Surge capacity preparing for the worst case scenario
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Surge Capacity: Preparing for the worst-case scenario. John L. Hick, MD Hamilton, Ontario May 29, 2006. What defines a disaster?. Demand for critical resources outstrips availability thus putting patients or staff in danger Goal is to plan ahead to ensure:

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Surge Capacity: Preparing for the worst-case scenario

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Surge Capacity: Preparing for the worst-case scenario

John L. Hick, MD

Hamilton, Ontario

May 29, 2006


What defines a disaster?

  • Demand for critical resources outstrips availability thus putting patients or staff in danger

  • Goal is to plan ahead to ensure:

    • More effective use of available resources

    • Mobilization of additional resources

  • Outcome: ‘special incident’ doesn’t become a ‘disaster’

  • May depend on time / day / facility


Capacity vs. Capability

  • Surge Capacity – ‘the ability to manage increased patient care volume that otherwise would severely challenge or exceed the existing medical infrastructure’

  • Surge Capability – ‘the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions’

    • Barbera and Macintyre


Surge Capacity Partners

  • EMS (and other patient transportation resources)

  • Emergency Management

  • Public Health

  • Public Safety/Law enforcement

  • Healthcare SystemsHospitals and hospital associations

  • Red Cross

  • Behavioral health

  • Jurisdictional legal authorities

  • Professional associations inc pharmacy, medical, nursing, mental health


Concepts and Principles

  • Standardization

    • Incident Management System

    • Multi-Agency Coordination System

    • Public Information Systems

    • Interoperability (eg: personnel and resource typing)

  • Scalability

  • Flexibility

  • Tiers of capacity (spillover to next level)


Surge Capacity Coordination


Tiers of Response – Patient Care

Provincial and National Response

6th Tier

National Response

5th Tier

Provincial Coordination

Province A

Province B

4th Tier

Regional Coordination

Jurisdiction I

(PH/EM/Public Safety)

Jurisdiction II

(PH/EM/Public Safety)

3rd Tier

Jurisdiction Incident Management

Medical Support

2nd Tier

Healthcare “Coalition”

HCF A

HCF B

HCF C

Non-HCF Providers

1st Tier

Healthcare Facility


Tiered Response Strategy

Capabilities and Resources

National Response

Provincial Response

Regional / Mutual Response Systems

Local Response

MinimalLowMediumHighCatastrophic

Increasing magnitude and severity


Emergency Management Plan

HVA

Command, control, communications

Community partners

Regional partners

Training

Drills

Review / modify

Functional Planning

MCI

Security Event

Fire

Chemical exposure

Radiologic Event

Infectious Disease

Evacuation

Facility / Community Planning


Local Attractions...


Emergencies Present Themselves In 2 Ways…

Unanticipated

and/or

Without Warning

Anticipated

and/or

With Warning

Oklahoma City Bombing

Hurricane Katrina

September 11, 2001

Midwest Floods

Northridge Earthquake

Pandemic Influenza

The Amount of Time We’re Given

To Pre-Organize People and Pre-Stage Equipment

Can Drastically Change Our Response Effectiveness


‘C’ first and foremost

  • Command

  • Control

  • Communication

  • Coordination


Command / Control

  • Who is in charge?

  • Who has authority to declare a special incident, evacuate, etc?

  • Where is the EOC/Command Post?

  • How does the EOC/CP interact with:

    • Community resources

    • Other hospitals/public health

  • Tiered, scalable, flexible plans

  • Use of Hospital Incident Command System


Getting Organized…

Nature

Day of the Week

What ?

Where ?

When ?

Who’s Involved ?

Where Is It Going ?

Size

Initially

Location

Time of Day

Mobilization

Checklist

  • INCIDENT BRIEFING

  • Date/time of start of incident

  • Type of incident

  • Services involved

  • Current incident status

  • Current resource status

  • Current strategy/objectives

  • Communications systems being used

  • Special problems/issues

Emergency

Operations

Center

Incident

Action

Planning


Communication

  • Within ED / hospital

    • Phone (redundant?), local cellular

    • Paging

    • Portable radios

    • Alpha pagers, SMS, email, VOIP

    • Runners

  • Outside facility – phone, cell, HEAR, amateur radio, internet – VOIP, email, net-based


Coordination

  • Within facility (for ICU, CT, etc.)

  • Outside facility:

    • Transfers (including ambulances, helos)

    • Resource requests

    • Outside agencies

  • Regional Hospital Resource Center (RHRC)

    • Coordinates hospital response and requests within region


‘S’ - Logistics

  • Space

  • Staff

  • Stuff


Space

  • Get ‘em up and get ‘em out (ED, clinics)

  • Discharges and transfers (eg: nursing home)

    • Discharge holding area

  • Board patients in halls

  • Cancel elective procedures

  • Convert procedure/PACU areas to patient care

  • Accommodate vents on floor (or BVM or austere O2 flow powered ventilators)

  • Alternative ambulatory care areas (lobbies, clinics, etc.)


Staff

  • Different events = different staff needs

    • Eg: HAZMAT vs. trauma vs. monkeypox

  • Scope of event = scope of staff call-in

  • Mechanism to reach staff

  • Support staff – eg: central supply, food, psychosocial

  • Labor pool unit leader

  • Assign staff to specific areas when possible

  • Nursing staff often limiting factor


Staffing


Personnel Augmentation

  • Hospital personnel

  • Clinic personnel

  • Non-clinical practice professionals

  • Retired professionals (eg: HC Medical Society)

  • Trainees in health professions

  • Service organizations

  • Lay public / faith-based / family members

  • Government personnel


Stuff

  • Patient care supplies – look at by type of event

  • Pharmacy – analgesia, sedation, dT, abx

  • PPE – masks, barrier gowns

  • Supply and staffing issues (72h ahead)

  • Logistics and planning sections


Surge Capability


Pharmaceuticals


Personal Protective Equipment


HCMC

Security

HCMC

Security


‘T’ - Operations

  • Triage

  • Treatment

  • Transport


Triage

  • Primary – immediate, often scene-based (eg: EMS)

  • Secondary – at hospital or for in-hospital resources, re-assessment

    • Location

    • Supplies

    • Personnel

  • Tertiary – after admission / initial care


Treatment

  • Where provided? (eg: will certain patients be cohorted in certain areas?)

  • What treatment will be provided? (resource limitations?)

  • What are the limiting factors?

    • Staff

    • Supplies

    • Space


Transportation

  • Ground assets (including buses and out-of-area EMS)

  • Rotor-wing

  • “Loading zones” for both ground and air units

  • Receiving facilities

  • Coordination of patients, records

  • Prioritization for evacuation and method


Transportation Capacity/Capability


Behavioral Health Surge

EMS-

Processed

Medical

Self-Transported

Medical Casualties

Bystanders or

Family

Members,

Friends,

Co-workers

of Incoming

Casualties

Family Members

Searching

for Missing

Loved Ones

Injured,

Exposed,

Distressed

Disaster/

Emergency

Workers

INCOMING

Psychological

Casualties

Media

Volunteers

Onlookers

INPATIENT

Distressed Inpatients

Family Members

of Inpatients

IN-HOUSE

Distressed Staff


Community-Based Surge

  • Clinics

  • Homecare

  • Nursing homes

  • Procedure centers

  • Family-based care

  • Off-site hospitals (Acute Care Center)

  • Off-site clinics (Neighborhood Emergency Help Centers) (assessment and clinic level care)

  • Local / Regional referral / NDMS


Influenza calls to MDH December 2003


Visits to MDH home and Flu Clinic web pages - Dec 2003


Hospital Metro Resources

  • Routinely staffed beds 4857

  • Avg. daily census 4143

  • Surge Capacity

    • Census vs. staffed variance 714

    • Unstaffed but available beds 1068

    • 15% of total beds staffed = 728

    • PACU/procedure rooms 536

    • Convertible rooms single to double 473

    • Total average overall surge capacity 2500-3519

    • Adjusted standard of care surge capacity 500-1000


Metro Hospital Resources

  • Stepdown beds 501 (surge 190 addtl)

  • ICU beds 416 (surge 192 addtl)

  • PICU beds 64 (surge 20-39 addtl)

  • ED beds 460

  • OR suites 295

  • Ventilators 533

  • Tabs of doxycycline 76,881


Hospital C

Hospital B

Clinic coord

Hospital A

Healthsystem

Regional Hospital

Resource Center

Multi-Agency Coordination

Center

EM EMS PH

A

A

B

B

C

C

A

C

Jurisdiction

Emergency

Management

B

Public Health

Agencies

EMS Agencies


Hospital Resources Metro

  • Population 2,600,000

  • 10% population affected by ‘pandemic’ = 260,000 patients

  • 20% of affected patients too sick to care for selves = 52,000

  • 20% of those patients lack family members that can care for them or are too sick for homecare (require IV fluids, etc.) = 10,400

  • Requires off-site care facilities and triage of resources


Off-site hospital

  • Incident recognized, regional coordination established, need for off-site care recognized

  • Primary and secondary sites pre-selected and screened

  • Public health authority is authorizing/controlling entity

  • Compact provides for first 48h:

    • Teams of providers (RN, MD, HCA/NA/EMT)

    • <200 beds – 1 team

    • >200 beds – 2 teams

    • Each 6-8 person team has up to 50 patients

  • May be required when hospital infrastructure damaged, especially in smaller community


Sample Site


Food

Restrooms

Staff rehab areas

Secure

HVAC system specs

Paging /messaging /radio

Power

Phone, T1 lines, etc.

City owned!

Sample Site


Adjusting Standards of Care

  • The last resort

  • ‘What do you do when you can’t surge any more’

  • Gracefully, systematically change your standard of care to one appropriate for the resources available

  • Staffing and staff roles / responsibilities

  • Policy changes (eg: documentation)

  • Resource triage decisions


Overarching Goal

Do the greatest good for the greatest number of persons you can based upon the resources available…


What are the goals?

  • Understanding by the community of the limits of resources and the plans when they are exhausted

  • Evidence-based strategy for triage of resources (based upon chance of survival, not subjective factors)

  • Regional, not facility-based criteria

  • Provide support and framework for physician decisions

  • Provide governmental support for response efforts including liability protection


Restrictions on Mechanical Ventilation

  • Do not offer or withdraw ventilator support for:

    • Tier 1 – multi-organ failure

    • Tier 2 – severe underlying disease conditions

    • Tier 3 – other criteria (event driven) possible:

      • Sequential Organ Failure Assessment Score

      • Age related?

      • Other markers for poor outcomes?


What can I do?

  • Know your role in your institutional plan

  • Work with your emergency preparedness committee

  • Look at your C, S, T - have you optimized your preparedness? Ask questions, run scenarios…

  • KISS

  • Job action sheets / task cards

  • Extension of daily tasks / responsibilities

  • Education where these differ from your plan

  • Start small, grow big


Questions?


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