The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans

2. The Transitional Medical Model (TMM) FrameworkFor Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen, RN, MSEd The University of Toledo College of Medicine Department of Public Health & Preventive Medicine

3. Pandemic • The Enigmatic Disaster

4. Most Disasters • Limited • Transparent • Obvious to all • Well-defined • Beginning • End • Help will come from somewhere

5. Response to most disasters • Based upon hazard analysis • Based upon risk assessment • Based upon precedent

6. Mitigation, Preparedness, Response, and Recovery • The broad strokes are sufficient for most disasters • 40-Car Pileup • Tornado through a Trailer Park • Explosion in the Downtown district

7. Pandemics are not your typical disasters • Precedents are few • Last major precedent (1918) before most people existed • Not transparent • No definite beginning, middle or end • External assistance may arrive late, if at all • Local response: Prominent

8. Pandemics: Outside of the Public’s Scope of Consciousness • Disproportional morbidity & mortality • Social distancing measures • Fractured infrastructure (schools, businesses, places of worship, etc.) • Limited personnel • Limited resources

9. Pandemics: Outside of the Public’s Scope of Consciousness • Prioritizing certain population subsets to receive those resources • Depriving other subsets from receiving those resources • For example, allocation of scarce resources • Cancellation of escapist activities

10. Potential Ramifications • Economic chaos • Worsening and prolonged effects on personal and communal mental health • Needless illness and death • Greater potential for violence • Domestic • Non-domestic • Risk of child exploitation and victimization • Prolonged interval of time to return to the community’s baseline infrastructure

11. What must be recognized… • Any disaster response begins locally • Don’t depend on external agencies to determine the fate of your jurisdiction • Any response must be early, incremental, and temperate • Reference: 1918 response

12. Why early, incremental and temperate? • Puts your jurisdiction ahead of events • Allows acclimatization for all citizens • Builds public confidence • Cost-effective • A “ramping-up or ramping-down” would ultimately be cheaper than an all-or-none action.

13. The Transitional Medical Model (TMM) • Intermeshed with mitigation, preparedness, response, and recovery concepts • Incorporates a strategy that bridges the activities of normal day-to-day living with those that are employed during a potential pandemic.

14. The Paradigm • Traditional Medical Phase • Mitigation & planning • The Transitional Medical Phase • Level 1 • Level 2 • Level 3 • Level 4 • The Catastrophic Phase • The Recovery Phase • Recovery Response

15. Moving from Traditional to Transitional • The evolution from the Traditional Phase to the Transitional Phase is not dependent upon external agencies, but upon the Public Health Commissioner. • All disasters are local

16. Traditional Medical Phase • There is no evidence of an actual or imminent disaster threatening your jurisdiction. • The principal activities: planning and education • The community’s efforts are directed towards activities that will help that community prepare for a response to any disaster, infectious or otherwise. • identification of resources, • acquisition of resources, • education of professionals and the public, and • development, testing and refinement of response strategies.

17. The Transitional Medical Model For details: http://www.ncbi.nlm.nih.gov/pubmed

18. Mission: Transitional Medical Phase • To augment, enhance, and empower a jurisdiction’s medical infrastructure in order to provide medical care to all with skill and compassion, regardless the venue; • To mitigate the worst medical, psychological, ethical, societal, legal consequences of a pandemic thereby minimizing the proportion of ill and dead; • To preserve the community’s infrastructure as long as possible.

19. Transitional Phase, Level 1 • Trigger:Distant outbreak • Description: • No change in care delivery because there is no definitive pandemic. • Information suggests a pandemic could be developing. • Principal actions: • Place the jurisdiction on alert • Urge stakeholders and citizens to review their plans and commence preparations to respond efficaciously. (Please refer to TMM Quickview document for details on triggers)

20. Transitional Phase, Level 2 • Trigger: • Multiple distant outbreaks • Significant morbidity/mortality • Description: • The possibility of a pandemic is more real than theoretical. • Stakeholders and public should begin activating their plans. • Principal Actions: • Expand delivery via expanding capability of extant practices and clinics

21. Transitional Phase, Level 3 • Trigger: • Outbreak approaching jurisdiction • Outbreak repercussion felt within jurisdiction • Description: • A significant outbreak is occurring. • It has begun to impact your jurisdiction. • Principal Actions: • Begin activation of teams • Begin activation of Alternate Care Sites

22. Transitional Phase, Level 4 • Trigger: • Definite outbreak occurring in your jurisdiction • Morbidity/mortality escalating • Description:Active and passive surveillance have revealed the pandemic has arrived in the jurisdiction and surrounding regions. • Principal Actions: • Functional teams • Functional ACSs • Public aware • Care to all, but at non-traditional venues

23. The Catastrophic Phase • Mission: “Providing the Greatest Good for the Greatest Number” • Trigger:jurisdiction losing its support infrastructure • Description: • Deterioration at all healthcare sites: patient volume, lack of personnel, and/or inadequate resources. • Numbers of fatalities overwhelm mortuary venues. • Hospitals are inundated with critical care patients. • Disruption of infrastructural services at all levels • Prioritization of care delivery • Re-allocation of scarce resources to certain patients • Inclusion criteria • Exclusion criteria • Palliative care

24. The Recovery Phase • Mission: Restoration of normalcy or “business as usual” • Triggers: • Your jurisdiction: Drop in ILI among its citizens • Ohio: Drop in ILI among its citizens • The United States: Drop of ILI among its citizens • CDC has declared the pandemic is on the wane. • Description: • Occurs when the Public Health Commissioner believes that all the indicators point to an end of the outbreak. • The measures in place to mitigate the spread of disease are not removed too quickly. • A gradual liberalization from these measures coupled with an intense epidemiological evaluation of the jurisdiction’s health status in order to witness any adverse rise in infectious cases.

25. Major Take-Home Point of the Transitional Medical Model • If done early and thoroughly, your jurisdiction may neverexperience the worst ramifications of the pandemic. • Witness: Communities during the 1918 Pandemic who instituted early and prolonged strategies fared better than others.

26. Someone has to lead… Why not the stakeholders in our jurisdiction?

27. Next Steps • Identify the key stakeholders • Compare the jurisdiction’s plans to the sample plans in the toolkit • Determine whether and how the jurisdiction's plans fit with the TMM levels • Begin the dialog about what each stakeholder is doing during each level

28. Next Steps (contd.) • Modify response plans as needed to develop a congruence of response • Form an Exercise Planning Team and use the toolkit to test your plans. See “Creating Exercises Using the Transitional Medical Model” in this toolkit.