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

Surge Capacity: Preparing for the worst-case scenario

John L. Hick, MD

Hamilton, Ontario

May 29, 2006


What defines a disaster

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

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

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

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

Surge Capacity Coordination


Surge capacity preparing for the worst case scenario

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

Tiered Response Strategy

Capabilities and Resources

National Response

Provincial Response

Regional / Mutual Response Systems

Local Response

MinimalLowMediumHighCatastrophic

Increasing magnitude and severity


Facility community planning

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

Local Attractions...


Emergencies present themselves in 2 ways

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

‘C’ first and foremost

  • Command

  • Control

  • Communication

  • Coordination


Command control

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

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

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

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

‘S’ - Logistics

  • Space

  • Staff

  • Stuff


Space

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

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

Staffing


Personnel augmentation

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

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

Surge Capability


Pharmaceuticals

Pharmaceuticals


Personal protective equipment

Personal Protective Equipment


Surge capacity preparing for the worst case scenario

HCMC

Security

HCMC

Security


T operations

‘T’ - Operations

  • Triage

  • Treatment

  • Transport


Triage

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

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

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

Transportation Capacity/Capability


Behavioral health surge

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

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

Influenza calls to MDH December 2003


Visits to mdh home and flu clinic web pages dec 2003

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


Hospital metro resources

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

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


Surge capacity preparing for the worst case scenario

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

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

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

Sample Site


Sample site1

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

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

Overarching Goal

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


What are the goals

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

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

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


Surge capacity preparing for the worst case scenario

Questions?


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