Hospital Care

1. Hospital Care John L. Hick, M.D. Emergency Physician Hennepin County Medical Center Chair, Metropolitan Hospital Compact

2. Overwhelming demand Greatest good Resources lacking No temporary solution Federal level may provide guidance Operational implementation is State/local State emergency health powers Provider liability protection Planning Assumptions

3. Coordinated Mass Casualty Care • Effective incident management critical • Fully integrated • Conduct action planning cycles • Anticipate resource needs • Make timely requests and allocate

4. Coordinated Mass Casualty Care • Increased system capacity (surge capacity) • Decisionmaking process for resource allocation • Shift from reactive to proactive strategies • Administrative vs. clinical changes

5. Incremental changes to standard of care Usual patient care provided Austere patient care provided Low impact administration changes High-impact clinical changes Administrative Changes Clinical Changes to usual care to usual care Triage set up in lobby area Re-allocate ventilators due to shortage Significant reduction in documentation Vital signs checked less regularly Meals served by nonclinical staff Significantly raise threshold for admission (chest pain with normal ECG goes home, etc.) Significant changes in nurse/patient ratios Deny care to those presenting to ED with minor symptoms Nurse educators pulled to clinical duties Stable ventilator patients managed on step-down beds Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Allocate limited antivirals to select patients Cancel most/all outpatient appointments and procedures Disaster documentation forms used Minimal lab and x-ray testing Need increasingly exceeds resources

6. Recognize resource shortfall Request additional resources or facilitate transfer of patients/alternative care site Provide supportive policy and decision tools Provide liability relief Manage the scarce resources in an equitable framework State-level responsibilities

7. Hospital Responsibilities • Plan for administrative adaptations (roles and responsibilities) • Optimize surge capacity planning • Practice incident management and work with regional stakeholders • Decisionmaking process for scarce resource situations

8. Scarce Clinical Resources • Process for planning vs. process for response • Response concept of operations: • IMS recognizes situation • Clinical care committee • Triage plan • Decision implementation

9. Clinical Care Committee • Multiple institutional stakeholders decide, based on resources and demand: • Administrative decisions – primary, secondary, tertiary triage • Ethical basis – AMA principles, etc. • Decision tool(s) to be used

10. Triage Plan • Assign triage staff • Review resources and demand • Use decision tools and clinical judgment to determine which patients will benefit most • Advise “bed czar” or other implementing staff

11. Implementing Decisions • “Bed Czar” or other designated staff • Transition of care support (as needed) • Behavioral health issues • Security issues • Administrative issues • Palliative care issues