Download 13. Outpatient Surge Capacity - Wisconsin Disaster Medical

x
Guidelines for
Managing
Inpatient and
Outpatient
Surge Capacity
Recommendations of the State Expert Panel on
Inpatient and Outpatient Surge Capacity
November 2005
Table of Contents
Introduction ……………………………………………………………………….Intro -1
1. Types of Incidents ……………………………………………………………Page 1-1
2. Increasing Availability of Existing Inpatient Beds …………………………Page 2 -1
3. Field Triage …………………………………………………………………….Page 3-1
4. Opening/Creating Areas or Wings for Inpatient Surge Capacity ………………Page 4-1
Classification of Surge Capacity Beds by Triage Colors ……………..…….Page 4-2
Application of Color-Coded Surge Beds to the Level of Incident……..........Page 4-3
Example of Surge Capacity Matrix ………………...……………………… Page 4-4
Surge Capacity Matrix …………………………….………………………Page 4-5
Cohorting Surge Patients …………………………………………………. Page 4-6
Summary of Surge Capacity Beds …………………………..…………… Page 4-7
St. Camillus Hospital Surge Capacity Support Area Matrix …………… Page 4-8
5. Inpatient Units for Special Considerations …………………………………...Page 5-1
6. Criteria for an Inpatient Surge Capacity Bed ………………………………… Page 6-1
7. State Stockpile of Inpatient Surge Capacity Beds …………………………… Page 7-1
8. Patient Care Staffing for Inpatient Surge Capacity Areas ……………………. Page 8-1
Staffing Strategies………………………………………………………… Page 8-1
Assignment of Staff to Color-Coded Beds ………………………………..Page 8-2
Job Action Sheets ………………………………………………………… Page 8-3
Managing the Continuum of Care After the Initial Surge of Inpatients …Page 8-3
Transition Matrix …………………………………………………………Page 8-4
Secondary Surge …………………………………………………………. Page 8-4
Discharge Planning and Case Management …………………….. Page 8 -5
9. Ancillary Care Staffing for Inpatient Surge Capacity Areas ……………Page 9 -1
Anci l l a r y S uppo rt Mat ri x …………… …………………… … … P a ge 9 -2
10. Staff Support Considerations ………………………………………………. Page 10-1
11. Equipment and Supplies …………………………………………………….. Page 11-1
Equipment Location Matrix ……………………………………………… Page 11-2
Equipment Source Matrix ……………………………………………… Page 11-2
Critical Supply Inventory ………………………………………………. Page 11-3
Supply Source Matrix …………………………………………………… Page 11-5
12. Triage Center …………………………………………………………………. Page 12-1
Criteria for Triage Center ………………………………………………. Page 12-1
Decontamination ………………………………………………………… Page 12-1
13. Outpatient Surge Capacity …………………………………………………… Page 13-1
Alternative Treatment Site Matrix ……………………………………….. Page 13-2
14. Exercise ………………………………………………………………………. Page 14-1
15. Off-Site Alternative Inpatient Treatment Centers ……………………………. Page 15-1
16. Risk Communications ……………………………………………………… Page 16-1
17. Business Continuity Plan …………………………………………………… Page 17-1
18. Guidelines for Completing Your Hospital Surge Capacity Plan ……………. Page 18-1
Appendices
Appendix A: Map of HRSA Hospital Disaster Preparedness Regions …………Appendix A-1
Appendix B: START Triage Algorithm …………………………………………Appendix B-1
Appendix C: JumpSTART Triage Algorithm …………………………………Appendix C-1
Appendix D: Example of Hospital Surge Capacity ………………………….. Appendix D-1
Appendix E: Prioritization of Patient Care Tasks ……………………………. Appendix E-1
Appendix F: Job Action Sheets ………………………………………………..Appendix F-1
Appendix G: Medications in ChemPacks …………………………………….Appendix G-1
Appendix H: Accessing the ChemPacks ………………………………………Appendix H-1
Appendix I: Rationing Supplies …………………………………………………Appendix I-1
Appendix J: Access to Personal Protective Equipment ………………………….Appendix J-1
Appendix K: Strategic National Stockpile List of Assets ……………………….Appendix K-1
Appendix L: Template Memorandum of Understanding ………………………Appendix L-1
Worksheets
Worksheet 1: Incident Level Matrix ……………………………………………Worksheet 1-1
Worksheet 2: Surge Capacity Matrix …………………………………………..Worksheet 2-1
Worksheet 3: Surge Capacity Summary ………………………………………..Worksheet 3-1
Worksheet 4: Surge Support Area Matrix ………………………………………Worksheet 4-1
Worksheet 5: Staffing Ratios for Surge Capacity Matrix …………………….Worksheet 5-1
Worksheet 6: Transition Matrix ……………………………………………….Worksheet 6-1
Worksheet 7: Ancillary Support Matrix ……………………………………….Worksheet 7-1
Worksheet 8: Equipment Location Matrix ……………………………………..Worksheet 8-1
Worksheet 9: Equipment Source Matrix ………………………………………..Worksheet 9-1
Worksheet 10: Critical Supply Inventory Matrix…………………………….Worksheet 10-1
Worksheet 11: Critical Supply Source Matrix ……………………………….Worksheet 11-1
Worksheet 12: Alternative Treatment Site Matrix ……………………………Worksheet 12-1
Introduction
This document provides guidelines and recommendations for hospitals to manage a surge
of inpatients and outpatients in a mass casualty incident. The National Bioterrorism
Hospital Preparedness Program of the Health Resources and Services Administration
(HRSA) has granted funds to help hospitals better manage a surge of inpatients, based on
a minimum capability of hospitals being able to treat 500 adult and pediatric patients per
1,000,000 population. For the State of Wisconsin this translates to being able to care for a
minimum surge of 2,683 additional inpatients.
Presently, there are 12,922 staffed beds for the 128 medical/surgical hospitals in the state.
Initially, it was felt that surge capacity could be achieved by establishing Alternative
Treatment Facilities, that is, other sites, apart from the hospital, such as community
centers, schools and other such large buildings that could be converted into use as
inpatient facilities. The many logistical, clinical, legal and financial issues involved with
the implementation of the Alternative Treatment Centers are myriad.
128 hospitals participated in an exercise in May 2004 to measure their ability to increase
inpatient bed capacity. The results of the exercise demonstrated that:


Hospitals were able to “empty” existing beds by early discharge and other strategies
so that there were approximately 7,000 available inpatient beds1
Hospitals were able to open and/or convert other areas or wings of their facilities to
care for inpatients so that there were approximately 17,700 additional inpatient beds
available2
The State Expert Panel on Inpatient and Outpatient Surge Capacity was convened to
make recommendations, based on the surge capacity goals, presented to hospitals by
HRSA, and the options that are available to hospitals to achieve this goal. This Panel was
composed of Inpatient Nursing and Emergency Department managers.
These Guidelines then are based on the results of the May 2004 exercise and the
recommendations of the Expert Panel. The strategy recommended for Wisconsin
hospitals is to both “empty” existing inpatient beds to the extent possible (to deal with the
initial surge of inpatients) and to open other areas for inpatient care.
Based on the results of the May 2004 Exercise, the following matrices represent the surge
capacity potential for Wisconsin Hospitals by region (see Appendix A: Map of HRSA
Hospital Disaster Preparedness Regions).
These beds cannot be counted as surge beds. “Emptying Beds” may be a strategy that can be used in a
time-limited traumatic event. In a sustained event, however, these beds will quickly be filled by the
“normal sick and injured.”
2
Hospitals were asked to look at all available spaces for conversion to inpatient surge capacity to determine
the maximum capacity. This number will be refined with the publication of these “Guidelines”.
1
Intro-1
Region
1
2
3
4
5
6
7
State Total
Staffed Beds
1,211
1,184
1,028
694
2,381
991
5,433
12,922
Available Beds3
808
641
588
452
1,066
651
2,757
6,963
Surge Beds4
2,198
1,710
1,828
1,016
2,629
1,337
6,985
17,703
Note: It is important to recognize that the above number of “17,703 additional
inpatient beds” does not mean that hospitals have actual beds that can be deployed.
The matrix below displays the actual “available surge beds” to accommodate a surge
of inpatients.
Region
Surge Beds
1
2
3
4
5
6
7
State Total
Surge Cots
Surge Beds Needed
2,198
1,710
1,828
1,016
2,629
1,337
6,985
17,703
Available Surge
Beds5
1,171
552
612
448
1,284
370
2,199
9,230
Surge Beds
Needed6
1,027
1,158
1,216
568
1,345
967
4,786
11,067
(2,600)7
8,473
Since any mass casualty incident will be local in nature, it is the responsibility of each
hospital to have the ability to implement this Inpatient and Outpatient Surge Capacity
Plan. How long the hospital will need to manage this surge of patients will depend, of
course, on the intensity and geographical footprint of the area affected.
“Available Beds” are defined as those inpatient beds that can be made available through such strategies as
early discharge, cancellation of elective admissions, etc.
4
“Surge Beds” are defined as those additional inpatient beds, not now operational or staffed, that can be
deployed if necessary.
5
“Available Surge Beds” are those beds that hospitals identified in the May 2004 exercise that they have
physically available on-site. It should be noted that these are beds that do not necessarily meet the criteria
for surge capacity beds as outlined in Section 6 of this plan, since these criteria were not available to
hospitals at the time of the exercise.
6
“Surge Beds Needed” are additional inpatient beds that will need to be obtained from other sources.
7
These “beds” are specially designed military cots that will be pre-positioned at hospitals for use in a surge
capacity incident.
3
Intro-2
These Guidelines provide hospitals with a plan to manage a potential surge of
approximately 11,830 patients8. This surge of patients could result from an extremely
traumatic incident such as a grandstand or building collapse. However, a pandemic flu
incident could begin to push even these limits. Each flu season finds many hospitals at
full bed capacity with their resources pushed to the limit.
In the event of a catastrophic mass casualty incident such as a nuclear explosion or a
“Hurricane Katrina Incident”, even this mass casualty surge capacity may not provide
sufficient inpatient and outpatient treatment capacity and thus overwhelm the capacity of
the healthcare system to manage a catastrophic event.
8
This number is based on available surge beds at hospitals (9,230) in addition to the surge cots (2,600) that
are to be pre-positioned at hospitals.
Intro-3
1.
Types of Incidents
There are two major types of mass casualty incidents that may occur:
Traumatic incidents may be caused by multiple vehicle accidents, building collapse,
explosions, chemical spills, airplane crash, etc. Hospitals will be alerted as to the time of
the incident and the Estimated Time of Arrival of the casualties. These incidents are
usually time-limited as to their duration. In most cases, within 24 hours from the
inception of the incident, the total surge of patients will have arrived at the hospital. Soon
thereafter, patients will have been stabilized and treated and the discharge of the first of
these patients will occur. Within days, the hospital can expect to return to near normal
operations. Except for explosive events, where there may be large numbers of burn
patients, it is expected that, in most traumatic incidents, hospitals will be able to manage
those in need of long-term hospitalization.
Biological incidents may be caused deliberately by such agents as anthrax or smallpox or
indeliberately by pandemic flu or by other infectious disease outbreaks. In these
incidents, the identification of the incident will occur over time and the surge of patients
will occur slowly at first and may then peak considerably at a certain time due to the
incubation period. The duration of these incidents cannot be determined and may last for
weeks and even months, such as in the case of pandemic flu, which can come in several
waves over long periods of time.
These Guidelines will address surge capacity for both types of incidents. These
Guidelines will apply similarly to both types of incidents with a few special
considerations for biological incidents.
1-1
2.
Increasing Availability of Existing Inpatient Beds
There are various strategies to increase existing inpatient bed capacity such as early
discharge of patients, cancellation of elective admission, etc.
In a traumatic incident it is recommended that this strategy be used only as a secondary
strategy with the opening of surge capacity areas as the first strategy. This is due to the
fact that staff will be occupied with the surge of patients and will not have time initially
to begin the implementation of the strategies to make occupied beds available. It is
expected that patients in a traumatic incident will arrive faster than occupied beds can be
“emptied” or made available. In addition, the in-house and outside “traffic”, created by
these “emptying” strategies, may add to the congestion, caused by the incoming surge of
patients and the family members, media and general public that will arrive at the
hospitals along with these victims.
This “emptying” strategy will prove more effective and more clinically appropriate as the
“surge patients” are treated and then moved to more appropriate beds, which will be
made available through early discharge and other such “emptying” strategies. The goal is
to return to “normal” operations and bed configurations as soon as possible.
2-1
3.
Field Triage
Before a hospital can begin to establish its inpatient surge capacity plan, the staff
responsible for the implementation of this plan must be familiar with the triage protocols
that will take place in the field. This process involves triaging (“sorting”) patients by their
severity of injury, based on a color-code system, which is widely used by EMS and First
Responders and their hospital partners.
The Wisconsin EMS Emergency Preparedness Plan (WEEPP) has recommended the use
of START (Simple Triage and Rapid Treatment) as the triage protocols for adult patients
and JumpSTART as the triage protocols for pediatric patients (see Appendix B: START
Triage Algorithm and Appendix C: JumpSTART Triage Algorithm).
START and JumpSTART uses the following color codes to triage (“sort”) patients:

GREEN designates patients that are ambulatory and thus their injuries may be of a
minor nature. It is anticipated that GREEN patients, in a mass casualty incident, will
not be transported to hospitals, but rather will receive initial treatment in the field
and/or be transported to alternative outpatient treatment centers (see Section 13).

YELLOW designates patients that do not need immediate care and thus are triaged
for “delayed” treatment.

RED designates patients that are in need of immediate care.

BLACK designates patients that either have died or whose injuries are so severe that
they are expected to die and thus are designated as “Expectant”. In a mass casualty
incident, the number of BLACK patients may increase due to the limited resources
and will be brought to the hospital for palliative care. The triage principle that will be
used in the field and in the hospital is “Do the greatest good for the greatest number.”
3-1
4.
Opening/Creating Areas or Wings for Inpatient Surge Capacity
The May 2004 Exercise demonstrated that hospitals were very creative in the
identification of wings, areas and spaces that could be opened and/or converted for use as
inpatient treatment areas. These potential treatment areas included such areas or spaces
as:
 Waiting Rooms
 Wings previously used as inpatient areas that can be reopened
 Conference Rooms
 Physical Therapy Gyms
Appendix D: Example of Hospital Surge Capacity provides an example of the type of
data, produced by the May 2004 exercise, which is available for each of the 128
medical/surgical hospitals in the State of Wisconsin.
Obviously, there is a hierarchy among these rooms as to which would best and first be
used as inpatient surge capacity treatment areas. These Guidelines are intended to provide
hospitals with recommendations on how to determine which areas and rooms can best be
used for which patients.
It is important for the hospital to consider other areas that will be also be affected by the
surge of inpatients so that not all space is targeted for inpatient care. For example, a surge
of patients will also bring a surge of family members and visitors. Spaces need to be
identified to accommodate the needs of these people. For example, the cafeteria usually is
a large area that could accommodate inpatient surge beds. However, this space will be
necessary for food services for staff and visitors. Family members and visitors will also
need spaces to congregate and relax. Patients from distant areas will be accompanied by
family and friends, who may stay at the hospital for long periods of time.
This selection of areas to be used for surge capacity can best take place when the hospital
has an understanding of the intensity of the incident and the resulting number of surge
patients that it may receive. Collaboration and the establishment of alert protocols with
EMS and other First Responders and the Emergency Operations Center (EOC) will
provide hospitals with the necessary information to implement the appropriate number of
inpatient surge beds.
The following Incident Level Matrix was developed by the Expert Panel to help hospitals
tier their plans for the implementation of inpatient surge capacity beds, based on the
number of patients expected:
4-1
INCIDENT LEVEL MATRIX
Incident Level
I
II
III
IV
V
Number of Patients Expected
1 – 10
11 – 25
26 – 50
51 – 100
>100
Each hospital is expected to build their inpatient surge capacity plan, based on the
number of staffed beds they have available. A rural Critical Access Hospital with 20
staffed beds will have a plan that is different than that of a metropolitan hospital with 300
beds.
Commentary: The Expert Panel agreed that a disaster code at most hospitals,
calls for a response from everyone at the hospital. Consideration is to be given to
calling a Disaster Code by the Level of Incident so that only the appropriate
resources are deployed, based on the different levels of incident. For example,
only ED staff and certain others may need to respond to a Level I incident, while
everyone responds to a Level V.
Classification of Surge Capacity Beds by Triage Colors
The following guidelines are written to help hospitals initially triage or “sort” their surge
capacity beds and identify which beds can best be used for which type of patient. Thus, if
a hospital is told that it should expect to receive 10 RED patients and 15 YELLOW
patients, the hospital will have pre-identified in this plan which rooms can best serve the
needs of these patients.
Thus, the inpatient surge capacity rooms should initially be designated by the following
triage color codes:

RED rooms are to be designated for the care of patients in need of immediate care.
These RED surge capacity rooms are rooms, which need to be similar to ED rooms
with the required gases and equipment. Examples of such rooms are PACU and ICU
rooms or, if necessary, a medical/surgical room.

YELLOW rooms are to be designated for the care of patients, whose treatment can
be delayed. These are medical/surgical rooms or areas or other rooms that are in close
proximity to existing medical/surgical rooms and also in close proximity to ancillary
services and supplies.

BLACK rooms are to be designated for the palliative or comfort care of patients and
may be rooms that are more distant from the core acute care service areas because
these patients will be provided only with minimal services.
4-2
IMPORTANT: As in the field, all these patients will need to be constantly retriaged.
The color designation may change several times for these patients.
Application of Color-Coded Surge Beds According to the Level of Incident
The initial alert from the field will give the hospital information regarding the number of
color-coded patients that are expected to be transported to the hospital. This will enable
the hospital to determine which areas or rooms it will use to care for RED, YELLOW and
BLACK patients.
Level I: It is expected that at this Level most hospitals9 will be able to handle the surge of
inpatients with its existing inpatient staffed bed capacity without the need to deploy any
inpatient surge capacity beds.
Level II: The first consideration for the hospital is how many RED patients will be
coming to the hospital. According to the Incident Level Matrix, Level II will involve 1125 patients. RED patients should ideally be placed in ED rooms. If there are more RED
patients than there are ED rooms, then there must be the deployment of areas that can be
designated as RED surge capacity rooms, where these RED patients can receive
immediate treatment. In this case, these rooms are more treatment areas than they are
inpatient rooms.
Level III, IV and V: The hospital is to have pre-identified inpatient surge capacity areas
for RED, YELLOW and BLACK patients. The Surge Capacity Matrix (see Worksheet
2) should also enable the hospital to identify the maximum number of RED, YELLOW
and BLACK patients that the hospital can manage.
However, even if hospitals have identified only a certain number of RED rooms, e.g. 10
RED rooms, if 15 RED patients are transported to the hospital10, then the hospital will
have to tap into the next level of YELLOW rooms and “do the best they can to meet the
needs of their patients, given the limited resources.”
9
The Panel recognizes that there is significant variation among hospitals in their ability to manage a surge
of patients and that for a small Critical Access Hospital, even 1 – 10 patients in a Level I incident may be
overwhelming.
10
Hospitals must keep in mind that in the midst of this surge incident, “normal sick and injured patients”
will still present to the hospital. An “MI” patient in this case will be designated as another RED patient.
4-3
Example of a Surge Capacity Matrix
The following Surge Capacity Matrix (see Worksheet 2) is an example of the Inpatient
Surge Capacity Plan for St. Camillus Hospital. The Surge Capacity Matrix (see
Worksheet 2) shows which surge capacity areas St. Camillus Hospital will open first and
for which type of color-coded patient.
Note: In the Surge Capacity Matrix (see Worksheet 2), the number in
parentheses is the estimated number of beds, which normally may be expected to
be unoccupied, based on the average daily census of the hospital.
According to the following Surge Capacity Matrix (see Worksheet 2), for a Level I
incident, St. Camillus projects that it may have (on average) 2 unoccupied beds in ICU
for RED patients, 13 for YELLOW patients and 10 for BLACK patients.
If St. Camillus Hospital were to receive more than 2 RED patients, the hospital would
then go to Level II of the Surge Capacity Matrix (see Worksheet 2) to see what rooms it
would then use for these additional RED patients. In this case, the hospital could utilize
either the 2 beds in PACU or the 5 beds on 3 West Rooms 301 - 315.
This Surge Capacity Matrix (see Worksheet 2) obviously is not “black-and-white” and
the nursing managers will need to meet periodically to evaluate bed availability and
decide which pre-designated, color-coded beds may best be used for which patients.
The following Surge Capacity Matrix (see Worksheet 2) provides guidance to St.
Camillus Hospital on how it will make unoccupied inpatient rooms available for a surge
of inpatient and also which surge capacity areas they will open first, based on the initial
estimate of patients that they have been told that they can expect.
Level I Incident (1- 10 surge patients expected): The hospital has available 25
unoccupied beds that can be used for a surge of inpatients. (This total is arrived
at by adding together all the numbers in parentheses: 2 RED beds, 13 YELLOW
beds and 10 BLACK beds.)
Level II Incident (11 – 25 surge patients expected): The hospital has available
28 unoccupied beds that can be used for a surge of inpatients and can open 10
surge capacity beds for a total of 38 surge capacity beds.
Level III Incident (26 – 50 surge patients expected): The hospital has available
31 unoccupied beds that can be used for a surge of inpatients and can open 25
surge capacity beds for a total of 56 surge capacity beds.
4-4
Level IV Incident (51 – 100 surge patients expected): The hospital has
available 29 unoccupied beds that can be used for a surge of inpatients and can
open 75 surge capacity beds for a total of 104 surge capacity beds.
Level V Incident (>100 surge patients expected): The hospital has available 31
unoccupied beds that can be used for a surge of inpatients and can open 123 surge
capacity beds for a total of 154 surge capacity beds.
SURGE CAPACITY MATRIX
Note: The number in parenthesis indicates the number of beds usually unoccupied on any given day. The
number in BOLD indicates the number of surge capacity beds that can be deployed.
I
Number of
Patients
Expected
1 – 10
Rooms for
RED
Patients
ICU: Rooms
1 – 6 (2)
Rooms for
YELLOW
Patients
3 West: Rooms
301 – 345 (13)
Rooms for
BLACK
Patients
2 West: Rooms
201 – 235 (10)
II
11 – 25
ICU: Rooms
1 – 6 (2)
PACU: Beds
1 – 4 (2)
3 West: Rooms
301 – 315 (5)
3 West: Rooms
316 – 345 (9)
2 West: Rooms
201 – 235 (10)
Meeting Room A:
10 beds
III
26 – 50
ICU: Rooms
1 – 6 (2)
PACU: Beds
1 – 4 (2)
3 West: Rooms
301 – 325 (11)
3 West: Rooms
325 – 345 (6)
2 West: Rooms
201 – 235 (10)
3 West Atrium:
10 beds
Meeting Room A:
10 beds
PT Gym:
15 beds
IV
51 – 100
ICU: Rooms
1 – 6 (2)
PACU: Beds
1 – 4 (2)
3 West: Rooms
301 – 335 (11)
3 West: Rooms
336 – 345 (3)
2 West: Rooms
201 – 235 (11)
3 West Atrium:
10 beds
2 West Atrium:
10 beds
Sun Porch:
10 beds
Meeting Room A:
10 beds
PT Gym:
15 beds
Employee Lounge:
20 beds
Level
4-5
V
>100
ICU: Rooms
1 – 6 (2)
PACU: Beds
1 – 4 (2)
3 West: Rooms
301 – 345 (13)
3 West: Rooms
336 – 345 (3)
2 West: Rooms
201 – 235 (11)
3 West Atrium:
10 beds
2 West Atrium:
10 beds
Board Room:
20 beds
Sun Porch:
10 beds
Meeting Room A:
10 beds
PT Gym:
15 beds
Employee Lounge:
20 beds
Chapel:
8 beds
Endoscopy:
5 beds
Basement Meeting
Room:
15 beds
Cohorting Surge Patients
The Expert Panel has recommended that hospitals cohort surge capacity patients rather
than spread them out through the hospital, based on which beds are unoccupied. This
cohorting will also be necessary for pediatric and adolescent patients. For example, the
following is the surge capacity availability for St. Camillus Hospital for a Level II
Incident:
Level
II
Number of
Patients
Expected
11 – 25
Rooms for
RED
Patients
ICU: Rooms
1 – 6 (2)
PACU: Beds
1 – 4 (2)
3 West: Rooms
301 – 315 (5)
Rooms for
YELLOW
Patients
3 West: Rooms
316 – 345 (9)
2 West: Rooms
201 – 235 (10)
Rooms for
BLACK
Patients
Meeting Room A:
10 beds
If the hospital receives 15 RED patients, it may want to move the existing patients from
the 3 West Rooms 301 – 315 to 3 West Rooms 316 – 345 so that RED patients can be
cohorted on 3 West Rooms 301 - 315. This cohorting will allow for better patient care for
both existing and surge patients. The same cohorting should occur for YELLOW patients.
4-6
Summary of Surge Capacity Beds
Another way to display this Surge Capacity Matrix (see Worksheet 2) is to simply list
the potential numbers of inpatient surge capacity beds by color-coded area to more easily
see the number of surge beds available for each patient type. According to this Surge
Capacity Summary (see Worksheet 3), St. Camillus does not have a good availability of
surge beds for RED patients. Thus, the hospital knows that it may need to use beds,
designated for YELLOW patients as treatment rooms for RED patients.
Please note that in this Surge Capacity Summary (see Worksheet 3), the numbers in the
columns should not be added. Rather, the numbers in each row are totaled to indicate the
number of surge patients that can be accommodated in each Level.
SURGE CAPACITY SUMMARY
I
Number of
Patients Expected
1 – 10
RED
Rooms
2
YELLOW
Rooms
13
BLACK
Rooms
10
II
11 – 25
9
19
10
III
26 – 50
15
26
25
IV
51 – 100
15
44
45
V
>100
17
64
73
Level
4-7
St. Camillus Hospital Surge Support Area Matrix
St. Camillus Hospital has also pre-designated areas that will be used for other purposes
such as waiting areas for family and friends, counseling areas, rest areas. The following
Surge Support Area Matrix (see Worksheet 4) provides a plan for designating rooms or
areas for such purposes. It shows which rooms will be used as the Level of Incident
increases.
Note: The support areas suggested in this Surge Support Area Matrix (see Worksheet 4)
are for exemplary purposes only and the list of support areas needed is not intended to be
inclusive:
SURGE SUPPORT AREA MATRIX
Room/Area
Family
Waiting
Level II
3 West Waiting
Room
Level III
Meeting
Room 5
Level IV
Meeting
Room 6
Counseling
Chaplain’s
Office
Discharge
Planning Office
Rest Area
(with cots)
2 West Waiting
Room
Medical Library
Administrative
Conference
Room
Medical Library
Hallway
Media
Physical
Therapy Office
Radiology
Conference
Room
Physical
Therapy Gym
EMS Garage
EMS/Law
Break Room
Child Care
Physical
Therapy Gym
Physical
Therapy Gym
Level V
High School
Neurology Lab
Emmanuel
Lutheran
Church Hall
Other essential room needs will be holding areas for patients that may have been early
discharged, who are waiting to be picked up. A surge of GREEN patients at the hospitals
or at alternative outpatient treatment sites may also need a holding area where they can
wait before they are cared for.
4-8
5.
Inpatient Units for Special Consideration
There are a number of inpatient areas that are not clinically suited for surge capacity use.
The following list is not to be considered as inclusive and each hospital will need identify
the areas that may not be suitable for surge capacity use.
OB is recommended to be considered as a “clean” unit (no infectious patients should be
placed in OB), but may be filled with other “clean” patients only as a last resort.
However, some OB rooms also should be held for new deliveries. It is not recommended
to count OB as potential surge capacity areas, since its use will be limited and any
available OB beds may need to be used for “normal sick and injured” female patients.
Any unit that is used for immuno-suppressed patients should be treated in the same way
as the OB unit and thus should not be counted as inpatient surge capacity beds.
PEDS beds that have smaller sized beds or cribs should be counted as potential inpatient
surge capacity beds, but only for PEDS patients.
Nursery beds are not to be considered as potential inpatient surge capacity beds even for
infants, since these beds are used only for neonates <28 days. If an infant with an
infectious disease or with trauma is brought in, the infant is to be placed in PEDS.
5-1
6.
Criteria for an Inpatient Surge Capacity Bed
The May 2004 Exercise documented that hospitals have physically available on-site a
limited number of beds that can be used when inpatient surge capacity areas are opened.
The question was raised in the exercise as to what can be used for a surge capacity “bed”.
The following criteria were developed by the Expert Panel to identify what should
qualify for a surge capacity “bed”:
1.
2.
3.
4.
the bed provides for full horizontal (head to toe) support of a patient
the bed has protective mechanisms such as litter straps or side rails
the bed is at working level height
the bed is designed to be moved by carry or by wheel. (Limited staff
availability to move the “bed” is also to be considered when evaluating
whether a “bed” can be used for inpatient surge capacity)*
5. the bed has the capability to hang an IV (if this capability is not available on
the bed, the hospital must have options to hang the IV (ceiling hooks, etc.) in
the surge capacity area.
*Note: Beds that are heavy or not easily moved can be used for BLACK patients,
since these beds are not likely to be moved.
6-1
7.
State Stockpile of Inpatient Surge Capacity Beds
A panel of experts (Infection Control, Ergonomics, Laundry, Pressure Mapping, Physical
Therapy) investigated an “army style cot” for use as a surge capacity bed. Various
recommendations were made to the manufacturer, resulting in the surge capacity cots that
are have been made available to hospitals:
a.
b.
c.
d.
e.
f.
the “army style” cot was 18 inches in height; it was raised to “24” to mimic
normal bed height and to allow a patient more easily to lift him/herself out of
the bed with his/her feet
the “army style” cot was 24” in width; it was widened to 34” to allow a patient
to roll on his/her side and to increase overall comfort
the “army style” cot had fabric that can easily be cleaned with normal hospital
cleaning supplies; no changes were recommended
the “army style” cot had construction and fabric with identified “pressure
areas” that could result in an immobile patient acquiring bed sores; inflatable
mattresses will be purchased as an adjunct to the cot;
the “army style” cot had no IV pole; a tethered IV pole 18” in height was
added to the cot
the “army style” cot came with a pocket that hangs from the side of the cot
that can contain patient personal items and also hold a patient chart/clipboard
An initial supply of 2,600 cots is to be pre-positioned at hospitals.
It is also planned to have an additional stockpile of these cots,
stored in trailers that can be brought to the hospital(s),
requesting additional surge beds.
7-1
8.
Patient Care Staffing for Inpatient Surge Capacity Areas
The Surge Capacity Matrix (see Worksheet 2) can also to be used as a tool to determine
the staff needed for these inpatient surge capacity beds.
Hospitals are to plan for staffing for the first 72 hours of a traumatic incident. It is felt
that in the first 72 hours of a traumatic incident, especially if other hospitals are involved,
there will not be the ability to call upon other organizations for assistance or to begin to
recruit volunteers to assist, given the time necessary to implement these processes.
A hospital will need “to do what it must do” to manage the surge of patients that comes to
the hospital. Given the human resource problems that hospitals face in filling existing
positions in “normal” times, there is no “surplus labor pool” in the community that the
hospital can easily draw upon.
For example, the state volunteer registry has over 1,100 registered volunteers. Of these
registered volunteers about 20% are RNS, 15 % LPNs and 1% are physicians. The
majority of these registered volunteers are already employed at various health care
organizations and may not be available for service, since they may be needed by their
own facility.
Staffing Strategy
Given the fact that, especially in the first 72 hours, there will be limited additional staff,
the Expert Panel has recommended the consideration of the following staffing strategies:
Strategy One: staffing ratios will need to be adapted to the need. Each of the colorcoded patient categories will require different staffing ratios.
Strategy Two: 8 hour shifts may be changed to 12 hour shifts
Strategy Three: work tasks are to be prioritized so that only essential patient care
tasks are provided by staff. (see Appendix E: Prioritization of Patient Care Tasks)
Strategy Four: hospitals are to consider using family members for certain tasks such
as bathing and feeding the patient
Strategy Five: the hospital can put out a call through the media for volunteer health
care workers
In regard to Strategy Five, although the hospital may consider a campaign to recruit
additional healthcare workers in an incident, this will be a service provided by the local
or state Emergency Operations Center (EOC), if the EOC is activated. Wisconsin
Disaster Credentialing (WDC) is a web-based process for the credentialing and
privileging of volunteer healthcare workers that is available to hospitals.
8-1
Assignment of Staff to Color-Coded Beds
In a surge incident, it is most likely that the hospital will not have the right mix of RNs,
LPNs and Nurse Assistants and other staff and will need to assign available staff and
volunteers to the color-coded beds, based on the skills sets that they possess. The Expert
Panel has recommended the following minimum skill sets that staff are to have in order
to provide patient care, based the color-coded designation of the patient:
1. Staff skills necessary to care for RED patients: These are to be staff or volunteers,
who are acute care RNs and Residents, who can perform primary and secondary
assessment of critical care patients. The hospital can also use acute care LPNs,
technicians, PCAs and student nurses to assist these RNs and Residents; this will
allow for increased productivity of these RNs and Residents.
2. Staff skills necessary to care for YELLOW patients: These are to be staff or
volunteers, who are RNs and LPNs, who can perform initial and on-going assessment
of patients and who are presently employed either in acute care settings or in nonhospital work sites.
3. Staff skills necessary to care for BLACK patients: These are to be staff or volunteers,
who are comfortable with death and dying, such as:
a.
b.
c.
d.
e.
f.
hospice volunteers
clergy
social workers
retired Health Care Workers
hospital volunteers
members of service organizations
It will be necessary to have a RN supervisor and Team Leader in each area to assess
these staff, their skills and their stress and rehabilitation needs.
Staffing Ratios
It will be very difficult to plan for staffing these areas, given existing staffing shortages in
most hospital in most areas. The following suggested ratios are meant only to give the
hospital an estimated number of staff that it will need for planning purposes:
Note: The higher ratio may be used if the patients are cohorted.
8-2
STAFFING RATIOS FOR SURGE CAPACITY MATRIX
I
Number of
Patients
Expected
1 – 10
Patient Care
Staff Ratios for
RED beds
Existing Staff
Patient Care Staff
Ratios for
YELLOW beds
Existing Staff
Patient Care Staff
Ratios for
BLACK beds
Existing Staff
II
11 – 25
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
III
26 – 50
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
IV
51 – 100
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
V
>100
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
Level
The above ratios assume that nurses and other care givers are providing only essential
patient care services. The ratios also will vary based on the acuity of the patients.
For example, based on these ratios, the hospital can estimate that if it is to be receiving 10
RED patients, it will need 5 RNs (1:2 ratio); if it is receiving 20 YELLOW patients, it
will need 4 RNs (1:5 ratio).
The hospital needs to consider at what point it can no longer accept other patients. The
best indicator of this threshold may be the physical and emotional status of the staff as
they manage this surge.
Job Action Sheets
The hospital is to have Job Action Sheets (see Appendix F) for each of the color-coded
areas, detailing the responsibilities that the staff are to carry out. In addition, these Job
Action Sheets are to detail the location of supplies, ancillary services and other such
information so that those HCWs, who may be unfamiliar with the particular area, have
available this information on where they can find supplies and equipment.
Managing the Continuum of Care after the Initial Surge of Inpatients
The categorization of rooms as RED, YELLOW and BLACK will assist the hospital with
initially receiving patients from the field. This initial period may last for approximately
24 hours. As patients are received and retriaged, it becomes more necessary to plan for
housing these patients, based on their acuity. It is suggested that the color-coded rooms
TRANSITION to your traditional hospital terminology. On the Transition Matrix (see
Worksheet 6) below, each hospital will use the terminology for beds that is common at
that hospital.
8-3
TRANSITION MATRIX
Beds: First 24 Hours
RED
Beds: > 24 Hours
Critical Care
YELLOW
Monitored Intermediate Care
YELLOW/BLACK
Medical/Surgical Care
Secondary Surge
It is very likely that the hospital will experience a secondary surge in inpatients 24 hours
or more after the initial surge, caused by the incident. This may be due to some GREEN
patients, who present with their illness/injury exacerbating, causing them to seek help at
the hospital. The “normal sick and injured” will continue to present to the hospital. Some
patients, who may have delayed presenting at the hospital, may now present, thinking that
the “surge” is over.
In addition, the hospital should consider that the patient length of stay will most likely
increase due to the lack of resources to care for patients according to the “normal”
protocols. Services such as surgery and the ancillaries may be fully “booked”, caring for
the surge of patients and thus patients may need to wait for these services.
It is recommended, in a surge capacity incident, that a Medical Staff Admissions
Committee be formed on an ad hoc basis to assist physicians in determining whether or
not certain patients need to be admitted. Some physicians may be reluctant to have the
admission of their patients delayed and will need the support of both hospital
administration and their physician peers to understand that the delay of admission of their
patient(s) is medically appropriate under these surge conditions.
8-4
Discharge Planning and Case Management
In the first 24 hours, these professionals may be concerned with “bed emptying”
strategies.
The role of these professionals becomes even more critical >24 hours after the incident as
they assist in the management of the inpatients, involved in the surge incident. They will
need to present options to physicians to assist in the management of these inpatients and
discharge them as soon as it is medically appropriate.
It is recommended, in a surge capacity incident, that a Medical Staff Discharge
Committee be formed on an ad hoc basis to assist physicians in the discharge of their
patients. Some physicians may be reluctant to have their patients early discharged and
will need the support of both hospital administration and their physician peers to
understand that the discharge of their patient(s) is medically appropriate under these
surge conditions.
It is also recommended that these professionals develop Job Action Sheets for other
person, who may be called upon to assist with the discharge process. Having “checklists”
prepared may assist with “just-in-time” training for those called upon to assist with the
discharge process.
8-5
9.
Ancillary Care Staffing for Inpatient Surge Capacity Areas
As it is essential for the hospital to have a plan and a strategy to have staff to provide
patient care in the inpatient surge capacity areas, it is equally important that each
ancillary department also have a plan and a strategy to have the staff and supplies
necessary to support these inpatient surge capacity areas. The Ancillary Support Matrix
(see Worksheet 7) can also be used as a tool for this purpose with each department
completing the Ancillary Support Matrix (see Worksheet 7).
Ancillary services are to consider not only the staffing necessary to care for patients and
staff, but also the staffing necessary to care for additional family members and visitors,
who may come to the hospital with the surge of inpatients. The following ancillary
departments are to complete their staffing plans and strategies (the list is an example only
and is not intended to be inclusive):













Housekeeping
Food Services
Security
Radiology
Laboratory
Admissions
Billing
Medical Records
Pastoral Care
Transport Services
Day Surgery
Chemotherapy
Dialysis
9-1
ANCILLARY SUPPORT MATRIX
I
Number of
Patients
Expected
1 – 10
II
11 – 25
III
26 – 50
IV
51 – 100
V
>100
Level
Housekeeping
Staff for
RED rooms
Existing Staff
Housekeeping
Staff for
YELLOW rooms
Existing Staff
Housekeeping
Staff for
BLACK rooms
Existing Staff
ANCILLARY SUPPORT MATRIX
I
Number of
Patients
Expected
1 – 10
II
11 – 25
III
26 – 50
IV
51 – 100
V
>100
Level
Food Services
Staff for
RED rooms
Existing Staff
Food Services
Staff for
YELLOW rooms
Existing Staff
Food Services
Staff for
BLACK rooms
Existing Staff
Each department is to complete its own Ancillary Support Matrix (see Worksheet 7).
Departments and functions, however, are to collaborate to determine which staff can be
pulled from other departments to assist with these functions so that departments do not
identify and depend upon the same staff.
9-2
10.
Staff Support Considerations
The following are other issues that the hospital is to consider for its staffing plans and
strategies. The hospital should consider the formation of Staff Disaster Support
Committee or have its Human Resources Department pre-plan for the following (the list
is not intended to be inclusive):
1. Some staff will not be able to report to work due to the fact that they or their
loved ones may have been directly involved in the incident. There should be a
policy to address these absences and also some strategies to provide support to
these employees.
2. Some staff will refuse to report to work due to concerns about their own and their
family members’ safety and health. In the case of a biological incident, they may
have fear of contracting the disease or bringing the disease home. There should be
a policy to address these absences and also some strategies to provide support and
or options to these employees.
3. Many staff will have concerns about childcare. The normal childcare provider
may not be able to provide these services in an incident. These same concerns
apply to staff, who may be caring for their parents or others. There should be
options available for childcare/eldercare so that staff are free to report to work.
4. Some staff may have concerns about the shelter and care of their pets.
5. The hospital is to consider the provision of rooms for staff for rest and sleep and
for personal hygiene needs (blankets, pillows, sheets, showers, towels, soap,
shampoo, etc.). In the case of a biological incident, there may be the
implementation of work quarantine in addition to staff working longer shifts or
not being able to go home. The hospital may also want to consider what is
available in local hotels, churches, and other such organizations for sleeping
accommodations and showers.
6. The hospital is to consider areas for staff to eat and have refreshments
7. Staff may be away from home for extended shifts and need to communicate with
family members and other loved ones. The hospital is to consider the availability
of telephones to call home and computer access for email.
8. For staff working extended shifts or not going home, there may be the need for
laundry services or the provision of scrubs. Staff are also to consider having an
“Emergency Kit” with personal items such as underwear, socks, toiletries, a
supply of medications, etc. readily available so that this “Kit” is readily available.
10-1
9. Staff are to also have a “Family Plan” so that everyone in the family knows what
will need to happen and who is responsible for various duties if a family member,
who works at the hospital, needs to work longer shifts or is quarantined at the
hospital.
10. The hospital should also give consideration for back-up of essential services such
as food services, laundry, housekeeping and other services, especially if these
services are out-sourced and the incident affects the ability of the contractor to
continue to provide these services and if the surge of patients and visitors
overwhelms the capacity of these contractors.
11. Most hospitals use “calling trees” to notify staff. The hospital is to consider a
back-up system for notifying staff should the telephone lines be down or the
circuits busy.
12. The hospital is to consider pre-identifying staff persons, who will manage and
supervise volunteers and in which areas or departments the hospital is likely to
utilize volunteers.
13. The hospital is also to consider that there may not be sufficient managers to
supervise the staff in the surge capacity areas.
14. With staff being asked to work in the surge capacity areas, work in these areas
may not necessarily involve their normal work responsibilities. It is suggested that
Job Action sheets be available for all positions in the RED, YELLOW and
BLACK surge capacity areas so that staff can receive “just-in-time” training by
reading the Job Action Sheets.
10-2
11.
Equipment and Supplies
The inpatient surge capacity areas demand not only the availability of additional staff and
beds. Each surge capacity areas will also needed the equipment and supplies necessary to
deploy these beds. The hospital needs to determine the amount of equipment that will be
needed in the area and how this equipment can be obtained for each Incident Level. This
list will include such critical equipment as (the list is not intended to be inclusive):













Crash carts
IV pumps
Defibrillators
Portable suction
Syringe pumps
Portable oxygen
Ventilators
Blood
PCA pumps
Commodes
Privacy Screens
Pressure infusers
Warming devices
The following are key issues that the hospital is to consider when developing its list of
equipment:
1.
The hospital is to estimate the amount of equipment that will be needed for
each color-coded area, tiered for each Incident Level.
2.
The hospital is to consider equipment needs for both adult and pediatric
patients.
3.
The hospital or its Material Management Director is to identify where this
equipment is located in relation to the surge capacity areas so that staff not
familiar with equipment location can know where to obtain it, based on the
surge capacity area they are working in (see Equipment Location Matrix:
Worksheet 8).
11-1
EQUIPMENT LOCATION MATRIX
Surge Area:
Critical Equipment
Crash carts
IV pumps
Defibrillators
Portable suction
Syringe pumps
Portable oxygen
Ventilators
Blood
PCA pumps
Commodes
Privacy Screens
Pressure infusers
Warming devices
Location
4.
The hospital is to consider what can be used as an alternative if particular
equipment is not available.
5.
The hospital or its Materials Management Director is to determine the
potential source(s) of where this equipment can be obtained (see Equipment
Source Matrix: Worksheet 9). This list should include not only suppliers and
vendors, but also local clinics, nursing homes, etc. that may be sources of this
equipment.
EQUIPMENT SOURCE MATRIX
Critical Equipment
Crash carts
IV pumps
Defibrillators
Portable suction
Syringe pumps
Portable oxygen
Ventilators
Blood
PCA pumps
Commodes
Privacy Screens
Pressure infusers
Warming devices
Source
11-2
6.
The hospital is also to identify the electrical power available in these surge
capacity areas. Rooms that will be powered by emergency power need to be
prioritized for RED patients, since these are the most likely patients to be
using electrical equipment. Although not included on the equipment list, the
hospital is to have flashlights or other battery-powered light sources that may
need to be used in those areas that will not have emergency power.
Special Note on Crash Carts: Staff are to determine where these crash carts will be
placed when inpatient surge capacity is activated. It is recommended that placement of
these crash carts is based on the concentration of patient population versus distance. The
hospital may also want to consider bringing in Automatic Electronic Defibrillators
(AEDs) from the community as an optional supply source. Thus, the hospital may
consider maintaining an inventory of where in the community these AEDs are maintained
and note this on the Equipment Source Matrix (see Worksheet 9).
Crash Cart Supplies from the ChemPacks: Medications and supplies on the crash carts
may be quickly depleted. Although AEDs may be utilized, AEDs do not come with
medications or supplies. The State has a cache of nerve agents antidotes (ChemPacks).
These caches contain atropine and other medications that may be accessed. Appendix G:
Medication in ChemPacks lists the medications and supplies that are included in the
ChemPacks. Appendix H: Accessing the ChemPacks provides instructions on how
these ChemPack caches may be accessed
Critical Supply Inventory
The hospital is to estimate the amount of supplies needed on the Critical Supply
Inventory Matrix (see Worksheet 10). The Critical Supply Inventory Matrix (see
Worksheet 10) is a tool to help the hospital determine the amount of supplies that may
be needed, based on the maximum number of patients that it can accept.
Instructions for Completing the Critical Supply Inventory Matrix (see Worksheet 10):
1.
Identify the maximum number of patients that the hospital can accept by
referring to the Surge Capacity Matrix (see Worksheet 2). (In the example
of St. Camillus Hospital, their maximum number of patients is 17 RED
patients, 64 YELLOW patients and 73 BLACK patients.)
2.
This maximum number provides the hospital with a number to use when
estimating the amount of supplies needed. This will help in comparing
what is in normal inventory as compared to what may be needed and
where these additional supplies can be obtained.
3.
The hospital should estimate the amount of supplies based on a 72 hour
period. After this time, there may be other resources available to help the
hospital replenish its resources.
11-3
4.
The hospital can add to or delete supplies from this list. For example
stethoscopes are items that may be needed.
5.
IMPORTANT: The hospital is to begin rationing and triaging of
supplies immediately when the surge capacity plan is implemented.
The process for requesting additional supplies is also to begin
immediately upon activation of the surge capacity plan. (see Appendix
I: Rationing of Supplies. For example, rationing may begin by not using
IV solutions for patients that can take oral fluids by mouth.
CRITICAL SUPPLY INVENTORY
Maximum Number of RED Patients
(X)
Maximum Number of YELLOW Patients
(X)
11-4
Critical Supply Inventory
(X) IV tubing
(X) IV start supplies
(X) IV fluids
(X) medicines
(X) bed pans/urinals
(X) needles/syringes
(X) catheters
(X) dressings
(X) linens
(X) alcohol wipes
(X) tape
(X) hand sanitizer
(X) PPE
(X) OB delivery supplies
(X) casting supplies
Critical Supply Inventory
(X) IV tubing
(X) IV start supplies
(X) IV fluids
(X) medicines
(X) bed pans/urinals
(X) needles/syringes
(X) catheters
(X) dressings
(X) linens
(X) alcohol wipes
(X) tape
(X) hand sanitizer
(X) PPE
(X) OB delivery supplies
(X) casting supplies
Maximum Number of BLACK Patients
(X)
Critical Supply Inventory
(X) IV tubing
(X) IV start supplies
(X) IV fluids
(X) medicines
(X) bed pans/urinals
(X) needles/syringes
(X) catheters
(X) dressings
(X) linens
(X) alcohol wipes
(X) tape
(X) hand sanitizer
(X) PPE
(X) OB delivery supplies
(X) casting supplies
The hospital or its Materials Management Director is to determine the potential source(s)
of where these supplies can be obtained (see Supply Source Matrix below). This list
should include not only suppliers and vendors, but also local clinics, nursing homes, etc.
that may be sources of this equipment.
SUPPLY SOURCE MATRIX
Critical Supplies
IV tubing
IV start supplies
IV fluids
Medications
Bed pans/urinals
Needles/syringes
Catheters
Dressings
Linens
Alcohol wipes
Tape
Hand sanitizer
PPE
OB delivery supplies
Casting supplies
Source
Special Note on Supply Inventory: It will be very difficult to list all the various supplies
that will be needed such as syringes, sponges, etc. The hospital is to have a process in
place with its vendors for the immediate ordering of additional supplies. “Just-in-Time”
inventories may cause problems in a surge capacity situation.
11-5
The goal is for the hospital to be self-sufficient for the first 72 hours.
The Materials Management Director is to discuss with the vendor/supplier the back-up
plan or Business Continuity Plan of the supplier/vendor, should the operations of the
supplier/vendor also be affected.
Memoranda of Understanding: All hospitals in the state have signed a Memorandum of
Understanding (MOU), declaring their willingness to share staff, equipment and supplies
with other hospitals. If the Emergency Operations Center in the jurisdiction has been
activated, the hospital can call upon the EOC to assist in procuring needed supplies. The
EOC Hospital Liaison will be available to assist the hospital Logistics Section Chief in
the procuring of needed supplies and equipment.
PPE Stockpiles: Each hospital, through the HRSA Cooperative Agreement, has received
increased inventories of PPE for use in an incident, involving infectious disease. The
State of Wisconsin also has stockpiled additional PPE that can be accessed by hospitals.
Appendix J: Access to Personal Protective Equipment lists the PPE that is stockpiled
and the protocol for accessing these stockpiles.
Strategic National Stockpile/Vendor Managed Inventory: In an incident that has been
declared a disaster by the Governor, the Strategic National Stockpile (SNS) will arrive in
the state within 12 hours of notification of the Centers of Disease Control (CDC) by the
state.
The SNS is a national repository of antibiotics, chemical antidotes, antitoxins, lifesupport medications, IV administration, airway maintenance supplies, and
medical/surgical items. The SNS is designed to supplement and re-supply state and local
public health agencies in the event of a national emergency anywhere and at anytime
within the U.S. or its territories.
The SNS is organized for flexible response. The first line of support lies within the
immediate response 12-hour Push Packages. These are caches of pharmaceuticals,
antidotes, and medical supplies designed to provide rapid delivery of a broad spectrum of
assets for an ill defined threat in the early hours of an event. These Push Packages are
positioned in strategically located, secure warehouses ready for immediate deployment to
a designated site within 12 hours of the federal decision to deploy SNS assets.
If the incident requires additional pharmaceuticals and/or medical supplies, follow-on
vendor managed inventory (VMI) supplies will be shipped to arrive within 24 to 36
hours. If the agent is well defined, VMI can be tailored to provide pharmaceuticals,
supplies and/or products specific to the suspected or confirmed agent(s). In this case, the
VMI could act as the first option for immediate response from the SNS Program.
Appendix K: Strategic National Stockpile List of Assets lists the equipment, supplies
and medications that are included with the SNS.
11-6
12.
Triage Center
The hospital is to consider the deployment of a triage center separate from the ER so as to
maintain an easy, unobstructed access for patients, being transported by ambulance to the
hospital. GREEN patients will be sent to alternative outpatient treatment centers for care
and treatment. Only RED, YELLOW and BLACK patients will be treated within the
hospital.
The purpose of the Triage Center is to manage walk-in patients, who present to the
hospital. It is expected that Transport Ambulances will notify the hospital prior to
transport and no later than en route of the number of RED, YELLOW and BLACK
patients that are being transported so that these patients can be taken directly to the ER.
This same “alert” protocol to the hospital is to apply to the “normal sick and injured”,
who are being transported to the hospital by the Transport Ambulance.
Criteria for the Triage Center include:
1. sufficiently distant from the ED entrance and ambulance driveway so as not to
congest the ED area
2. located on the hospital campus or in close proximity to the hospital campus
3. climate-controlled area
4. allow for unobstructed transport of patients by gurney or wheelchair from the
Triage Center to the hospital
5. (for infectious disease incidents) HVAC is separate from the hospital HVAC
system
6. communications capability with the hospital, especially ED, Nursing, and
Admissions
7. ability to lock down the Triage Center
It is important for the hospital to pre-identify this Triage Area and also to pre-identify
staff by function, which will staff this area when it is deployed. It is also advisable to
have Job Action Sheets for the persons, who will staff the Triage Center.
Note: Most hospital have received a portable decontamination shelter that has the
potential to be used as a Triage Center under certain weather conditions.
Decontamination: Special consideration will need to be given to the decontamination of
patients, if the incident calls for decontamination. If the hospital has a fixed
decontamination room, there will need to be a plan for the flow and holding of patients, if
there are large numbers of patients in need of decontamination. If the hospital has a
portable decontamination shelter, then consideration needs to be given as to its placement
relative to the Triage Center.
12-1
13.
Outpatient Surge Capacity
Each hospital is to have a plan whereby it can direct GREEN patients for care and
treatment. Hospitals in a surge incident will be overwhelmed, especially the Emergency
Department. The hospital will be challenged with the management of RED, YELLOW
and BLACK patients. It is expected that GREEN patients will be directed from the field
and through the media to go to Alternative Outpatient Treatment Sites. Various outpatient
centers such as physician offices, clinics and Urgent Care Centers are to be identified as
Alternative Outpatient Treatment Sites.
It is anticipated that the physicians and their staff, who normally work in these outpatient
centers, will be able to staff these areas. It is assumed that
1. these Alternative Outpatient Treatment Sites will need to be relatively close to the
Triage Center
2. that the physicians and staff will have training on the deployment of their office as
an Alternative Outpatient Treatment Site
3. that the physicians will bill for their services
4. that these offices will have limited supplies and equipment and a plan for
supplying and resupplying these Alternative Outpatient Treatment Sites needs to
be addressed
5. that these sites will serve not only the victims of the incident, but also the GREEN
“normal sick and injured”, who will not be able to be treated in the ED
The plan, to be developed in collaboration with the hospital and the physicians and staff
of these outpatient centers, is to include protocols to deploy these Alternative Outpatient
Treatment Sites after business hours and on weekends and holidays and also for extended
periods of time (as long as there are patients in need of care).
Critical to the success of the deployment of these alternative outpatient treatment sites
will be a system to call up the physicians and staff and notify them of the need to deploy
the site, especially outside normal business hours.
In some locations, there are no clinics or other suitable sites adjacent or near to the
hospital that can serve as these alternative outpatient treatment sites. In these cases, the
hospital swill need to determine which locations on campus can best be utilized as these
sites, since the goal is still to maintain the ED for RED and YELLOW patients.
Since GREEN patients will be directed to report to these sites from the “field” and will
also be redirected to these sites from the hospital, it is important that these sites be able to
become operational at the same time that the Triage Center becomes operational.
13-1
The Expert Panel recommends that the hospital have a Memorandum of Understanding
(MOU) with each clinic that will serve as an alternative outpatient treatment site. This
MOU is to spell out all the terms under which the clinic commits to serving as an
alternative outpatient treatment site. (see Appendix L: Template Memorandum of
Understanding)
The following Alternative Treatment Site Matrix (see Worksheet 12) can serve as a
planning tool to assist the hospital in determining what outpatient centers may serve as
alternative treatment sites for GREEN patients and also the “normal sick and injured”,
who do not need immediate ED care and treatment:
ALTERNATIVE TREATMENT SITE MATRIX
Type of
Patient/Injury/Illness
Pediatric Patients
Name and Location of Outpatient Center
OB Patients
Lacerations
Broken Bones
Patients in Need of Medical
Evaluation
Cardiac Symptoms
Psychiatry
Other
13-2
14.
Exercise
It is necessary for the hospital to exercise for “Day 2” and “Day 3” of surge incident
scenarios. These exercises are to focus on physicians and staff, who are dealing with the
2nd wave of surge and its related problems such as strain on OR and ancillary services,
the need to discharge patients, stress of staffing.
These exercises should also consider other service areas such as housekeeping, laundry,
food services and others, who are usually involved in a disaster drill through the “Labor
Pool.” In a surge incident, these staff will also be stressed and overwhelmed as they deal
with a surge of not only patients but also of the family members and visitors, who
accompany the patients. For example, Food Services may see a 200% or even 300%
increase in the cafeteria lines due to staff working longer shifts and an increased number
of visitors.
Each department is to exercise its own department surge capacity plan at least annually so
that the specific department can focus on the issues that it will face.
The exercise should also include discussion regarding the standard of care and how this
will need to be adjusted. A mass casualty incident will result in a severe mismatch
between “Patient Needs” and “Hospital Resources”. Thus, there may be a need to limit
care, based on the principle of “the greatest good for the greatest number.” Most health
care workers have not been faced with the situation where they will need to limit care for
patients. This may become a necessity in an incident that produces a surge of patients.
The Expert Panel recommends that the hospital look at exercising its surge capacity with
its lowest level of staffing (usually during the third shift or using the third shift staffing
levels as a proxy) to determine how well this surge of patents can be managed with these
limited resources.
14-1
15.
Off-Site Alternative Inpatient Treatment Centers
The State Expert Panel has recommended the implementation of this in-house inpatient
surge capacity plan versus the use of Off-Site Alternative Inpatient Treatment Centers.
The logistics involved with these alternative inpatient treatment sites are daunting and the
hospital may be better able to manage a surge on-site despite the challenges that this will
present to the hospital.
However, there is the scenario where the hospital has surpassed even its own in-house
surge capacity and can no longer accept further inpatients. In addition, there may be the
scenario where the hospital, itself, is damaged wholly or in part and may need to move its
services off-site.
The options in both of the above scenarios will be to transport patients from the “field” to
other hospitals or from the damaged hospitals to other hospitals. If either of these
scenarios occurs, it is likely then that the local or state EOC has been activated and this
EOC will able to serve as a resource to the affected hospitals.
15-1
16.
Risk Communications
Even with the deployment of in-house surge capacity and the deployment of alternative
outpatient treatment sites, these facilities may still be overwhelmed. Risk
Communications are then to be employed for the following purposes:
1. instructions on how to prevent transmission of the disease
2. instructions on quarantine and isolation
3. instructions on home-care for yourself and/or for your family members,
who are ill
4. instructions on what the indications are to seek care at the Physician’s
Office
5. instructions on what the indications are to seek care at the hospital
The purpose of these Risk Communications is to keep hospitals, Urgent Care Centers and
Physicians’ Offices and Clinics open only for those who can truly benefit from these
services.
It will be important to begin Risk Communications at the onset of the incident so as not
to overwhelm the hospitals and other treatment sites.
16-1
17.
Business Continuity Plan
A sustained disaster incident that takes place over days and even weeks will have serious
effects on the business operations of the hospital. Although initially all staff may be
called upon to help with patient care in some way, after a very short time, there is the
necessity to continue with essential business operations such as medical records, billing,
coding, etc. Each hospital department is to consider the effects of a sustained disaster on
its operations and determine how it will carry out essential functions with limited
resources in a sustained disaster.
17-1
18.
Guidelines for Completing Your Hospital Surge Capacity Plan
18-1
Appendices
Appendix A:
HRSA Hospital Disaster Preparedness Regions
Duluth
Bayfield
Douglas
Iron
Ashlan
d
Washburn
Pol
k
Twin
Cities
St. Croix
Pric
e
Sawye
r
Burnett
Barron
Dunn
Vilas
Florence
Onied
a
Rus
k
Forest
Marinette
Lincoln
Langlade
Taylo
r
Chippewa
Menomonee
Marathon
Clark
Pierce
Pepin
Buffalo
Oconto
Oconto
Door
Shawano
Eau Claire
Portage
Trempealeau
Adams
Junea
u
Vernon
Sau
k
Richlan
d
Gree
Marquette n
Lake
Dodg
e
Columbia
Gree
n
Sheboyga
n
Fond du Lac
Ozauke
e
Washington
Jefferson
Iowa
La
Fayette
Calumet
Waushara
Dan
e
Gran
t
Kewaune
e
Manitowoc
Winnebago
Monro
e
Crawford
Outagamie Brown
Outagamie
Wood
Jackso
n
La
Crosse
Waupaca
Rock
Rockford
Appendix A-1
Waukesha
Walworth
Milwauke
e
Racin
e
Kenosha
Appendix B: START triage Algorithm
Appendix B-1
Appendix C: JumpSTART Triage Algorithm
Appendix C-1
Appendix D: Example of Hospital Surge Capacity
St. Camillus Hospital
Patient Care Units
M/S
ICU
PEDS
BURN
PSYCH
TOTAL
Staffed Beds
Available Beds
217
91
33
8
14
8
0
0
25
14
289
121
Surge Capacity
Bed Capacity
Available Beds
Beds Needed
Private
Rooms
0
0
0
Converted
Areas
189
84
105
Converted Areas Include:
Rehab
Bays 1- 5
Hallway
OP Surgery
PreOP
Surgery and Care Center
CPU
Endoscopy
Bay 6
Meeting Rooms/Waiting Rooms
TOTAL
189
84
105
# of Beds
3
40
10
24
7
32
5
13
25
30
Total:
189
Detail of Patient Care
Units
5SW
6W
3SW
1NW
4SW
3NW
37
13
15
4
35
11
26
16
37
11
31
10
OB
M/S
36
26
217
91
MICU
PICU
SICU
NICU
ICU
12
2
7
4
10
0
4
2
33
8
Appendix D-1
Appendix E: Prioritization of Patient Care Tasks
This Appendix is in development
Appendix E-1
Appendix F: Job Action Sheets
These Job Action Sheets are in development
Appendix F-1
Appendix G: Medications in ChemPacks
EMS CHEMPACK Container for 1000 Casualties
Mark 1 auto-injector
Atropine Sulfate 0.4mg/ml 20ml
Pralidoxime 1gm inj 20ml
Atropen 0.5 mg
Atropen 1.0 mg
Diazepam 5mg/ml auto-injector
Diazepam 5mg/ml vial, 10ml
Sterile water for injection (SWFI) 20cc Vials
Sensaphone® 2050
Satco B DEA Container
Unit Pack
Cases
QTY
240
100
276
144
144
150
25
100
1
11
1
1
2
2
4
4
3
1
2640
100
276
288
288
600
100
300
1
1
1
1
Hospital CHEMPACK Container for 1000 Casualties
Unit Pack
Cases
QTY
Mark 1 auto-injector
Atropine Sulfate 0.4mg/ml 20ml
Pralidoxime 1gm inj 20ml
Atropen 0.5 mg
Atropen 1.0 mg
Diazepam 5mg/ml auto-injector
Diazepam 5mg/ml vial, 10ml
240
100
276
144
144
150
25
2
9
10
1
1
1
26
480
900
2760
144
144
150
650
Sterile water for injection (SWFI) 20cc Vials
Sensaphone® 2050
100
1
23
1
2300
1
1
1
1
Satco B DEA Container
Appendix G-1
Appendix H: Accessing the ChemPacks
This Appendix is in development
Appendix H-1
Appendix I: Rationing of Supplies
This Appendix is in development
Appendix I-1
Appendix J: Access to Personal Protective Equipment
This Appendix is in development
Appendix J-1
Appendix K: Strategic National Stockpile List of Assets
Appendix K-1
Appendix L: Template Memorandum of Understanding
This Appendix is in development
Appendix L-1
Worksheets
Worksheet 1: Incident Level Matrix
INCIDENT LEVEL MATRIX
Incident Level
I
II
III
IV
V
Number of Patients Expected
1 – 10
11 – 25
26 – 50
51 – 100
>100
Worksheet 1-1
Worksheet 2: Surge Capacity Matrix
SURGE CAPACITY MATRIX
Note: The number in parenthesis indicates the number of beds usually unoccupied on any given day. The
number in BOLD indicates the number of surge capacity beds that can be deployed.
I
Number of
Patients
Expected
1 – 10
II
11 – 25
III
26 – 50
IV
51 – 100
V
>100
Level
Rooms for
RED
Patients
Worksheet 2-1
Rooms for
YELLOW
Patients
Rooms for
BLACK
Patients
Worksheet 3: Surge Capacity Summary
SURGE CAPACITY SUMMARY
I
Number of
Patients Expected
1 – 10
II
11 – 25
III
26 – 50
IV
51 – 100
V
>100
Level
RED
Rooms
Worksheet 3-1
YELLOW
Rooms
BLACK
Rooms
Worksheet 4: Surge Support Area Matrix
SURGE SUPPORT AREA MATRIX
Room/Area
Family
Waiting
Level II
Level III
Counseling
Rest Area
(with cots)
Media
EMS/Law
Break Room
Child Care
Worksheet 4-1
Level IV
Level V
Worksheet 5: Staffing Ratios for Surge Capacity Matrix
STAFFING RATIOS FOR SURGE CAPACITY MATRIX
I
Number of
Patients
Expected
1 – 10
Patient Care
Staff Ratios for
RED beds
Existing Staff
Patient Care Staff
Ratios for
YELLOW beds
Existing Staff
Patient Care Staff
Ratios for
BLACK beds
Existing Staff
II
11 – 25
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
III
26 – 50
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
IV
51 – 100
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
V
>100
1:2 to 1:4
1:5 to 1:12
1:10 to 1:16
Level
Worksheet 5-1
Worksheet 6: Transition Matrix
TRANSITION MATRIX
Beds: First 24 Hours
RED
Beds: > 24 Hours
Critical Care
YELLOW
Monitored Intermediate Care
YELLOW/BLACK
Medical/Surgical Care
Worksheet 6-1
Worksheet 7: Ancillary Support Matrix
ANCILLARY SUPPORT MATRIX
I
Number of
Patients
Expected
1 – 10
II
11 – 25
III
26 – 50
IV
51 – 100
V
>100
Level
Housekeeping
Staff for
RED rooms
Existing Staff
Housekeeping
Staff for
YELLOW rooms
Existing Staff
Housekeeping
Staff for
BLACK rooms
Existing Staff
ANCILLARY SUPPORT MATRIX
I
Number of
Patients
Expected
1 – 10
II
11 – 25
III
26 – 50
IV
51 – 100
V
>100
Level
Food Services
Staff for
RED rooms
Existing Staff
Food Services
Staff for
YELLOW rooms
Existing Staff
Worksheet 7-1
Food Services
Staff for
BLACK rooms
Existing Staff
Worksheet 8: Equipment Location Matrix
EQUIPMENT LOCATION MATRIX
Surge Area:
Critical Equipment
Crash carts
IV pumps
Defibrillators
Portable suction
Syringe pumps
Portable oxygen
Ventilators
Blood
PCA pumps
Commodes
Privacy Screens
Pressure infusers
Warming devices
Location
Worksheet 8-1
Worksheet 9: Equipment Source Matrix
EQUIPMENT SOURCE MATRIX
Critical Equipment
Crash carts
IV pumps
Defibrillators
Portable suction
Syringe pumps
Portable oxygen
Ventilators
Blood
PCA pumps
Commodes
Privacy Screens
Pressure infusers
Warming devices
Source
Worksheet 9-1
Worksheet 10: Critical Supply Inventory Matrix
CRITICAL SUPPLY INVENTORY
Maximum Number of RED Patients
(X)
Maximum Number of YELLOW Patients
(X)
10-1
Critical Supply Inventory
(X) IV tubing
(X) IV start supplies
(X) IV fluids
(X) medicines
(X) bed pans/urinals
(X) needles/syringes
(X) catheters
(X) dressings
(X) linens
(X) alcohol wipes
(X) tape
(X) hand sanitizer
(X) PPE
(X) OB delivery supplies
(X) casting supplies
Critical Supply Inventory
(X) IV tubing
(X) IV start supplies
(X) IV fluids
(X) medicines
(X) bed pans/urinals
(X) needles/syringes
(X) catheters
(X) dressings
(X) linens
(X) alcohol wipes
(X) tape
(X) hand sanitizer
(X) PPE
(X) OB delivery supplies
(X) casting supplies
Maximum Number of BLACK Patients
(X)
Critical Supply Inventory
(X) IV tubing
(X) IV start supplies
(X) IV fluids
(X) medicines
(X) bed pans/urinals
(X) needles/syringes
(X) catheters
(X) dressings
(X) linens
(X) alcohol wipes
(X) tape
(X) hand sanitizer
(X) PPE
(X) OB delivery supplies
(X) casting supplies
Worksheet 10-2
Worksheet 11: Critical Supply Source Matrix
SUPPLY SOURCE MATRIX
Critical Supplies
IV tubing
IV start supplies
IV fluids
Medications
Bed pans/urinals
Needles/syringes
Catheters
Dressings
Linens
Alcohol wipes
Tape
Hand sanitizer
PPE
OB delivery supplies
Casting supplies
Source
Worksheet 11-1
Worksheet 12: Alternative Treatment Site Matrix
ALTERNATIVE TREATMENT SITE MATRIX
Type of
Patient/Injury/Illness
Pediatric Patients
Name and Location of Outpatient Center
OB Patients
Lacerations
Broken Bones
Patients in Need of Medical
Evaluation
Cardiac Symptoms
Psychiatry
Other
Worksheet 12-1