Transcript HAZMAT for Emergency Physicians

Surge Capacity:
Preparing for the worstcase scenario
John L. Hick, MD
Hamilton, Ontario
May 29, 2006
What defines a disaster?
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Demand for critical resources outstrips
availability thus putting patients or staff in
danger
Goal is to plan ahead to ensure:
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More effective use of available resources
Mobilization of additional resources
Outcome: ‘special incident’ doesn’t become a
‘disaster’
May depend on time / day / facility
Capacity vs. Capability
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Surge Capacity – ‘the ability to manage
increased patient care volume that otherwise
would severely challenge or exceed the
existing medical infrastructure’
Surge Capability – ‘the ability to manage
patients requiring unusual or very specialized
medical evaluation and intervention, often for
uncommon medical conditions’
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Barbera and Macintyre
Surge Capacity Partners
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EMS (and other patient transportation resources)
Emergency Management
Public Health
Public Safety/Law enforcement
Healthcare Systems
Hospitals and hospital associations
Red Cross
Behavioral health
Jurisdictional legal authorities
Professional associations inc pharmacy, medical,
nursing, mental health
Concepts and Principles
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Standardization
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Incident Management System
Multi-Agency Coordination System
Public Information Systems
Interoperability (eg: personnel and resource
typing)
Scalability
Flexibility
Tiers of capacity (spillover to next level)
Surge Capacity Coordination
Neighborhood
Emergency Help
Centers
LTC Facilities
Mass Dispensing Clinics
Screening Centers
Home
In-Home
Family Care
Homecare
Off-Site Care Facilities
Clinics and/or
Private MDs
e.g., Procedure Centers,
Churches, Hotels, Community/
Recreation Centers, Warehouses
Treatment/Triage
Urgent Care
Centers
Hospitals
Tiers of Response – Patient Care
Provincial and National
Response
Province A
Jurisdiction I
(PH/EM/Public Safety)
Province B
HCF B
6th Tier
Provincial Coordination
5th Tier
Regional Coordination
4th Tier
Jurisdiction II
(PH/EM/Public Safety)
Jurisdiction Incident
Management
Medical
Support
HCF A
National Response
HCF C
Non-HCF
Providers
3rd Tier
Healthcare “Coalition”
2nd Tier
Healthcare Facility
1st Tier
Capabilities and Resources
Tiered Response Strategy
National Response
Provincial Response
Regional / Mutual Response Systems
Local Response
Minimal
Low
Medium
High
Increasing magnitude and severity
Catastrophic
Facility / Community Planning
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Emergency
Management Plan
HVA
Command, control,
communications
Community partners
Regional partners
Training
Drills
Review / modify
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Functional Planning
 MCI
 Security Event
 Fire
 Chemical exposure
 Radiologic Event
 Infectious Disease
 Evacuation
Local Attractions...
Emergencies Present Themselves
In 2 Ways…
Unanticipated
and/or
Without Warning
Anticipated
and/or
With Warning
Oklahoma City Bombing
Hurricane Katrina
September 11, 2001
Northridge Earthquake
Midwest Floods
Pandemic Influenza
The Amount of Time We’re Given
To Pre-Organize People and Pre-Stage Equipment
Can Drastically Change Our Response Effectiveness
‘C’ first and foremost
Command
 Control
 Communication
 Coordination
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Command / Control
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Who is in charge?
Who has authority to declare a special
incident, evacuate, etc?
Where is the EOC/Command Post?
How does the EOC/CP interact with:
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Community resources
Other hospitals/public health
Tiered, scalable, flexible plans
Use of Hospital Incident Command System
Getting Organized…
Nature
Size
Day of the Week
Initially
Location Time of Day
Emergency
Operations
Center
Incident
Action
Planning
What ?
Where ?
When ?
Who’s Involved ?
Where Is It Going ?
INCIDENT BRIEFING
Mobilization
• Date/time of start of incident
Checklist
• Type of incident
• Services involved
• Current incident status
• Current resource status
• Current strategy/objectives
• Communications systems being used
• Special problems/issues
Communication
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Within ED / hospital
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Phone (redundant?), local cellular
Paging
Portable radios
Alpha pagers, SMS, email, VOIP
Runners
Outside facility – phone, cell, HEAR, amateur
radio, internet – VOIP, email, net-based
Coordination
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Within facility (for ICU, CT, etc.)
Outside facility:
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Transfers (including ambulances, helos)
Resource requests
Outside agencies
Regional Hospital Resource Center (RHRC)
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Coordinates hospital response and requests
within region
‘S’ - Logistics
 Space
 Staff
 Stuff
Space
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Get ‘em up and get ‘em out (ED, clinics)
Discharges and transfers (eg: nursing home)
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Discharge holding area
Board patients in halls
Cancel elective procedures
Convert procedure/PACU areas to patient care
Accommodate vents on floor (or BVM or austere O2
flow powered ventilators)
Alternative ambulatory care areas (lobbies, clinics,
etc.)
Staff
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Different events = different staff needs
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Eg: HAZMAT vs. trauma vs. monkeypox
Scope of event = scope of staff call-in
Mechanism to reach staff
Support staff – eg: central supply, food,
psychosocial
Labor pool unit leader
Assign staff to specific areas when possible
Nursing staff often limiting factor
Staffing
Personnel Augmentation
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Hospital personnel
Clinic personnel
Non-clinical practice professionals
Retired professionals (eg: HC Medical Society)
Trainees in health professions
Service organizations
Lay public / faith-based / family members
Government personnel
Stuff
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Patient care supplies – look at by type of
event
Pharmacy – analgesia, sedation, dT, abx
PPE – masks, barrier gowns
Supply and staffing issues (72h ahead)
Logistics and planning sections
Surge Capability
Pharmaceuticals
Personal Protective Equipment
HCMC
Security
HCMC
Security
‘T’ - Operations
 Triage
 Treatment
 Transport
Triage
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Primary – immediate, often scene-based (eg:
EMS)
Secondary – at hospital or for in-hospital
resources, re-assessment
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Location
Supplies
Personnel
Tertiary – after admission / initial care
Treatment
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Where provided? (eg: will certain patients be
cohorted in certain areas?)
What treatment will be provided? (resource
limitations?)
What are the limiting factors?
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Staff
Supplies
Space
Transportation
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Ground assets (including buses and out-ofarea EMS)
Rotor-wing
“Loading zones” for both ground and air units
Receiving facilities
Coordination of patients, records
Prioritization for evacuation and method
Transportation Capacity/Capability
Behavioral Health Surge
INCOMING
EMSProcessed
Medical
Self-Transported
Medical Casualties
Psychological
Casualties
Media
Bystanders or
Family
Family Members
Members,
Searching
Friends,
for Missing
Co-workers
Loved Ones
of Incoming
Casualties
Volunteers
Injured,
Exposed,
Distressed
Disaster/
Emergency
Workers
Onlookers
INPATIENT
Distressed Inpatients
Family Members
of Inpatients
Distressed Staff
IN-HOUSE
CommunityBased
Surge
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Clinics
Homecare
Nursing homes
Procedure centers
Family-based care
Off-site hospitals (Acute Care Center)
Off-site clinics (Neighborhood Emergency Help
Centers) (assessment and clinic level care)
Local / Regional referral / NDMS
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Influenza calls to MDH
December 2003
3000
2500
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Visits to MDH home and Flu Clinic
web pages - Dec 2003
12,000
10,000
MDH Home Page
Flu Clinic Page
8,000
6,000
4,000
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12/3 12/6 12/9 12/12 12/15 12/18 12/21
Hospital Metro Resources
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Routinely staffed beds 4857
Avg. daily census 4143
Surge Capacity
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Census vs. staffed variance 714
Unstaffed but available beds 1068
15% of total beds staffed = 728
PACU/procedure rooms 536
Convertible rooms single to double 473
Total average overall surge capacity 2500-3519
Adjusted standard of care surge capacity 5001000
Metro Hospital Resources
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Stepdown beds 501 (surge 190 addtl)
ICU beds 416 (surge 192 addtl)
PICU beds 64 (surge 20-39 addtl)
ED beds 460
OR suites 295
Ventilators 533
Tabs of doxycycline 76,881
Hospital C
Hospital B
Clinic coord
Hospital A
Healthsystem
Regional Hospital
Resource Center
Multi-Agency Coordination
Center
EM
A
EMS
PH
A
B
Jurisdiction
Emergency
Management
B
C
C
A
B
EMS Agencies
C
Public Health
Agencies
Hospital Resources Metro
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Population 2,600,000
10% population affected by ‘pandemic’ =
260,000 patients
20% of affected patients too sick to care for
selves = 52,000
20% of those patients lack family members
that can care for them or are too sick for
homecare (require IV fluids, etc.) = 10,400
Requires off-site care facilities and triage of
resources
Off-site hospital
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Incident recognized, regional coordination
established, need for off-site care recognized
Primary and secondary sites pre-selected and
screened
Public health authority is authorizing/controlling
entity
Compact provides for first 48h:
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Teams of providers (RN, MD, HCA/NA/EMT)
<200 beds – 1 team
>200 beds – 2 teams
Each 6-8 person team has up to 50 patients
May be required when hospital infrastructure
damaged, especially in smaller community
Sample Site
Sample Site
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Food
Restrooms
Staff rehab areas
Secure
HVAC system specs
Paging /messaging
/radio
Power
Phone, T1 lines, etc.
City owned!
Adjusting Standards of Care
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The last resort
‘What do you do when you can’t surge any
more’
Gracefully, systematically change your
standard of care to one appropriate for the
resources available
Staffing and staff roles / responsibilities
Policy changes (eg: documentation)
Resource triage decisions
Overarching Goal
Do the greatest good for the
greatest number of persons
you can based upon the
resources available…
What are the goals?
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Understanding by the community of the limits of
resources and the plans when they are exhausted
Evidence-based strategy for triage of resources
(based upon chance of survival, not subjective
factors)
Regional, not facility-based criteria
Provide support and framework for physician
decisions
Provide governmental support for response efforts
including liability protection
Restrictions on Mechanical
Ventilation
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Do not offer or withdraw ventilator support
for:
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Tier 1 – multi-organ failure
Tier 2 – severe underlying disease conditions
Tier 3 – other criteria (event driven) possible:
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Sequential Organ Failure Assessment Score
Age related?
Other markers for poor outcomes?
What can I do?
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Know your role in your institutional plan
Work with your emergency preparedness committee
Look at your C, S, T - have you optimized your
preparedness? Ask questions, run scenarios…
KISS
Job action sheets / task cards
Extension of daily tasks / responsibilities
Education where these differ from your plan
Start small, grow big