Florida Hurricanes 2004 Models of Integration Between FL-1 DMAT and Local Hospitals

2. Florida Hurricanes 2004Models of Integration Between FL-1 DMAT and Local Hospitals David GC McCann MD Chief Medical Officer FL-1 DMAT Fort Walton Beach, Florida

3. To understand methods of integrating a DMAT with local EDs during disaster response To appreciate the differing challenges facing DMATs attempting to integrate with local EDs: 1. When the DMAT is “first out” 2. When the DMAT is relieving another team already on-site Objectives

4. To appreciate the advantages and disadvantages of various integration scenarios To make recommendations for integration in future disaster deployments Objectives

5. Four major hurricanes hit Florida in 2004: Charley Frances Ivan Jeanne A record number of landfalls and tremendous damage Florida Hurricanes 2004

6. Florida Changes Its State Slogan

7. Hurricane Charley Landfall Friday, August 13 at Charlotte Harbor in SW Florida at 3:45 PM EDT Wind speed=150 mph (Cat 4) Damage to insured property=$14 billion Direct Fatalities: 10 Hurricane Frances Landfall Sunday, Sept 5 at Sewall’s Point, Stuart in South Florida at 1 AM EDT Wind speed=105 mph (Cat 2) Damage to insured property=$8.9 billion Direct Fatalities: 23 Florida Hurricanes 2004

8. Hurricane Charley

10. Hurricane Ivan Landfall Thursday, September 16 at Gulf Shores, AL at 3 AM EDT Wind speed=130 mph (Cat 3) Damage to insured property=$13 billion Direct Fatalities: 25 in Florida Hurricane Jeanne Landfall Saturday, Sept 25 at North Hutchison Island, Stuart in South Florida at 11:50 PM EDT Wind speed= 120 mph (Cat 3) Damage to insured property=$6.5 billion Direct Fatalities: 12 Florida Hurricanes 2004

11. Hurricane Ivan Signals Offshore…

12. Jeanne Hits Stuart, FL

14. Better too much than too little… Push resources toward affected area prior to eventwhen safe! A quick, overwhelming response is better than a slow, well-planned response If you wait until you have all the facts, it will be harder to change the outcome. Disaster Response Principles

15. Starting Pitcher vs. Ace Reliever DMAT Roles

16. There are advantages and disadvantages to being “first out” versus relieving another team already on-site Knowing the upside and downside of each scenario helps you prepare to meet challenges Starter versus Reliever?

17. Set up physical plant the way you wantdo it so patient flow is under your control and optimized Initial contact with local hospital “get off on the right foot”communication! All team members psycheddisaster has just occurredLet’s roll… First Out TeamPros

18. Hurricane Charley

19. Hurricane Jeanne

20. No pharmacy cache available until some time after set up on-site (usually) Possibly difficult getting to deployment site due to downed trees, power lines etc. Rapid Needs Assessment (RAN) still ongoingmission may not be completely elucidated when you deploy”waiting game” First Out TeamCons

21. RAN is completemission is certain and needs well determined Pharmacy cache, air-conditioned tents on-site Properly done handover allows continuity of careno need to reinvent the wheel Relieving TeamPros

22. Set up of physical plant is pre-determined if problems, now yours! Any communication or interpersonal problems between previous team and local hospital you have to smooth over Can be problem disengaging “we like having a DMAT, you can’t leave!” Relieving TeamCons

23. Set up physical plant so patient flow controlled by DMAT At Hurricane Charley we did this set up right in ED entrance worked very well At Hurricane Jeanne, set up was across roadway inefficient and decreased numbers seen by DMAT as ED did triage and kept more patients. DMAT Triage

26. In a study of 29 major disasters, only 10-15% of casualties were injured seriously enough to require overnight admission to hospital; only 6% of affected hospitals suffered supply shortages, and only 2% had personnel shortages. Disaster Principle

27. Custodial care (e.g. if Nursing Homes damaged/destroyed) Basic medical care Mental Health care Prescription medications/refills Treatment for chronic illnesses (e.g. diabetes, asthma/COPD, CAD, etc.) Oxygen for people on chronic oxygen So What Do Disaster Victims Need in Healthcare?

31. Study by Nufer & Wilson-Ramirez (2004) looked at NM-1 DMAT experience Commonest Chief Complaints to DMAT: Wounds Musculoskeletal Pain Med refill URI Rash/Cellulitis Abdominal complaints (pain, vomiting/diarrhea) Healthcare Visits to DMATs

32. Commonest Treatments Provided: Tetanus vaccination Wound care Antibiotics Pain reliever Medication refills Nufer & Wilson-Ramirez

33. Triage Categories: Green 80% Yellow 16% Red 4% Patient Disposition: Home 91% Hospital 6% Left AMA 3% Nufer & Wilson-Ramirez

34. We found sending a letter by fax to all local pharmacies with doctors’ DEA numbers and FEMA credentials decreased call backs for verification Do this as soon as DMAT set up Obtain list daily of open pharmacies and local doctors’ offices to communicate to patients—try to arrange follow-up with their own physician if possible Prescriptions & Refills

35. DMATs need pharm cache sufficient to at least partially fill majority of scripts Pre-printed prescription pads with doctor’s DEA and FEMA information—or at least a stamp with this info Narcotic abuse is rampantdon’t write drugs of abusesend into ED where “regulars” well-known Prescriptions & Refills

36. Community-acquired MRSA is now a fact of life “Spider-bites” and abscesses may be CA-MRSAculture then treat We used Clindamycin as outpatient treatment of skin infections—recent reports also found TMP-SMX works on CA-MRSA BUT, clindamycin-inducible CA-MRSA resistance commonthere is a test for this through lab CA-MRSA

37. Disengagement—work closely with emergency managers and hospital admin Implement demobilization incrementally Chart call volume, peak times and duration watch trends especially in relation to expected post-disaster historical trends Systematically reduce local dependence on DMAT Breaking Up Is Hard To Do…

38. “We’re from FEMA—we are federalizing this ED and taking over….” “We’ll stay as long as you feel we are needed.” (That might be a long time…) Telling patients: “Everything is free, you won’t have to pay for anything!” Things Not to Say

39. Disaster Research

40. According to FEMA IS-700 course on NIMS: “The NIMS Integration Center will also develop a national database for incident reports” Excellent idea to do it we need a system of uniform data entry/capture across all incident types and missions NIMS and Disaster Research

41. We need uniform capture of data across all DMAT/IMSURT Missions: Design an MS Access/Excel Program which all patient encounters would use for registration (mandatory field entry) Print out Patient Encounter forms with entered data Field codes to be saved in Access database Disaster Research & Data Capture

42. Ideal program would log following fields: Age Sex Race Ethnicity Disaster Category Classification (patient) Disaster Related Activity Chief Complaint Co morbidities Diagnosis ICD-9 Code Disposition Triage Category Disaster Uniform Data Entry System (DUDES)

44. DUDES data should be kept in central server repository (NIMS Integration Center) make available for disaster researchers with appropriate clearance Disasters occur infrequently let’s not miss opportunity to collect and store data! Use Utstein template to internationally rationalize Disaster Research Disaster Research & Data Capture

46. Disaster Response Permutations

47. After a disaster either there is a hospital to serve the injured/sick or not Depending on the situation, either DMATs, IMSURTs or other portable medical assets may need deployment Let us look at the possible permutations… Disaster Response Permutations

49. After hurricanes, hospitals, clinics & doctors’ offices may be damaged or destroyed How can we (FEMA/DMATs) help prevent further loss of infrastructure due to economic impact? Don’t want local docs and surgeons packing up & leaving for good Maintaining Local Infrastructure

50. Damaged hospitals need to get “up & running” ASAP to decrease lost revenue which threatens long-term viability DMATs must use proper hospital order forms so tests run will be reimbursed DMAT Triage vs Hospital ED triagepros and cons both ways Competing Interests