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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?. 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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  1. Surge Capacity: Preparing for the worst-case scenario John L. Hick, MD Hamilton, Ontario May 29, 2006

  2. 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

  3. 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

  4. 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

  5. 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)

  6. Surge Capacity Coordination

  7. 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

  8. Tiered Response Strategy Capabilities and Resources National Response Provincial Response Regional / Mutual Response Systems Local Response Minimal Low Medium High Catastrophic Increasing magnitude and severity

  9. 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

  10. Local Attractions...

  11. 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

  12. ‘C’ first and foremost • Command • Control • Communication • Coordination

  13. 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

  14. 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

  15. 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

  16. 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

  17. ‘S’ - Logistics • Space • Staff • Stuff

  18. 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.)

  19. 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

  20. Staffing

  21. 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

  22. 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

  23. Surge Capability

  24. Pharmaceuticals

  25. Personal Protective Equipment

  26. HCMC Security HCMC Security

  27. ‘T’ - Operations • Triage • Treatment • Transport

  28. 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

  29. 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

  30. 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

  31. Transportation Capacity/Capability

  32. 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

  33. 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

  34. Influenza calls to MDH December 2003

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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. Sample Site

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