New England Society for Health Care Material Management

1. New England Society for Health Care Material Management Preparing for Pandemic Surge March 22, 2006

2. New England Society for Health Care Material Management Robert P. Paone, B.S., Pharm. D. Statewide Strategic National Stockpile Coordinator Center for Emergency Preparedness Massachusetts Department of Public Health (508) 820-2011 (desk) (617) 438-8249 (cell) Robert.paone@state.ma.us

3. Objectives • Review current impact projections of a Pandemic Flu in Massachusetts • Describe Pandemic Response Plans at state and local levels • Discuss surge preparations

4. Potential Impact of Next Pandemic In Massachusetts: Planning Assumptions • Outbreaks will occur simultaneously throughout the US • Up to 40% absenteeism in all sectors at all levels • Order and security disrupted for several months, not just hours or days

5. Pandemic v. Usual Surge Event • Likely to happen across Commonwealth and affect all regions simultaneously • Expected to occur in at least 2 waves of approximately 8 weeks duration each • Projected numbers are spread across the wave, with a peak occurring mid-wave • High attack rate among healthcare workers

6. Example of an Epidemic Curve

7. MDPH FLU SURGE ASSUMPTIONS • Attack rate: 30% • Hospitalization rate: 4% of ill • Death rate: 1% of ill • Duration of epidemic wave: 8 weeks • Avg. length of non-ICU stay for flu related illness: 5 days • Avg. length of ICU stay for flu related illness: 10 days • Avg. length of vent usage for flu related illness: 10 days • Flu admissions requiring ICU care: 50% • Flu admissions requiring mechanical ventilation: 15% • Flu deaths assumed to be hospitalized: 70% • Daily increase of cases compared to previous day: 3%

8. Surge Bed Definitions • Level 1: Staffed and available • Level 2: Licensed, Staffed • Two types • Beds made available through patient discharge and transfers. These beds are NOT additive – they are within the Level 1 bed number, but are vacated and made available for surge. • Beds made available through canceling of elective surgery, such as day surgery or endoscopies. Both the beds and the staff for those beds can be redirected for general hospital patients. These beds ADD to overall capacity. (Redirected level 2 beds, or 2R) • Level 3: Licensed but not staffed • Generally equipped, including wall gases • Level 4: Overflow beds in non-traditional patient care areas • Cafeterias, lobbies, etc. • Require purchase of equipment (including beds), supplies and in need of staff

9. Hospital Surge Capacity Level I 13,067 Current staffed beds Level II 2,000* Re-directed Level III 3,568 Un-staffed beds Level IV 5,071 Non-trad. space Total: 23,706* *Adjusted number reflects omission of beds that had been double counted through transfers out to other hospitals. This number will decrease over time as the “elective” admissions become non-elective. All beds are ultimately dependent on available staffing, so maximum number may not always be attainable.

10. Comparison of Pandemic Planning Numbers *Based on 3X 1968 projections (Trust For America’s health report: A Killer Flu, www.healthyamericans.org, June 2005)

11. outbreak 30% attack rate

13. Surge Bed Capacity vs. Need * Requires Purchase of Beds & Supplies

14. State: Need 23,560out of 23,705 Beds

15. 128 Crescent (4AB):Need 562 more beds than available

16. Southeast (5): Need 994 more level 4 beds than available

17. Gaps in Bed Capacity • All 6 regions expected to fill 100% of level 3 beds (licensed but unstaffed) • All regions will need to open some level 4 beds (overflow areas) • Two regions will exceed their surge capacity (Regions 4AB and 5) • Staffing and supplies required for ALL level 3 and 4 beds • Equipment, supplies, and staffing needed for level 4 beds

18. Hospital Surge Capacity • Despite operational changes, hospitals may become overwhelmed depending on usage in communities served • Alternate care spaces will need to be identified to expand hospital capacity • Pre-hospital triage will be needed to relieve pressure on hospital operations

19. Alternate Care Sites (ACS) • Hospitals: flu patients requiring mechanical ventilation, or those with complex medical management needs • ACS: Sickest flu patients not meeting the criteria for hospital admission but for whom home care is not possible • Location and number to be determined by local hospital bed availability.

20. SNS Stakeholders Conference Federal Medical Station Type III (Basic)(FMS TIII) February 21, 2006

21. FMS Goal • Address the nation’s potential shortfall in all-hazard mass casualty care events and create a federal-level contingency care program as directed in HSPD 10. • Deploy a surge capability throughout the Nation, pre-positioned and configured to respond rapidly and effectively to all types of public health emergencies, from significant incidents to large-scale catastrophic disasters

22. FMS TypesStandardized Capabilities Across Agencies • Type I (Advanced): Has capability to care for severely ill or injured patients, equivalent to conventional operating room, ICU, and basic laboratory (Lead: DHS) (DHS uses “FMCS”) • Type II (Specialized): Configured for specific clinical scenarios, such as respiratory isolation and burn care. Future prototypes to be developed. (Lead: DHHS) • Type III (Basic): Low to mid-level acuity of care to provide platform for DMAT teams, special needs shelters, quarantine function, alternate care facility to augment community hospital capability (Lead: DHHS) • Type IV (FMS): Special Needs Shelter (Lead: DHHS)

23. FMS TIII (Basic)Concept • A Federal, deployable medical asset designed to support regional, state, and local healthcare agencies responding to catastrophic events. It provides two critical capabilities: - Inpatient, non-acute treatment capability for areas where hospital bed capacity has been exceeded. - A quarantine capability to isolate persons suspected of being exposed to or affected by a highly contagious disease. Features: - Consists of three core modules and bed expansion module - Very few recoverable items in the FMCS kit - Easily adapted to meet a range of mass medical care needs following disaster - Deploys with SNS technical team to facilitate FMCS set up and transfer to Federal Health Care Professionals

24. Type III Basic Bed Aug (50) FMS TIII 250 Bed Module FMS TIII 250 Bed Module Configuration e Configuration Type III Basic Treatment Type III Basic Pharmaceutical Type III Basic Base Support With Quarantine • Pharmaceutical • Special Medications • Prophylaxis • Administration • Support • Feeding • Quarantine • Beds(50) • Housekeeping • First Aid Equipment • Pediatric Care • Adult Care • Personal Protective Equipment • Primary Care • Non-acute Treatment • Special Needs • Non-acute Treatment • Special Needs • Beds • Bedding • Bedside Equipment • Current Pack • 634 items - 3 days supply • 170 pallets (uni-pacs and pallets) • 4 tractor trailer (53 ft) loads FMS

26. Staffing • Remains biggest challenge we face • Legal protections are key to recruiting personnel • Large number of non-clinical personnel also needed • Potential sources of clinical surge personnel: • Internal Hospital Strategies • MSAR volunteers • Medical Reserve Corps that are not included in hospital staff • Retired, inactive health professionals • Students (medical, nursing, pharmacy) • Connect and Serve (www.mass.gov)

27. Health Care Professionals • Professional qualifications must be checked and verified ahead of time • Volunteers cannot be assigned to take care of patients until their specific knowledge and skills are understood • It takes time to do this – volunteers who have not been pre-registered and pre-credentialed may be delayed in receiving an assignment

29. Masks v. Respirators http://www.fda.gov/cdrh/ppe/masksrespirators.html* • Viruses spread primarily by droplet spray therefore surgical mask is appropriate protection if working within three feet of infected patients. (Upon entering the patient’s room) • Respirators (i.e. N-95 masks, properly fitted*) should be worn by HCWs who are involved with patients undergoing procedures in which aerosolized particles may be generated. (endotracheal intubation, suctioning, nebulizer therapy, etc.) WHO recommendation November 2005, *FDA

30. Oxygen Needs • Model presumes that patients in Level IV and ACS who require oxygen will require oxygen therapy at 4-6 liters/minute (l.p.m.) flow. • Level IV and ACS model is based on 50 patients being treated for 10 day period. • Assumption is that at any given time, 25 patients will require constant oxygen. • Cost estimates derived from preliminary survey of local vendors.

31. Delivery Systems • Oxygen Gaseous Cylinder • Oxygen Concentrator • Liquid Oxygen • Stockpile/Cache Planning

32. Gaseous Cylinder • H tank cylinder being used at 4-6 l.p.m. will last approximately 1 day per patient. • Therefore, each ACS will need a minimum of 250 H cylinders worth of oxygen. • Most oxygen vendors lease H cylinders to end users and recycle the empties replacing them with full tanks (similar to bottled water cooler set ups used in offices)

33. Oxygen Concentrators • Different models can be used at 1 to 6 liters per minute. • Each patient would need their own concentrator. • Primarily used for lower flow (1-2 l.p.m.) applications, however units do exist that do 6 l.p.m. and more expensive units could provide oxygen up to 10 l.p.m. • Concentrators produce oxygen from room air and therefore do not require any gaseous or liquid oxygen to be supplied.

34. Liquid Oxygen • Based on cryogenic technology. • Most hospitals have liquid oxygen tanks on their premises used to supply oxygen throughout facility. • Cost is based on pounds. • It is estimated that at approx. 6 l.p.m., each patient would probably use approx. 280 pounds for a 10 day period

35. Oxygen Stockpile/Cache Planning • MDPH representatives have started to conduct outreach such as attending New England Medical Equipment Dealers quarterly meeting Dec. 8th in Boxboro, MA. • MDPH will contact major medical supply vendors/distributors including local and regional oxygen suppliers to explore the topic of securing adequate oxygen supplies during a regional, statewide and national pandemic surge situations.

36. Ventilators • Hospital Ventilators cost approx. $25,000/unit. • Portable ventilator contained within SNS stock costs approx.$7,900/unit. • Looking into prices for portable ventilators. • MDPH will work with ventilator suppliers and manufacturers to explore state and nationwide ventilator availability.

37. Ventilators • Massachusetts Department of Public Health is currently in the process of evaluating ventilators and O2-concentrators. • DPH is considering purchasing 1000-2000 vents and O2-concentrators for our state wide stockpile.

38. Surge Supply Caches: Total Cost for 50 Bed ACS: $250,000 • Approx. $5000 per patient • Approx. $20,000 Oxygen and Suction supplies • Approx. $40,500 durable medical supplies • Approx $17,600 for Intravenous related supplies • Approx. $78,800 for infrastructure/administrative supplies

39. Alternate Care Site Costs (cont.) • Approx $28,000 for support service costs (laundry, food, lab-work etc.) • Approx. $46,600 Pandemic related medicines • Approx $7500 for acute/non-emergent maintenance meds • Approx. $13,000 for stocked Crash Cart

40. Maximizing the Supply Chain • Identify items for surge • Increase par levels for on site cache • For pharmaceuticals, distributors maintain ~21 day inventory • Work with suppliers • Place orders early in pandemic • Identify alternate sources

41. Maximizing the Supply Chain (cont.) • What else? • All suggestions are welcomed!

43. Interventions to decrease transmission Provide quality medical care Infection control in medical & long term care settings Maintain essential community services/emergency response activities Antiviral treatment & prophylaxis Pandemic Response Actions: Timing and Potential Impacts Pandemic influenzadisease Impact Vaccination Time

44. Most of the impact and most of the response will be local. Local Infectious Disease Emergency Planning