Basic Principles of Field Medical Site Selection During Disasters

Dan Bochicchio, MD, FCCP.

Baltimore VA Medical Center

Assistant Professor, University of Maryland

Colonel, Medical Corps Army National Guard

Daniel.Bochicchio@va.gov

Learning Objectives

• Develop familiarity with the requirements of Alternative Care locations

• Learn the basic requirements of field medical site selection

• Recognize the critical site selection criteria:1. Safety

2. Security

3. Size

4. Location

Terminology • Medical Surge Capacity

– The ability of a healthcare facility to adequate care in excess of their normal operating capacity.

• Refers to expanding the workload on existing infrastructure

• Alternate Care Facility (ACF)– Aka: Alternative care site

– Defined by HHS as: “alternate locations for providing care that usually would be provided in an inpatient facility”

• Buildings of convenience (ie: warehouse, hanger)

• Mobile medical facilities (ie: truck, rail mounted or floating )

• Portable medical facilities (ie: tents, shipping containers

What Types of Support (internal or external) May Be Requested

Establish an ACF to:1. Provide patient care in

the event the medical center is inaccessible (ie: flooded)

2. Establish additional bed space in support of the National Response Framework (NRF)

3. Establish a pharmacy Point of Distribution (POD)

4. Provide the personnel to supplement the staff via DEMPS

Federal Medical Station (FMS)250-bed FMS set consists of three modules:3.Base Support : Administrative, food service, housekeeping, basic medical supplies and personal protective equipment. 4.Treatment : Medical/surgical items5.Pharmacy : Medications

Site Selection

• Site selection is an important factor impacting on the accomplishment of the mission.

• Improper site selection can result in inefficiency and possibly danger to personnel and patients

Site Selection Steps: “The What Phase”

• An event occurs or is anticipated to occur…..

• A capability is requested by an appropriate authority

• Identify mission:1. What is the nature of the event ??

• Hurricane; flooding; earthquake; biological; nuclear…?

• Expected numbers and types of patients. – Veterans and/or military only

– Civilian population: Adult, Pediatric…....Obstetrics??

• Duration that the facility will be operational; Days ---> Weeks, Months??

2. Scope of operations• Emergency medical care; Outpatient; Surgical; Medication/Vaccination distro?

• What are you being tasked to accomplish?– Provide personnel?

– Equipment?

Site Selection Steps: “The How Phase”

1. Coordinate with authorities to identify potential sites– Identify other medical capabilities in the area of responsibility to help

develop unity of effort

2. Consider co-locating with other related ESF functions– ie: Food and Water distro, Mass Sheltering Ops, Points of Embarkation,

Logistics nodes.

– Do you need to be close or far away from existing hospitals?

3. Conduct a “virtual’ map analysis to identify potential sites– Commercial open source web sites ( Google maps, Yahoo, etc.)

4. Conduct an actual site suitability visit– Get real time “eyes on” the area if time permits

5. Rank order the sites that fit the mission requirements – Pick 3 to 5 sites based on best current info and projected situation

Site Selection: “The Where Phase”

The Key Elements:

• Safety

• Security

• Size (Acreage)

• Location.. Location… Location….!!

The Principles Selecting Your Site: Location

1. Terrain featuresa. Level ground b. High ground: not prone to flooding during the anticipated operational

periodc. Good drainage d. Solid ground: needed to support vehicles

• Accessibility– Easy access for Evacuation vehicles ( One way traffic, please!!)

• Ambulances, Buses, etc.– Close to transportation nodes

• Roads, highways, Mass transit, Railroads • Logistics support

– Close proximity to Helicopter landing pad– Proximity to Patient Densities and patient collection points.

• Natural lines of drift (the routes that people will naturally walk )• Signage (easy to find and recognize) • Accessible to walking injured

The Principles Selecting Your Site: Safety and Security

1. Safetya. A safe distance from the event (ie: up wind!)b. Safe from secondary eventsc. Safe from(or can be made safe from) environmental hazards

• Floods, mudslides, fires, earthquake, extremes temperature, swamps • Disease vectors (rodents, insects, etc.)• Hazardous materials and fumes ( your own generators and waste!!! )

– Avoidance of dangerous facilities and activities• Potential targets of civil disturbance

– Food and Fuel distribution points– Vaccinations or Antibiotic distribution POD’s

• Security– Appropriate security force to ensure patients and staff remain safe– Controlled access to area for patients, visitors and families– Adequate perimeter fencing (a wall is better than barbed wire !)

The Principles Selecting Your Site

1. Selecting a Building of Opportunity– The HHS Disaster ACF:

Report and Interactive Tool• Rocky Mountain Regional

Care Model for Bioterrorist Events

– Uses separate 33 Criteria in five broad areas

1. Infrastructure (8)2. Space and layout (9)3. Utilities (6)4. Communications (3)5. Other (7)

– No show stoppers ??

General Site Layout:40 Cot Field Medical Site ( ~4 Acre)

Key Features:

2. One way traffic flow

3. Pt drop off area

4. Pt pick up area

5. Helicopter pad

6. Generators

7. Sleeping area

8. Site Density

250 Bed Field Hospital • Admitting Area / Triage E. Staff Sleeping tents• Operating rooms and Critical Care Areas F. Latrines and Shower• Power Generation• Med-Surg Wards

CBRN Contaminated Environment

1. Safe distance upwind from event

2. Decon in Hot Zone

3. Triage on both sides of Hot Line

4. Only clean patients enter facility

5. Contaminated vehicles remain in Hot Zone for duration

Port au Prince, Haiti January, 2010

IMSuRT-DMAT Gheskio Field Hospital Port au Prince, Haiti January, 2010

IMSuRT-DMAT SiteIMSuRT-DMAT Site

IMSuRT- DMAT Site

IMSuRT Site

Potential IMSuRT-DMAT Relocation Site ?? Perhaps not…. Why not?

50 Acre Site with view of Marsh and Tank Farm…

Potential IMSuRT-DMAT Relocation Site

Potential IMSuRT-DMAT Relocation Site

Key Criteria• Safety

– Natural or Man made Hazards

• Security– Can be

protected from threats

• Size– Adequate for

needs

• Location– Terrain

Features– Accessibility– Patient Density

The New Orleans Superdome

Key Criteria• Safety

– Natural or Man made Hazards

• Security– Can be

protected from threats

• Size– Adequate for

needs• Location

– Terrain Features– Accessibility– Patient Density

NDMS-DMAT Team

Key Criteria• Safety

– Natural or Man made Hazards

• Security– Can be

protected from threats

• Size– Adequate for

needs• Location

– Terrain Features

– Accessibility– Patient density

NDMS-DMAT Team

Key Criteria

• Safety– Natural or Man

made Hazards

• Security– Can be protected

from threats

• Size– Adequate for

needs

• Location– Terrain Features

– Accessibility

– Patient Density

Summary

• Identify mission requirements– Nature of the event?– Scope of operations

• What are they asking us to do?

• Follow Basic Rules– Safety

• Natural or Man made Hazards– Security

• Can be protected from threats– Size

• Adequate for needs– Location

• Terrain Features• Accessibility • Patient density MacGyver meets Gilligan's Island

References • The Medical Company FM 4-02.6 (FM 8-10-1) Tactics Techniques, and Procedures August

2002 Headquarters, Department of the Army Washington, DC. Available at: https://akocomm.us.army.mil/usapa/doctrine/DR_pubs/dr_aa/pdf/fm4_02x6.pdf

• Disaster Alternate Care Facilities: Selection and Operation Cantrill S.V, Pons PT., et-al Department oh health and human Servises, Agency for Healthcare Research and Quailty Rockville, MD. October, 2009 Available at: http://www.ahrq.gov/prep/

• Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency. December 2004. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.ahrq.gov/research/altsites.htm

• Employment of the Combat Support Hospital; FM 8-10-14 Tactics Techniques, and Procedures December 1994 Headquarters, Department of the Army Washington, DC.

• Lam C, Waldhorn R, Toner E, Inglesby T. , The Prospect of Using Alternative Medical Care Facilities in an Influenza Pandemic; Biosecurity and Bioterrorism. Volume 4, Number 4, 2006.

• Waldhorn, R., What Role Can Alternative Care Facilities Play in an Influenza Pandemic? Biosecurity and Bioterrorism. Volume 6, Number 4, 2008 Available at: http://www.upmc-biosecurity.org/website/resources/publications/2008/2008-12-01-role_alt_care_flu_pandemic.html

• Franco C, Toner E, Waldhorn R, Maldin B, O’Toole T, Inglesby TV. Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror 2006;4(2):135-146

• Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina. A Failure of Initiative: The Final Report of the Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina. Washington, DC: Select Bipartisan Committee; February 15, 2006. Available at: http://a257.g.akamaitech.net/7/257/2422/15feb20061230/www.gpoaccess

• U.S. Senate. A Nation Still Unprepared: Report of the Committee on Homeland Security and Governmental Affairs. Washington, DC: U.S. Senate; May 2006. Available at: http://hsgac.senate.gov/_files/Katrina/FullReport.pdf