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Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department of Emergency Medicine Denver Health Medical Center 2007 Great Lakes Homeland Security Training Conference & Expo
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Page 1: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

Preparing for Pandemic Influenza:

The Hospital and Community

Perspective

Grand Rapids, MIMay 10, 2007

Stephen V. Cantrill, MDAssociate Director

Department of Emergency MedicineDenver Health Medical Center

2007 Great Lakes Homeland Security Training Conference & Expo

Page 2: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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US, State, Local Estimates of Moderate (1958/68-like) or Severe (1918) Pandemic

USGerberding J,

CDC

ColoradoCalonge N,

CDPHE

DenverPrice C,

DHHA

1958/68 1918 1958/68 1918 1958/68 1918

Illness 90M 90M 1.3M 1.3M 166K 166K

Output Care

45M 45M 645K 645K 83,000 83,000

Hospital 865K 9.9M 12,398 142K 1,577 18,305

ICU 128,750 1.5M 1,845 21,285 238 2,746

Ventilator 64,875 743K 930 10,643 120 1,373

Deaths 2,996 26,276 2,996 26,276 386 3,390

Page 3: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Assumptions for Healthcare

1st wave should last 6-8 weeks Specific vaccine will not be available for 1st wave Organizations need plans to deal with estimated

workforce absenteeism rates around 25% Health-care workers and first responders will be at

high risk of illnessStaffing issues due to illnessFear issues due to transmission risk

Will need to depend on local/institutional plans and resources

May have prolonged cyclic duration which will stress resources and personnel

Page 4: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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DHMC Emerging Infectious Diseases (EID) Task Force

Administration Legal Infection Control ED/Disaster Club Engineering Nursing Leadership Medical Executive Staff Critical Care Laboratory Respiratory Therapy Chaplain/Social Work

Environmental Public Relations Security Materials Management Occupational Health Radiology Pharmacy Information Technology Public Health Medical Education Infectious Diseases

Page 5: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Surveillance Formal process of reviewing public health alerts Information Technology to track patients Inpatient fever surveillance Syndromic surveillance in the ED

Page 6: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Communications

StaffCall down systemEmail/ intranet

PatientsSignagePhone Info HotlinesEducational brochures

MediaPR list of Key ContactsDesignated Spokesperson

Public Health + other institutions

Page 7: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Education and Training

Current healthcare provider web based training allows for rapid training and tracking compliance

Library of educational materials and website H(E)ICS training

AdministrationClinical providersSupport personnelPublic health

Just-in-time training in respiratory care

Page 8: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Supplies/EquipmentAdditional PPE

N95 masksGownsGloves, etc2 months supply

Ventilators – 2 additional full units5 smaller units for $29,000Many “Disposable” Units

Drugs -Minimal stockpile of oseltamivir at this time

Page 9: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Patient Triage Alternative triage locations

Institutional lockdown for walk-in patients

Decompress EDPrevent disease spread

Ideal location depends on specific EID transmission and volume of patients affected

Page 10: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Patient Triage and Admission

Use of automobiles as a social distancing mechanism

Nurse Advice Line to avoid hospital visits Specific criteria for admission Inpatient fever surveillance

Page 11: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Inpatient isolation cohorting by floor

Isolation ward w/ negative airflow capability

Can be completed within 4 hours

Plastic sheeting and 2x4’s Can accommodate

ventilated patients Expandable to 2 floors if

needed: ~50-60 beds

Page 12: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Facility Access

Plan for limiting visitors Main entrance and ED entrance

only access points during epidemic; other entrances closed

Restricted access procedures rehearsed

Threshold for Passive Screening (i.e. signs)

Threshold for Active Screening Patient transport pathways

Page 13: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Occupational Health

A system for rapidly delivering vaccine/prophylaxis to HCWs developed and tested Mass Vax clinics in 2004, 2005 Used incident command system

HCWs have been prioritized Degree of exposure to infectious droplets

Respiratory fit testing/ PAPR training Furlough of contagious staff Detection of symptomatic staff Altering work for high risk staff

Page 14: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Surge Capacity Plan: Surging with Limited Staff

Database of retired healthcare personnel and former traineesLegal issues (e.g. licensing) being reviewed

Limit non-essential patient care Use of phone triage to free up providers Restructuring/reassigning HCW tasks daily

through incident command Just-in Time training, LEAN

Use of family members (bathing, bathroom, vital signs, meals)

Maximize protection of current personnel: vaccines, prophylaxis, infection control

Day care center for employee families?

Page 15: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Psychosocial Support Plan Identify rest and

recuperation sites for responders

Telephone support lines Establish links with

community organizations Train HCWs in basic

psychosocial support services

Create educational brochures

Page 16: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Infection Control Basics:Hand Hygiene and Respiratory Etiquette

Help Stop the Spread of Colds and Flu!

I f you have any of these symptoms: Fever Cough or Sneezing Shortness of Breath Runny Nose

Please put on a yellow mask and clean your hands with the hand foam provided.

Page 17: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Facility Based Surge Capacity

Expedited dischargesAdaptation of existing capacity

Single rooms become doublesTake over areas of the hospital for acute care

(Internal “Alternative Care Sites”)ClassroomsOfficesLobbiesHallways

Page 18: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Surge Capacity Issues

Physical space Organizational structure Medical staff Ancillary staff Support (nutrition, mental health, etc) Supply Pharmaceuticals Other resources

Page 19: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Part of the Problem:

ED overcrowding Inpatient bed loss: 38,000 (4.4%) between

1996 and 2000 ICU capacity loss: 20% between 1995 and

2001Most health care is in the private sector not

under governmental or municipal authority

Page 20: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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DHMC Disaster Contingency Discharge Drill – 1/05

Services participating: Internal Medicine, Surgery, Pediatrics

26% of patients could be transferred off-site to lower care facility (alternative care site)

28% of patients could be discharged home14% could be transferred from ICU to wardPatients transferred with Problem List and

Kardex

Page 21: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Community Based Surge Capacity:Alternative Care Sites

Requires close planning and cooperation amongst diverse groups who have traditionally not played togetherHospitalsOffices of Emergency ManagementRegional plannersState Department of Health

MMRS may be a good organizing force

Page 22: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Where Have We Been?

Page 23: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Hospital Reserve Disaster Inventory

Developed in 1950’s-1960’sDesigned to deal with trauma/nuclear

victimsDeveloped by US Dept of HEWHospital-based storage Included rotated pharmacy stock items

Page 24: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Packaged Disaster Hospitals

Developed in 1950’s-1960’sDesigned to deal with trauma/nuclear victimsDeveloped by US Civil Defense Agency &

Dept of HEW2500 deployedModularized for 50, 100, 200 bed units45,000 pounds; 7500 cubic feet

Page 25: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Packaged Disaster Hospitals

Last one assembled in 1962Adapted from Mobile Army Surgical

Hospital (MASH)Community or hospital-based storage

Page 26: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Packaged Disaster Hospital: Multiple Units

Pharmacy Hospital supplies /

equipment Surgical supplies /

equipment IV solutions / supplies Dental supplies X-ray

Records/office supplies Water supplies Electrical

supplies/equipment Maintenance /

housekeeping supplies Limited oxygen

support

Page 27: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Packaged Disaster Hospital

Page 28: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Packaged Disaster Hospitals

Congress refused to supply funds needed to maintain them in 1972

Declared surplus in 1973Dismantled over the 1970’s-1980’sMany sold for $1

Page 29: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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The Re-Emergence of a Concept

Medical Armory (Medical Cache)Think of the National Guard Armory

Driving Forces:Loss of institutional flexibility

“Just-In-Time” Everything

Loss of physical surge capacityDenver has 1000 fewer physical beds that it did 10

years ago

Page 30: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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The Re-Emergence of a Concept:The Medical Cache

Issues:Augmentation vs Alternative Site?Inclusion of actual structure?Cost?Storage?Ownership?Pharmaceuticals? Level of care provided?

Page 31: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Level I Cache:Hospital Augmentation

Bare-bones approach Physical increase of 50 beds: may be an “Internal

Alternative Care Site” Would rely heavily on hospital supplies Stored in a single trailer About $20,000 Within the realm of institutional ownership Readily mobile - but needs vehicle

Page 32: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Level I Cache:Hospital Augmentation

TrailerCotsLinens IV pollsGlove, gowns, masksBP cuffsStethoscopes

Page 33: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Used During Katrina Evacuee Relief

Page 34: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Page 35: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Level II Cache:Regional Alternative Site

Significantly more robust in terms of supplies

Designed by one of our partners, Colorado Department of Public Health and Environment

Page 36: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Level II Cache:Regional Alternative Site

Designed for initial support of 500 patientsPer HRSA recommendations of 500 patient surge per

1,000,000 populationModular packaging for units of 50-100 pts

Regionally located and stored Trailer-based for mobility Has been implemented Approximate price less than $100,000 per copy

Page 37: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Level III Cache:Comprehensive Alternative Care Site

Adapted from work done by US Army Soldier and Biological Chemical Command

50 Patient modulesMost robust modelClosest to supporting non-disaster level of

care, but still limitedMore extensive equipment support

Page 38: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Work at the Federal Level

DHHS: Public Health System Contingency StationSpecified and demonstrated250 beds in 50 bed unitsQuarantine or lower level of careFor use in existing structuresMultiple copies to be strategically placedOwned and operated by the federal government

Page 39: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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PHS-CSBase Support

WithQuarantine

PHS-CSTreatment

PHS-CSPharmaceutical

PHS-CSBed Aug

(50)

• Administration• Support• Feeding• Quarantine• Beds(50)• Housekeeping• First Aid Equipment• Pediatric Care• Adult Care• Personal Protective Equipment

• Primary Care• Non-Acute Treatment• Special Needs

• Pharmaceutical• Special Medications• Prophylaxis

• Beds• Bedding• Bedside Equipment

“PHS-CS” 250 Bed Module

Configuration

Basic Concept: HHS Public Health ServiceContingency Stations

(Federal Medical Stations)

Page 40: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Demo Scenario

Denver (notionally) experiences an event that demands 100 beds of surge relief.

OPHEP initiates set up of a PHS Contingency Station The Denver Convention Center serves as the building of opportunity

Denver Health Medical Center decides which patients transfer to the Station, and then makes these transfers

Federal manpower operates the Station PHS and/or Medical Reserve Corps provide professional services Federal Logistics Manager operates Station logistics

Colorado and Denver PH/EMS provide service support (notionally)—food, water, utilities, etc

Page 41: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Page 42: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Page 43: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Page 44: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Page 50: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Work at the Federal Level

DHS: Critical care unitSpecified, not yet implementedICU level of care

Specialty care units

Page 51: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Problem

Disaster event overwhelms current hospital capacity

An “Alternative Care Site” must be opened to treat victims

What is the best existing infrastructure/site in the region for delivering care?

Page 52: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Concept of Alternative Care Site

• It is not a miniature hospital• Level of care will decrease• Need to decide in advance: What

types of patients will be treated at the site? • Disaster victims?• Low-level of care patients from

overwhelmed hospitals?

Page 53: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Possible Alternative Care Sites

Hotel

Recreation Center

Church

Stadium

School

Page 54: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Potential Non-Hospital Sites

Aircraft hangers Churches Community/recreation

centers Convalescent care

facilities Fairgrounds Government buildings Hotels/motels Meeting Halls Military facilities

National Guard armories Same day surgical

centers/clinics Schools Sports Facilities/stadiums Trailers/tents

(military/other) Shuttered Hospitals Detention Facilities

Page 55: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Some Issues:

Private sites vs Public sitesWho can grant permission to use?Need for decontamination after use to

restore to original function

Page 56: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Infrastructure Requirements

Infrastructure factors listed on axis of a matrix.

Additional relevant factors can be added/deleted based on your area or the type of event.

Relative weight scale created on 5-point scale comparing factor to that of a hospital

Page 57: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Factors to Weigh in Selection an Alternative Care Site

Ability to lock down facility Adequate building security

personnel Adequate lighting Air conditioning Area for equipment storage Biohazard & other waste disposal Communications Door sizes Electrical power (backup) Family Areas Floor & walls Food supply/prep area

Heating Lab/specimen handling area Laundry Loading Dock Mortuary holding area Oxygen delivery capability Parking for staff/visitors Patient decon areas Pharmacy areas Toilet facilities/showers (#) Two-way radio capability Water Wired for IT and Internet Access

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Weighted Scale5 = Equal to or same as a hospital.

4 = Similar to that of a hospital, but has SOME limitations (i.e. quantity/condition).

3 = Similar to that of a hospital, but has some MAJOR limitations (i.e. quantity/condition).

2 = Not similar to that of a hospital, would take modifications to provide.

1 = Not similar to that of a hospital, would take MAJOR modifications to provide.

0 = Does not exist in this facility or is not applicable to this event.

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Potential Non-Hospital Site Analysis Matrix

Ability to lock down facility

Adequate building security personnel

Adequate Lighting

Air Conditioning

Area for equipment storage

Biohazard & other waste disposalCommunications (# phones, Local/Long Distance, Intercom)Door sizes adequate for gurneys/beds

Electrical Power (Backup)

Family Areas

Floor & Walls

Food supply/food prep areas (size)

Heating

Lab/specimen handling area

Laundry

Loading Dock

Mortuary holding area

Oxygen delivery capability

Parking for staff/visitors

Patient decontamination areas

Pharmacy Area

Proximity to main hospital

Roof

Space for Auxillary Services (Rx, counselors, chapel)

Staff Areas

Toilet Facilities/Showers (#)

Two-way radio capability to main facility

Water

Wired for IT and Internet Access

Total Rating/Ranking (Largest # Indicates Best Site) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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Customizing the Site Selection Matrix

A facility and/or factor can be easily added as a new row to excel spreadsheet.

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Issues to ConsiderIs each factor of equal weight?What if another use is already stated for

the building in a disaster situation? • (i.e. a church may have a valuable community

role)

Are missing, critical elements able to be brought in easily to site?

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WHO needs this tool?

Incident commandersRegional plannersPlanning teams including: fire, law, Red

Cross, security, emergency managers, hospital personnel

Public works / hospital engineering should be involved to know what modifications are needed.

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WHEN should you use this tool?

Before an actual event.Choose best site for different scenarios so

have a site in mind for each “type”.

www.denverhealth.org/bioterror/tools.htm

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The Supplemental Oxygen Dilemma

Supplemental oxygen need highly likely in a pan flu / bioterrorism incident

Has been carefully researched by the Armed Forces Most options are quite expensive Most require training/maintenance All present logistical challenges Remains an unresolved issue Most have high cost/patient Many have very high power requirements

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EMERGENCY OXYGEN GENERATION EMERGENCY OXYGEN GENERATION AND DISTRIBUTION SYSTEMAND DISTRIBUTION SYSTEM

OO22 Generation Generation SystemSystem OO22 Storage Storage

SystemSystem

Patient rooms

or

O2 Distribution System

Patient rooms

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EMERGENCY OXYGEN GENERATION AND EMERGENCY OXYGEN GENERATION AND DISTRIBUTION SYSTEMDISTRIBUTION SYSTEM

LOX Storage / LOX Storage / Filling TankFilling Tank

Patient rooms

LOX Storage LOX Storage SystemSystem

NPTLOX

O2 Distribution System

6 patients per LOX

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Oxygen Concentrator

Up to 10 liters per min @ 7 psi

110V AC 57 lbs Approx $1,400

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Staffing Classes Physician Physician extenders

(PA/NP) RNs or RNs/LPNs Health technicians Unit secretaries Respiratory Therapists Case Manager Social Worker Housekeepers Lab

Medical Asst/Phlebotomy Food Service Chaplain/Pastoral Day care/Pet care Volunteers Engineering / Maintenance Biomed-to set up equipment Security Patient transporters

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Per 12 Hour Shift: 33 Physician [1] Physician extenders

(PA/NP) [1] RNs or RNs/LPNs [6] Health technicians [4] Unit secretaries [2] Respiratory Therapists [1] Case Manager [1] Social Worker [1] Housekeepers [2] Lab [1]

Medical Asst/Phlebotomy [1] Food Service [2] Chaplain/Pastoral [1] Day care/Pet care Volunteers [4] Engineering/Maintenance

[.25] Biomed [.25] Security [2] Patient transporters [2]

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Staffing Considerations

Requires significant pre-planningState {S}Local {L}Institutional {I}

Unclear who would volunteerContained vs Population-based Surge event

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Facilitation of Emergency Staffing

Establish legal authority to utilize out-of-state licensed personnel {S}

Establish supervision criteria for volunteer and out-of-state licensed personnel {S}

Establish/maintain list of retired individuals who could be called upon to staff {S L I}

Availability of prophylaxis for employees and volunteers (? and their families) to guarantee workforce availability {S L I}

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Facilitation of Emergency Staffing

Communication of institutional workforce plan in advance to employees {I}

Develop, test and maintain emergency call-in protocol {L I}

Expectation and capacity for flexibility in roles{S L I}

Establish linkages with community resources (ie. hotel housekeeping) {L I}

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Facilitation of Emergency Staffing

Address specific needs of employees (transportation, single mother, pets) {I}

Implement a reverse 911 or notification system for all employees {S L I}

Establishment of institutional policies for credentialing of non-employees {S L I}

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Emergency System for Advanced Registration of Volunteer Health Professionals:

ESAR-VHP

State-based registration, verification and credentialing of medical volunteers

Should allow easier sharing of volunteers across states

Still missing:Liability coverageCommand and control

Page 75: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Medical Reserve Corps

Local medical volunteersNo corps unit uniform structure330 units of 55,000 volunteersDeployments do not qualify for FEMA

reimbursementLiability concerns are still an issueESAR-VHP may help with credentialing

Page 76: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Development of Gubernatorial Draft Executive Orders

Developed by the Colorado Governor’s Expert Emergency Epidemic Response Committee (GEEERC)

Multi-disciplinary20 different specialties/fields (from attorney

general to vets)To address pandemics or BT incidentsWork started in 2000

Page 77: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Development of Gubernatorial Draft Executive Orders

Declaration of Bioterrorism Disaster Suspension of Federal Emergency Medical

Treatment and Active Labor Act (EMTALA) Allowing seizure of specific drugs from private

sources Suspension of certain Board of Pharmacy

regulations regarding dispensing of medication

Page 78: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Development of Gubernatorial Draft Executive Orders

Suspension of certain physician and nurse licensure statutesAllows out-of-state or inactive license holders to

provide care under proper supervision

Allowing physician assistants and EMTs to provide care under the supervision of any licensed physician

Allowing isolation and quarantine Suspension of certain death and burial statutes

Page 79: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Other Issues and Decision Points

“Ownership”, command and controlHICS is a good starting structure

Who decides to open an ACS?Scope of care to be delivered?

Offloaded hospital patientsPrimary victim careNursing home replacementAmbulatory chronic care / shelter

Page 80: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Other Issues and Decision Points

Operational supportMealsSanitary needsInfrastructure

Documentation of careSecurity

Page 81: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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81

Other Issues and Decision Points

CommunicationsRelations with EMSRules/policies for operationExit strategyExercising the plan

Page 82: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Available from AHRQ:www.ahrq.gov/research/mce/mceguide.pdf

Page 83: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Also Available:

Altered Standards of Care in Mass Casualty Events: Bioterrorism and Other Public Health Emergencies.

AHRQ Publication No. 05-0043, April 2005. Agency for Healthcare Research and Quality, Rockville, MD.

www.ahrq.gov/research/altstand/

Page 84: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Katrina: ACS Issues

Importance of regional planning Importance of securityAdvantages of manpower proximitySegregating special needs populationsOrganized facility layout Importance of ICS

Page 85: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Katrina: ACS Issues

The need for “House Rules” Importance of public health issues

Safe foodClean waterLatrine resourcesSanitation supplies

Page 86: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Tiered Response Plan: Based on Epidemiology

Category 0: No cases of EID at DHMC EID elsewhere in the world EID transmission in the region

Passive/active surveillance; Just-in-time training

Category 1: A few cases at DHMC but all cases are imported

Cohort patients; limit visitors to infectious patients; institute patient transport routes

Page 87: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Tiered Response Plan: Based on Epidemiology

Category 2: A larger number of EID cases at DHMC (e.g. more than 5-10) OR nosocomial transmission has occurred, but source clear.

Limit visitors to all patients; limit elective procedures; fever screen at entry; fever surveillance on wards

Category 3: Nosocomial transmission has occurred and the nosocomial cases have NO clear source

No visitors; facility closed to elective or non-life/limb threat admits

Page 88: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Summary Institutional preparedness is a challengeWe are rediscovering some old conceptsSupplemental oxygen and respiratory

support remain problems for an ACSSurge staffing facilitation requires advance

planning at multiple levels and may still fail

Page 89: Preparing for Pandemic Influenza: The Hospital and Community Perspective Grand Rapids, MI May 10, 2007 Stephen V. Cantrill, MD Associate Director Department.

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Be Prepared


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