Hospital Preparedness for Emergency Response: United States, 2008

1. Hospital Preparedness for Emergency Response:United States, 2008 Richard Niska, MD, MPH, FACEP Captain, USPHS Iris M. Shimizu, PhD National Center for Health Statistics 22 June 2011

2. Objective Summary of hospital preparedness for responding to public health emergencies: • Mass casualties • Epidemics of naturally occurring diseases

3. Prior work Bioterrorism and Mass Casualty Preparedness Supplement • 2003-2004 • National Hospital Ambulatory Medical Care Survey (NHAMCS) • Funded by Office of the Assistant Secretary for Planning and Evaluation (OASPE)

4. Publications from 2003-2004 supplement • Hospital collaboration with public safety organizations on bioterrorism response. Prehospital Emergency Care; 2008; 12:12-17. • Emergency response planning in hospitals, US: 2003-04. Advance Data from Vital and Health Statistics; 2007; 391. www.cdc.gov/nchs/data/ad/ad391.pdf • Percentage of hospitals with staff members trained to respond to selected terrorism-related diseases or exposures – NHAMCS, US, 2003-04. MMWR. 2007; 56(16):401. www.cdc.gov/mmwr/preview/mmwrhtml/mm5616a6.htm • Training for terrorism-related conditions in hospitals: US, 2003-04. Advance Data from Vital and Health Statistics, 2006; 380. www.cdc.gov/nchs/data/ad/ad380.pdf • Percent of hospitals having plans or holding drills for attacks by explosion or fire. MMWR, 2005; 54(42). www2c.cdc.gov/podcasts/download.asp?f=1096061&af=h&t=1 • Bioterrorism and mass casualty preparedness in hospitals: US, 2003. Advance Data from Vital and Health Statistics, 2005; 364. www.cdc.gov/nchs/data/ad/ad364.pdf

5. Current work Pandemic Emergency Response Preparedness Supplement – 2008 • Parent survey: NHAMCS • Again funded by OASPE

6. Methods:NHAMCS • NHAMCS uses a national probability sample: • U.S. nonfederal general and short-stay hospitals • Data weighted to produce national estimates • Collects facility & visit level hospital characteristics • Facility level: emergency response supplement • Visit level: emergency and outpatient department records

7. Methods:Emergency response supplement • Eight-page survey instrument • Delivered on site to hospital administrator by U.S. Census Bureau field representative • Self-administered by hospital staff member deemed appropriate by administrator • Collected later by Census field representative

8. Emergency response plans • Scenarios: • Hospital overcrowding • Disasters • Mass casualties • Disease outbreaks • Terrorism • Choices: • in emergency response plan • implemented in actual incident during 2007 • not in emergency response plan

9. Percent of hospitals with emergency response plans for selected types of incidents:United States, 2008 95% confidence intervals Percent • NUC-RAD = Nuclear-radiological. (2) EXP-INC = Explosive-incendiary • SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

10. Collaboration with outside entities • Memorandum of understanding (MOU) with other hospitals to accept patients in transfer from the emergency department when no beds are available: • adults • pediatric patients to children’s hospitals • MOU with regional burn center to accept transfers in the aftermath of an explosive or incendiary incident • MOU with other outpatient facilities to augment outpatient services • Regional communication systems to track: • emergency department closures or diversions • available intensive care unit beds (adult, pediatric, neonatal) • available hospital beds (adult, pediatric, neonatal) • specialty coverage • Mutual aid agreements with other agencies to share supplies and equipment

11. Percent of hospitals having memorandum of understanding to accept emergency department transfers during overcrowding incidents or public health emergencies, by receiving hospital type:United States, 2008 95% confidence intervals Percent SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

12. Expansion of on-site surge capacity • Cancellation of elective procedures and admissions • Isolation of airborne disease patients in negative pressure areas • Conversion of inpatient units to augment intensive care unit (ICU) capacity • Alternate care areas with beds, staffing and equipment • inpatient unit hallways • decommissioned ward space • non-clinical space • Setting up temporary facilities when the hospital is unusable (without power, flooded, etc.)

13. Percent of hospitals with plans for selected components of on-site surge capacity expansion: United States, 2008 95% confidence intervals Percent SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

14. Priority setting for limited resources • Delivery of potassium iodide in response to radioactive release • Adjusted standards of care for initiation and withdrawal of mechanical ventilation • Triage processes for limited intensive care resources • Regional coordination of standards of care during a pandemic or other mass casualty incident

15. Percent of hospitals having written plan for adjusted standards of care for mechanical ventilators during a public health emergency:United States, 2008 SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

16. Expanding on-site health care work force • Continuity of operations • Mutual aid agreements to share health care providers • Advance registration of volunteer health professionals • Staff absenteeism due to personal impact from the emergency • On-site child care to maintain staff in hospital

17. Percent of hospitals having written plan for advance registration of volunteer health professionals during a public health emergency:United States, 2008 SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

18. Mass casualty management • Within-hospital transport of large patient numbers • Inter-hospital transport of large patient numbers • Hospital evacuations • Establishing an on-site large capacity morgue

19. Percent of hospitals with plans for selected components of mass casualty management:United States, 2008 95% confidence intervals Percent SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

20. Pediatric • Guidelines on increasing pediatric surge capacity • Protocol to identify and protect displaced children rapidly • Tracking accompanied and unaccompanied children • Reunification of children with families • Supplies for sheltering healthy displaced children

21. Percent of hospitals with plans for selected components related to pediatrics:United States, 2008 95% confidence intervals Percent

22. Special populations • Communication with: • deaf patients • blind patients • non-English-speaking patients • Sheltering of: • mobility-impaired patients • technology-dependent patients • pregnant women • patients with special health care needs • mentally challenged patients

23. Percent of hospitals with plans for selected components of communication with special populations: United States, 2008 95% confidence intervals Percent

24. Percent of hospitals with plans for selected components of sheltering special populations patients:United States, 2008 95% confidence intervals Percent

25. Communications • Notification of alerts from health departments • Participation with local public health departments in education on influenza vaccination

26. Mass casualty drills In how many drills has your hospital participated in the last year? • Internal drills • Drills in collaboration with other organizations • law enforcement, health department, emergency management, fire department, emergency medical services, hazardous materials teams, decontamination teams • Full scale simulations • How many victims (adult, pediatric, elderly)? • How long did the drill last? • Table-top exercises

27. Drill scenarios • General disaster and emergency response • Biologic accidents or attacks • acute decontamination of aerosol exposure • delayed disease outbreak management • Severe epidemic or pandemic • Mass vaccinations • Mass medication distribution to: • hospital personnel • community • Chemical accidents or attacks • Nuclear or radiological accidents or attacks • Decontamination procedures • Explosive or incendiary accidents or attacks

28. Percent of hospitals participating in selected mass casualty drill scenario types:United States, 2008 95% confidence intervals Percent SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

29. Ambulance diversion Total number of hours in 2007 that: • Emergency department (ED) was on ambulance diversion • Hospital was on trauma diversion • Hospital was on diversion for critical care cases

30. Percent of hospitals on ambulance diversion status, by number of hours spent on diversion: United States, 2008 95% confidence intervals Percent Cut point based on mean of 220.4 hours spent on diversion. Distribution highly skewed with median and mode both equal to zero (no diversion hours). SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

31. Key points:Explosions and fires • Preparedness for explosions and fires less frequent than for other mass casualties • Explosive terrorism infrequent in U.S. • No incidents since 2001 • More common internationally • Fires more common • 15,500 fires in high-rises (1996-1998) • 6% of these were in hospitals U.S. Fire Administration. High-rise fires. Topical Fire Research Series 2(18):1-7. 2002.

32. Key points:Emergency department crowding ACEP recommends that hospitals develop adequate inpatient surge capacity by: • canceling elective admissions and procedures • 83.6% of hospitals have plans for this • opening unused areas • 52.3% have plans to use inpatient hallways • using alternate areas for extra critical care space • 50.7% of hospitals have this American College of Emergency Physicians (ACEP). National strategic plan for emergency department management of outbreaks of novel H1N1 influenza.

33. Key points:Emergency department crowding Study of adverse events from admitting ED-boarded patients to inpatient hallway beds during overcrowding situations. • Compared to patients admitted to standard beds: • In-hospital mortality significantly lower for hallway patients • ICU transfers significantly lower for hallway patients • Conclusion: hallway boarding not harmful Viccellio et al. The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med 54(4):511-3. 2009.

34. Key points:Crisis standards of care • IOM recommends development of consistent state crisis standards of care. Institute of Medicine (IOM) of the National Academies. Guidance for establishing crisis standards of care for use in disaster situations. Report Brief 1-4. 2009. • Only 43% of hospitals plan for adjusted standards of care for ventilators during mass casualties. • Model for developing such standards: • Triage system for using ventilators based on clinical factors related to survival potential • Implemented through health department • Supported by governor declaration • Liability protections in place Hick & O’Laughlin. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med 13(2):223-9. 2006.

35. Key points:Epidemic drills • ACEP also recommends staging exercises to test validity of pandemic flu training and plans. • 59% of hospitals staged severe epidemic drills. • 33% included mass vaccinations. • 23% included community medication distribution. • Survey of health care epidemiologists • 60% felt hospital was well-prepared for pandemic • 31% reported shortages of antiviral medications • Important priorities: • Pandemic flu plan revisions • Mandatory flu vaccination for health care workers Lautenbach et al. Initial response of health care institutions to emergence of H1N1 influenza: experiences, obstacles, and perceived future needs. Clin Infect Dis 50(4):528-30. 2010.

36. Key points:Advance registration of health professionals • Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) • Office of Assistant Secretary of Preparedness & Response (OASPR) • Grant program for health care facilities to verify credentials of volunteers during emergencies • Only 56% of hospitals had plans for advance registration of outside health care professionals.

37. The report and contact information • Niska RW, Shimizu IM. Hospital preparedness for emergency response: United States, 2008. National health statistics reports; no 37. Hyattsville, MD: National Center for Health Statistics. 2011. • http://www.cdc.gov/nchs/data/nhsr/nhsr037.pdf • Contact: • CAPT Rick Niska, MD, MPH • Rniska@cdc.gov