclear victims Developed by US Dept of HEW Hospital-based storage Included rotated pharmacy stock items Cantrill 5 Packaged Disaster Hospitals Developed in 1950’s-1960’s 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 6 Cantrill Packaged Disaster Hospitals Last one assembled in 1962 Adapted from Mobile Army Surgical Hospital (MASH) Community or hospital-based storage Cantrill 7 Packaged Disaster Hospital: Multiple Units Pharmacy Hospital supplies / equipment Surgical supplies / equipment IV solutions / supplies Dental supplies X-ray Cantrill Records/office supplies Water supplies Electrical supplies/equipment Maintenance / housekeeping supplies Limited oxygen support 8 Packaged Disaster Hospital Cantrill 9 Packaged Disaster Hospitals Congress refused to supply funds needed to maintain them in 1972 Declared surplus in 1973 Dismantled over the 1970’s-1980’s Many sold for $1 Cantrill 10 The Re-Emergence of a Concept: The 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? Cantrill 11 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 Cantrill 12 ACF Planning Issues Staffing Medical Staff Ancillary Staff Operational support Meals Sanitary needs Infrastructure Supplies Pharmaceuticals Documentation of care Security Cantrill 13 ACF Planning Issues Communications Hospitals EMS Emergency Management: State/Local Relations with EMS Rules/policies for operation Exit strategy Exercising the plan Cantrill 14 Level I Cache: Hospital 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 Cantrill 15 Level I Cache: Hospital Augmentation Trailer Cots Linens IV poles Glove, gowns, masks BP cuffs Stethoscopes (Developed under AHRQ Task Order: Cantrill Rocky Mountain Regional Care Model for Bioterrorist 16 Events) Used During Katrina Evacuee Relief Cantrill 17 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 Cantrill 18 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 Cantrill 19 Level II: Level I Plus: Ambu bags Bed pans / Urinals Medical ID bracelets Chairs Cribs Emesis basins Forms for documentation IV sets Oxygen masks Cantrill Ice packs Pillows Privacy screens Soap Tables Duct tape Adhesive tape Thermometer strips Tongue depressors (Still No Drugs) 20 Level III Cache: Comprehensive 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 Cantrill 21 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 Cantrill 22 Basic Concept: HHS Public Health Service Contingency Stations (Federal Medical Stations) “PHS-CS” 250 Bed Module Configuration PHS-CS Base Support With Quarantine • Administration PHS-CS Treatment PHS-CS Pharmaceutical • Support • Feeding • Quarantine • Beds(50) • Housekeeping PHS-CS • First Aid Equipment Bed Aug (50) • Pediatric Care • Adult Care • Personal Protective Equipment Cantrill • Primary Care • Non-Acute Treatment • Special Needs • Pharmaceutical • Special Medications • Prophylaxis • Beds • Bedding • Bedside Equipment 23 Cantrill 24 Station Layout Hall A Feeding Area HouseCleaning Storage Latrine Area and Patient Wash Area 250 sq. ft. Waiting 126'-0" Admin Supp. Pallet Administration & Admission 1614 sq. ft. Tri-fold Main Power Distribution Box Morgue 100 sq ft Treatment Area Isolated Power House Support 760 sq. ft. Medical Support Curtain Pharmacy First Aid Pack Curtain 2x7 2x7 Treatment Area Tri-fold Holding Area Bio-Med Tech Area 399 sq. ft. Staging Area To Generators 25 275'-0" Cantrill Folded Litter Cantrill 26 Cantrill 27 Possible Alternative Care Facilities Hotel Stadium Recreation Center School Church Cantrill 28 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) Cantrill 29 Rocky Mountain Regional Care Model for Bioterrorist Events (RMBT) Working Group FEDERAL Participants STATE Participants US Northern Command Montana DPH US Air Force •Office of Surgeon General Colorado DPHE •Homeland Security Office Utah DPH •Development Center for Wyoming DPH Operational Medicine Colorado US Air Force, Army and North Dakota DPH South Dakota DPH National Guard Bases US Public Health Service-Region VIII Colorado Hospital Association National Disaster Medical System (NDMS) Colorado Rural Health Center Department of Veteran Affairs Medical Center LOCAL Participants Cantrill Tri- County Health Department Denver County Health Department Jefferson County Health Department Denver Mayor’s Office of Emergency Management The Children’s Hospital of Denver Exempla Healthcare Denver Health HealthOne Centura Health Kaiser Permanente Front Range Metropolitan Medical Response System Denver Center for Public Health Preparedness 30 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. Cantrill 31 Potential ACF Sites (pre-selected) Aircraft hangers Churches Community/recreation centers Convalescent care facilities Fairgrounds Government buildings Hotels/motels Meeting Halls Military facilities Cantrill National Guard armories Same day surgical centers/clinics Schools Sports Facilities/stadiums Trailers/tents (military/other) Shuttered Hospitals Detention Facilities 32 Factors to Weigh in Selection of an Alternate Care Facility Site Infrastructure Total Space and Layout Utilities Communication Other Services Cantrill 33 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 Cantrill 34 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 Cantrill 35 Factors to Weigh in Selection of an Alternate Care Facility Site Utilities Air conditioning Electrical power (backup) Heating Lighting Refrigeration Water Cantrill 36 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 Cantrill 37 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 Cantrill 38 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. 39 Cantrill Ai rc ra Ch f t H u r an c g Co hes ers m m C o un nv ity/ R Co ales ecr n v cen ea t Fa entio t Ca ion C irg r n ro Fa e Fa ente Go un ci c ve ds litie ilitie rs r s s H o nm t e en t l Me s/Mo Bui eti tel ldin gs Mi ng H s lita al l Na ry F s tio aci l Ot nal G ities he ua r rd Sa Ar me mo D rie Sc ay s ho ols Sur g Sp i ca or lC ts en Tr F ail aci ter liti er s/C US s/T es/ lin AF ent Sta ics s( diu Mi lita ms ry /O th er ) Potential Non-Hospital Site Analysis Matrix Ability to lock down facility Adequate building security personnel Adequate Lighting Air Conditioning Area for equipment storage Biohazard & other waste disposal Communications (# phones, Local/Long Distance, Intercom) Door sizes adequate for gurneys/beds Electrical Power (Backup) Family Areas Floor & Walls Food supply/food prep areas (size) Heating Lab/specimen handling area Laundry Loading Dock Mortuary holding area Oxygen delivery capability Parking for staff/visitors Patient decontamination areas Pharmacy Area Proximity to main hospital Roof Space for Auxillary Services (Rx, counselors, chapel) Staff Areas Toilet Facilities/Showers (#) Two-way radio capability to main facility Water Wired for IT and Internet Access Total Rating/Ranking (Largest # Indicates Best Site) 40 Cantrill 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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. Cantrill 41 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? Cantrill 42 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. Cantrill 43 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.htm Cantrill 44 Who has used this tool? Greece, in preparation for the Olympics California Florida Other states/locations Available from: www.ahrq.gov/research/altsites.htm Cantrill 45 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 Cantrill 46 And Then The “Other” Problems: Ventilators: Currently in US: 105,000 In daily use: 100,000 Projected pandemic need: 742,500 Respiratory Therapists Cantrill 47 Ventilators – Surge Supply Additional full units - $32,000 each Smaller units for $6,000 each Many “Disposable” Units - $65 each Cantrill 48 Respiratory Therapists: Just-In-Time Training AHRQ: Project XTREME: www.ahrq.gov/prep/projxtreme/ MD RT Trainee Trainee RT Trainee Trainee Trainee Trainee Trainee Trainee Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Pt Cantrill 49 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] Cantrill 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] 50 MEMS ACC guidelines 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 Cantrill 51 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 Cantrill 52 Development of Gubernatorial Draft Executive Orders Developed by the Colorado Governor’s 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 Cantrill 53 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 Cantrill 54 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 Cantrill 55 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 Cantrill 56 Katrina: ACF Lessons Learned The need for “House Rules” Importance of public health issues Safe food Clean water Latrine resources Sanitation supplies Cantrill 57 Available from AHRQ: www.ahrq.gov/research/mce/mceguide.pdf Contents: Ethical considerations Legal aspects Prehospital care Hospital/Acute care Alternative care sites Palliative care Pan-flu case study Cantrill 58 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 Cantrill 59 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 Cantrill 60 Task Order Review, reconsider, revise site selection tool Develop draft staffing and resource requirements for a full range of ACFs Develop draft ACF conops Cantrill 61 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 62 Cantrill