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NACCHO Advanced Practice Center (APC) Road Shows Albuquerque, New Mexico August 11-12, 2009

Mass Medical Care During an Influenza Pandemic: Establishing Influenza Care Centers PRESENTATION AND WORKBOOK. NACCHO Advanced Practice Center (APC) Road Shows Albuquerque, New Mexico August 11-12, 2009. APC Toolkit. Toolkit Sections. Concept of Operations Command and Control

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NACCHO Advanced Practice Center (APC) Road Shows Albuquerque, New Mexico August 11-12, 2009

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  1. Mass Medical CareDuring an Influenza Pandemic: Establishing Influenza Care CentersPRESENTATION AND WORKBOOK NACCHO Advanced Practice Center (APC)Road Shows Albuquerque, New MexicoAugust 11-12, 2009

  2. APC Toolkit

  3. Toolkit Sections • Concept of Operations • Command and Control • Communications • Staffing and Training • Clinical Standards, Protocols and Operations • Infection Control • Fatalities and Morgue • Facilities • Equipment and Supplies • Security • Transportation

  4. Toolkit Tools

  5. Today’s Objectives • Present highlights of the toolkit. • Focus on your local area requirements for mass medical care. • Use the workbook to startyour planning.

  6. What Are Expectations or Requirements? • In California: • Hospitals surge to care for seriously ill or injured. • Public health activates ACS/ICCs to care for moderately acute ill or injured patients, thereby taking the load off hospitals. • (Originally, hospitals were expected to set up and run the ACS...). • What are State-wide expectations or requirements for ACS activation?

  7. What’s the Status of Current Planning ? • Healthcare Surge Plan (area-wide)? • Hospital surge plans? • Mass dispensing site (s) operational plan? • Alternate Care Site (ACS) operational plan?

  8. ACS Planning Resources • APC Toolkit – based on SCC’s ICC. http://www.sccgov.org/portal/site/phd/agencychp?path=%2Fv7%2FPublic%20Health%20Department%20(DEP)%2FAdvanced%20Practice%20Center%20(APC) • CA Dept Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume 2 http://bepreparedcalifornia.ca.gov/NR/rdonlyres/640A3732-2667-4F61-B044-413478888816/0/volume2_ACS_FINAL.pdf • CA Government-Authorized Alternate Care Site Operational Tools Manual. http://bepreparedcalifornia.ca.gov/NR/rdonlyres/C2AD6528-F781-4D8C-B900-828A1C2C6F0C/0/Operational_ACS_Ops_Tool_FINAL.pdf • Seattle-King County APC Video http://www.kingcounty.gov/healthservices/health/preparedness/%7e/media/health/publichealth/documents/hccoalition/AltCareVideo.ashx

  9. Elements of Planning: Interconnected Decisions

  10. Influenza Care Centers (ICC) • For pandemic planning, Santa Clara County established the concept of Influenza Care Centers (ICC). • ICCs are alternative care sites designed to address the needs of moderateacuity patients in a pandemic.

  11. ICC Pandemic Planning Assumptions: • Local hospital capacity will not meet hospitalization demand: • Bed capacity limits (adult and pediatric acute care, adult critical care, pediatric & neonatal critical care). • Ventilator limits (all ventilators, including disposable, mass casualty ventilators).

  12. ICC Pandemic Planning Assumptions: • Illness, hospitalizations, fatalities • 25-35% popn clinically ill • 13-22% require hospitalization • 2.5-5.0% fatalities • 12 months w/illness, hospitalizations, fatalities evenly distributed each quarter.

  13. Surge and Capacity Challenges

  14. Estimate # Patients, Sample – Albuquerque, New Mexico • Estimated (Albuquerque) population 600,000 • 600,000 x .25 = 150,000 = # clinically ill • 150,000 (# clinically ill) x .22 = 33,000 = # require hospitalization • 33,000 (# require hospitalization) / 4 = 8,250 pts / quarter = (12-week pandemic “wave”)

  15. Estimate # Beds for Flu Patients Sample – Albuquerque, New Mexico • # of local area (Albuquerque) hospital beds • University of New Mexico Hospital - 431 • Heart Hospital of New Mexico - 55 • Presbyterian Hospital - 453 • The Children's Center at Presbyterian Hospital - 81 • Lovelace Women's Hospital - 185 • Kaseman Presbyterian Hospital – 252 • Specialty Hospital of Albuquerque - 82 • Kindred Hospital-Albuquerque – 61 • Total = 1,519 beds • In hospital surge, 50% for flu patients = 760 beds(total includes ICU beds).

  16. Estimate # of ACS Patients, Sample – Albuquerque, New Mexico

  17. Workbook – Estimate # Patients • Estimated population: ________ • _____ x .25 = ______ = # clinically ill • _______ (# clinically ill) x .22 = ________ = # require hospitalization • _______ (# require hospitalization) / 4 = ______ pts / quarter = (12-week pandemic “wave”)

  18. Workbook: Estimate # Patients • # of local area hospital beds __________ • In hospital surge, 50% for flu patients • = _________ beds(total includes ICU beds).

  19. Workbook: Estimate # ACS/ICC Patients • # beds available for flu patients _______________ • # patients / quarter = __________ • Figure % of pts/qtr for each week. (Use %’s shown). • Identify peak weeks. • Subtract # beds available from the #hospitalized (cumulative – add the weeks up to and including the peak week). • This is the number to plan for at the ACS/ICC.

  20. Toolkit Sections • Concept of Operations • Command and Control • Communications • Staffing and Training • Clinical Standards, Protocols and Operations • Infection Control • Fatalities and Morgue • Facilities • Equipment and Supplies • Security • Transportation

  21. Concept of Operations Step 1 – Describe the ICC, Objectives • Standard of Care • Level of Care Step 2 – Operational Periods Step 3 – Activation Step 4 – De-activation

  22. ICC Objectives Primary objectives for the establishment of an ICC include, but are not limited to, the following: • Decompression of acute care hospital inpatient beds (receiving site for hospital discharge patients who are not able to be cared for at home) • Used instead of acute care hospital inpatient beds (inpatient care for moderate-acuity patients and palliative care)

  23. Standard of Care • Standard of care during a healthcare surge is the utilization of skills, diligence and reasonable exercise of judgment in furtherance of optimizing population outcomes that a reasonably prudent person or entity with comparable training, experience or capacity would have used under the circumstances. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes*. • California Department of Public Health (CA DPH)

  24. Pandemic Levels of Care • Influenza Care Centers • Intermediate Care • IV & Oral Hydration • Oxygen • Nursing Services • MD on call At Home Care • Isolation • Oral Hydration • Oral Antibiotics Hospital Admissions • Critical Care • Ventilators • Ancillary Services

  25. Level of Care Planning Decisions

  26. Workbook: Level of Care Planning Decisions • Estimated # patients_______ • Level of Care at hospital (s) _________________ • Level of Care at the ACS/ICC ________________

  27. Operational Periods • Define and describe the Operational Periods in terms of a likely pandemic cycle and daily operation. • It is anticipated that an ICC will be operational from eight to fourteen weeks for the first wave of a pandemic influenza event and then for an additional eight to twelve weeks during the second wave. • Operational periods = 12 hours. • Staffing

  28. ACS Activation • Follows area’s event/emergency activation procedures per NIMs. • Authority to activate/operational policy: • The Health Officer will notify the local officials of the intent to activate and then coordinate implementation through the Medical-Health Branch of the Operational Area Emergency Operations Center. Positions in the ICC are filled according to National Incident Management System (NIMS). Once ICCs have been activated, only patients routed to ICCs or those triaged on-site for admission will be accepted. Patients that are admitted to an acute care hospital at the time the ICC is activated will remain in the acute care facility and will not be transferred to an ICC.

  29. Workbook: Activation • Describe how emergency operations are activated per NIMS. • Who has authority to activate the ACS? • What patients are admitted upon activation?

  30. Deactivation • Authority to de-activate. • NIMS position to oversee deactivation. • Exit strategy in catastrophic failure: • Facility fire • Civil unrest, gun fire • Government, societal failure

  31. Workbook: Deactivation • Who has authority to deactivate the ACS? • Which NIMS position oversees deactivation? • Describe catastrophic failures that might occur:

  32. 2. Command/Control USE TOOL #2 • ICC organization • Hospital Incident Command (HICS) • Planning with: • Hospital representatives • Emergency management representatives • Fire and Law enforcement • Inventory managers

  33. 2. Command/Control USE TOOL #2 • Step 1 – Describe relationship of ICC to Public Health • Step 2 – Describe relationship between ICC to the EOC – Medical Health Branch • Step 3 – Prepare organizational charts

  34. ICC Division Manager Safety Officer Operations Section Chief Logistics Section Chief (See below) Planning Section Chief (See below) Finance/Admin Section Chief (See below) Medical Care Branch Director (See below) Infrastructure Branch Director (See below) Security Branch Director (See below) ICC Organizational Chart General Staff

  35. Workbook – ICC Organization Chart USE TOOL #2 and TOOL #5 • The ACS/ICC is a field operation of __________________. • The ACS/ICC Incident Commander reports to ____________. • Logistics and support is provided by: __________________________

  36. 3. Communications USE TOOL #3TOOL #18 • Step 1 – Determine ICC needs. • Step 2 – Describe methods. • Step 3 – Consider communications: • Within the ICC • Between the ICC and other ICCs • Between the ICC and hospitals/healthcare providers • Between the ICC and the EOC

  37. 3. Communications USE TOOL #3TOOL #18 • Wireless Laptop Computer • (5) Portable 800 MHz radios (EMS Frequencies) • Access to existing landline fax machines • Access to existing landline phones • Access to internet-accessible computers • Access to a television with cable or satellite service • Access to a radio • Handheld Patient Tracking Devices • Wireless router

  38. 4. Staffing and Training USE TOOLS #4 and #5 • Step 1 – Determine staff ratios. • Step 2 – Describe functional roles. (Tool 4 – Functional Roles Matrix) • Step 3 – Determine training requirements for categories of positions. • Step 4 – Identify types of support staff needed.

  39. 4. Staffing and Training USE TOOLS #4 and #5 • Local public health agency employees will not be sufficient for staffing the ICCs. The broader health care community, city governments, and community volunteers must provide human resources to ensure adequate staffing of the ICCs.

  40. 4. Staffing and Training USE TOOLS #4 and #5 • The recommended staffing patterns are based on the following scenario for Santa Clara: • Total number of patients per ICC = 450 • 12-hour shifts for all staff • Patient population includes 50% patients on IV fluids (n=225) and 60% on Oxygen via nasal cannula (n=270) • Each ICC is divided into sections (treatment units) of up to 40 patients each.

  41. 4. Staffing the ICC USE TOOLS #4 and #5

  42. Workbook: Staffing USE TOOLS #4 and #5 • Number of patients (beds) in the ICC = (#) • Using staffing ratio chart, determine staffing ratios to be used. • Review and revise Tool #5 Job Action Sheets • Identify community support for staffing.

  43. Workbook: Staffing USE TOOLS #4 and #5

  44. 4. Training USE TOOLS #4 and #5 • ICC Orientation – Just in Time Training • Pre-event Clinical Operations Training – Public Health Clinical ICC Staff • Pre-event Clinical Skills Training

  45. 5. Clinical Standards, Protocols and Operations • Standing Orders • General • Admitting • Asthma • Heart Failure • Diabetes • Pregnancy • Palliative Care • Clinical Triage • Oxygen Delivery Alternatives • Insulin and Blood Glucose Monitoring Sheet • Pharmacy Order Form • Patient disposition log • ICC Intake Assessment Form

  46. Elements of Planning: Interconnected Decisions

  47. 5. Clinical Standards, Protocols and Operations • Step 1 – Develop triage guidelines. • Step 2 – Describe admissions/intake process. • Step 3 – Describe pt./bed tracking. • Step 4 – Define documentation and patient charting. • Step 5 – Describe daily evaluation. • Step 6 – Describe pharmacy formulation protocols. • Step 7 – Describe discharge criteria/procedures. • Step 8 – Develop visiting rules/regulations. • Step 9 – ID housekeeping/environmental services.

  48. 5. Clinical Protocols & Patient Care Tools USE ALL THESE TOOLS

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