Public Health and Medical Surge Capacity Research

1. Public Health and Medical Surge Capacity Research Sally Phillips, RN, PhD June 8,2008

2. Surge Capacity The ability of a health care system to rapidly expand beyond normal services to meet the increased demand for medical care and public health services that would be required to care for patients in the event of a large-scale pubic health emergency or disaster. Resources: • Beds, • Personnel to staff the beds, • Equipment, ( qualified staff to set up and administer care) • Ability to transport victims and personnel, and • The ability to provide ongoing care.

4. Discharge Criteria for Creation of Hospital Surge Capacity The Grant focus was the development of: • an easy-to-apply method for pre-designating hospitalized patients suitable for early discharge in the event of a disaster. • a tool tested and evaluated in comparison with the current ad hoc method of identification of such patients. Kelen, G. Johns Hopkins University Current development of a decision support tool underway with the Disaster Alternative Care Site Project with ASPR on this topic

6. Model for Health Professional’s Cross Training for Mass Casualty Respiratory Needs Tool for assisting with mechanical ventilator staff surge Curriculum developed for ‘just in time’ training for SNS Identifies appropriate health care professionals to be trained and used in a surge situation http://ahrq.gov/prep/projxtreme/ Project Xtreme Cross Training Video

7. Exploring the Special Needs and Potential Role of Nursing Homes in Surge Capacity This project examined the potential role of nursing homes in addressing a community's surge capacity needs precipitated by a bioterrorist event or a public health emergency. http://www.ahrq.gov/prep/nursinghomes/report.htm Products include: • an atlas displaying the geographic variation of nursing homes in the U.S.; • a case studies series highlighting the special needs and roles of nursing homes in surge capacity planning and; • a refined needs assessment tool that could be used to incorporate nursing homes into regional preparedness strategies.

8. Re-opening Shuttered Hospitals to Expand Surge Capacity Identifying Alternative Resources for Surge Surge Toolkit and Facility Checklist http://www.ahrq.gov/research/shuttered/

9. Home Health Care in Pandemic Influenza: Issues and Resources • Current state of Home care case load • Surge capacity in normal type homecare clients • Increase in clients sheltering in place • Increase client load from early discharged patients • Increase in acute care • Sick family members

10. Resource Requirement Models • AHRQ Surge Model • Estimates hospital resources needed to treat casualties from nine different WMD scenarios • Mass Evacuation Transportation Model • Estimates transportation resources needed to evacuate patients from healthcare facilities

11. The Eight Scenarios Biological • B.anthracis released from compressed air spray device mounted on back of a van • Smallpox virus (variola major) released by cold-air burst in large theater Chemical • Liquid chlorine in railroad car bombed as it travels through suburb • Sulfur mustard (HD) released via explosive munition in a large outdoor gathering • Sarin (GB) released via a fogger in a crowded sports arena Nuclear/Radiological • 1KT and 10KT improvised nuclear device detonated in city center • Radiological dispersion device in a city center • Radiological point source placed in large train station frequented by commuters daily

12. Currently Underway • Pandemic Influenza • Pneumonic Plague • Improvised Bomb • Food Contamination

13. Select a scenario

14. Scenario Options: Anthrax

15. Output – Arrival Pattern at Hospital

16. Output – Number Patients in the Hospital

17. Daily Resource Requirements for Non-Critical Care Nurses

18. Comparison of Required and Available Resources • Display of staffing levels from HHS Area Resource File

20. Providing Mass Medical Care with Scarce Resources: A Community Planning Guide Collaboration between AHRQ and ASPR • Ethical Considerations in Community Disaster Planning • Assessing the Legal Environment • Prehospital Care • Hospital/Acute Care • Alternative Care Sites • Palliative Care • Influenza Pandemic Case Study

21. PREHOSPITAL CAREThe Main Issue For Planners In the event of a Catastrophic MCE, the emergency medical services (EMS) systems will be called on to provide first-responder rescue, assessment, care, and transportation and access to the emergency medical health care system. The bulk of EMS in this country is provided through a complex system of highly variable organizational structures.

22. RECOMMENDATIONS: EMS PLANNERS • Use and availability of EMS personnel • Transport capacity • Role of dispatch and Public Safety Answering Points Plan and implement strategies to maximize to the extent possible:

24. Overwhelming demand Greatest good Resources lacking No temporary solution Federal level may provide guidance Operational implementation is State/local State emergency health powers Provider liability protection Hospital Care Planning Assumptions

25. Coordinated Mass Casualty Care • Increased system capacity (surge capacity) • Decisionmaking process for resource allocation • Shift from reactive to proactive strategies • Administrative vs. clinical changes

26. Incremental changes to standard of care Usual patient care provided Austere patient care provided Low impact administration changes High-impact clinical changes Administrative Changes Clinical Changes to usual care to usual care Triage set up in lobby area Re-allocate ventilators due to shortage Significant reduction in documentation Vital signs checked less regularly Meals served by nonclinical staff Significantly raise threshold for admission (chest pain with normal ECG goes home, etc.) Significant changes in nurse/patient ratios Deny care to those presenting to ED with minor symptoms Nurse educators pulled to clinical duties Stable ventilator patients managed on step-down beds Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Allocate limited antivirals to select patients Cancel most/all outpatient appointments and procedures Disaster documentation forms used Minimal lab and x-ray testing Need increasingly exceeds resources

27. Triage Plan • Assign triage staff • Review resources and demand • Use decision tools and clinical judgment to determine which patients will benefit most • Advise “bed czar” or other implementing staff

28. Alternative Care Sites

29. Concept of an Alternative Care Site • Nontraditional location for the provision of health care • Wide range of potential levels of care: • Traditional inpatient care • Chronic care • Palliative care • Home care

30. Potential Uses of an ACS • Primary triage of victims • Offloaded hospital ward patients • Primary victim care • Nursing home replacement • Ambulatory chronic care/shelter • Quarantine • Palliative care • Vaccine/drug distribution center

31. Mass Casualty Response: Alternate Care Site Selector • Tool helps regional planners locate and rank potential alternative sites during a bioterrorism or other public health emergency • Recommendations for staff, supplies and equipment are included as appendices • Levels of Caches • Selecting an Alternative Site • The Supplemental Oxygen Problem • Staffing an Alternative Site • Included in report, Rocky Mountain Regional Care Model for Bioterrorist Events: http://www.ahrq.gov/research/altsites.htm

33. Palliative Care • The minimum goal: die pain and symptom free. • Effective pain and symptom management is a basic minimum of service.

34. Prevailing circumstances Catastrophic MCE Triage + 1st response Receiving disease modifying treatment Existing hospice and PC patients The optimal for treatment The too sick to survive The too well

35. Catastrophic MCE and Large Volume The too sick to survive * Initially left in place Other than active treatment site Then: Transport • * • Those exposed who will die over the course of weeks • Already existing palliative care population • Vulnerable population who become palliative care due to scarcity

36. Mass Medical Care with Scarce Resources: A Community Planning Guide http://www.ahrq.gov/research/mce

37. http://www.ahrq.gov/prep/

38. Publications & Tools • To order a copy of reports, tools, or resources: • contact the AHRQ Publications Clearinghouse at 800-358-9295 • Send an E-mail to ahrqpubs@ahrq.hhs.gov.

39. For More Information Contact: Sally Phillips, RN, PhD Email: sally.phillips@ahrq.hhs.gov