The Hospital Response

Real Time Experience at AMCH

Sarah Elmendorf, MD

Rebecca O’Donnell MT,CIC

IntroductionIntroduction

Hope for the best, plan for the worstHope for the best, plan for the worst Evolving plan, never completed!Evolving plan, never completed! Current approach-not all the answersCurrent approach-not all the answers 4 initial measures 4 initial measures (J healthcare management 2004 49 (40 227-235))(J healthcare management 2004 49 (40 227-235))

– hospital staff educationhospital staff education– information technologyinformation technology– disease surveillance improvementdisease surveillance improvement– additional equipment and staffadditional equipment and staff

Regional effortsRegional efforts

ApproachApproach

Assess a single patients entry into Assess a single patients entry into AMCH systemAMCH system

– Real timeReal time

Identify current strengths and Identify current strengths and weaknessesweaknesses

– Table topTable top

Respond to weaknessesRespond to weaknesses– Additional needs assessment/planning at Additional needs assessment/planning at

department and division leveldepartment and division level

Assess surge capacityAssess surge capacity

Key AssumptionsKey Assumptions

SARS planning applied to Avian Flu SARS planning applied to Avian Flu PreparednessPreparedness

Overall threat is smallOverall threat is small

Science 2004 304:968-969 Science 2004 304:968-969 BUTBUT High case fatality rateHigh case fatality rate Who (5/05): Who (5/05): Avian flu making ominous Avian flu making ominous

changeschanges Potential global health impact could be Potential global health impact could be

catastrophiccatastrophic

ArrivalArrival

ChallengesChallenges Safe entry into Safe entry into

the systemthe system Preparedness for Preparedness for

the unknown the unknown

StrategiesStrategies Education of Education of

triage stafftriage staff Signage Signage

ArrivalArrival

ChallengesChallenges Diagnosis unknownDiagnosis unknown

– Distinguish from Distinguish from other respiratory other respiratory infectionsinfections

Changes in case Changes in case definitionsdefinitions

StrategiesStrategies Respiratory etiquetteRespiratory etiquette Anyone who presents Anyone who presents

with a cough is with a cough is immediately maskedimmediately masked

Triage alertTriage alert Recognize risk Recognize risk

factorsfactors– Travel, exposure to Travel, exposure to

poultry, exposure to poultry, exposure to other casesother cases

ArrivalArrival

ChallengesChallenges Sign Sign

interpretation interpretation

StrategiesStrategies English and English and

Spanish signsSpanish signs Signs with Signs with

pictures- don’t pictures- don’t reinvent, use!reinvent, use!

Are you confident infection is not being spread?

ArrivalArrival

Visual AlertsVisual Alerts

ArrivalArrival

ChallengesChallenges Surge Capacity Surge Capacity

StrategiesStrategies Influx of patients Influx of patients

will require will require regional regional collaboration and collaboration and coordination coordination

Triage Triage

ChallengesChallenges Triage staff Triage staff

unsure of current unsure of current events and case events and case definitionsdefinitions

StrategiesStrategies Communication Communication

– ICP rep on ED QIT ICP rep on ED QIT – IC roundsIC rounds

AlertsAlerts– Central locationCentral location

EducationEducation Test the systemTest the system

TriageTriage

ChallengesChallenges Enforcement of Enforcement of

respiratory etiquetterespiratory etiquette– Legal issuesLegal issues– Security issues Security issues

StrategiesStrategies Segregate patient Segregate patient

from main waiting from main waiting areaarea

Separate waiting Separate waiting areas/family areas/family conference roomconference room

Development of Development of respiratory etiquette respiratory etiquette bagsbags

Are you prepared to enforce policy?

Triage Triage

Isolation Isolation

ChallengesChallenges Extended Extended

PrecautionsPrecautions

Visitors and Visitors and FamilyFamily

StrategiesStrategies Contact/Airborne Contact/Airborne

signs for signs for doorframedoorframe

Stickers for chartStickers for chart CommunicationCommunication

– Notify infection Notify infection controlcontrol

Visitor/family Visitor/family screening, PPE, screening, PPE, check in logscheck in logs

Isolation Isolation

ChallengesChallenges Correct use and Correct use and

removal of removal of personal personal protective protective equipment (PPE)equipment (PPE)

Compliance with Compliance with PPEPPE

Availability of PPEAvailability of PPE

StrategiesStrategies Contact /Airborne Contact /Airborne

signsign PPE removal signPPE removal sign PPE observer PPE observer PPE cartPPE cart Education Education

sessionssessions

IsolationIsolation

IsolationIsolation

ChallengesChallenges Disinfection of Disinfection of

environment and environment and equipmentequipment

StrategiesStrategies Dedicate where Dedicate where

possiblepossible Empty room of Empty room of

unnecessary unnecessary suppliessupplies

Disinfect! Disinfect! Disinfect! Disinfect! Disinfect!Disinfect!

Are you prepared for extended precautions?

Patient MovementPatient Movement

ChallengesChallenges Contain diseaseContain disease CommunicationCommunication

StrategiesStrategies Mask patient Mask patient Identify most Identify most

direct routedirect route Security Security

participation and participation and traffic controltraffic control

ICP involvement ICP involvement Use of PPE duringUse of PPE during

transporttransport

CommunicationCommunicationChallengesChallenges Multiple Multiple

disciplinary disciplinary involvement involvement

StrategiesStrategies Prepared policies-Prepared policies-

located on Intranet sitelocated on Intranet site-- NotificationNotification

- Patient placement- Patient placement

- Patient management- Patient management

- Identification of patient- Identification of patient

- Hand hygiene- Hand hygiene

- PPE- PPE

- Environment and equipment - Environment and equipment

disinfectiondisinfection

- Laboratory specimens- Laboratory specimens

- Linen and waste- Linen and waste

- Interdepartmental transfer- Interdepartmental transfer

- Visitors- Visitors

CommunicationCommunication

ChallengesChallenges Internal/External Internal/External

communicationcommunication

Laboratory Laboratory notificationnotification

StrategiesStrategies County County

notification notification Testing the Testing the

system with other system with other communicable communicable diseasesdiseases

Stickers for lab Stickers for lab specimensspecimens

EducationEducation Intranet site Intranet site

Communication Scheme Communication Scheme Internal ED Medical/Nursing Staff

Epidemiology

Medical Director/Administration

Laboratory

Public Relations

County Health Departments

External

Radiology

NYSDOH Regional Epidemiology

NYSDOH Wadsworth Laboratory

Multiple specialties

Pt Care Unit

Communication: a critical but time consuming element

Medical EvaluationMedical Evaluation

Medical EvaluationMedical Evaluation

ChallengesChallenges Medical staff fit Medical staff fit

testing/complianctesting/compliancee

StrategiesStrategies Powered air Powered air

purifying purifying respirator (PAPR)respirator (PAPR)

Fit testing critical Fit testing critical medical staffmedical staff

All sizes/types of All sizes/types of N-95 respirators N-95 respirators

available on units available on units

Medical EvaluationMedical Evaluation

ChallengesChallenges

Multi-specialty Multi-specialty involvement/ involvement/ educationeducation

Movement of Movement of patientspatients

StrategiesStrategies Emergency Preparedness Emergency Preparedness

Readiness SiteReadiness Site Streamline clinical Streamline clinical

managementmanagement

Maintain precautionsMaintain precautions Intubate/extubate in Intubate/extubate in

negative pressure roomnegative pressure room Limit movement of Limit movement of

patient patient

DiagnosisDiagnosis

ChallengesChallenges What specimens to What specimens to

collect?collect?

Avian flu/other Avian flu/other respiratory infectionsrespiratory infections

StrategiesStrategies Intranet siteIntranet site

– Identify specimens Identify specimens neededneeded

– Current case Current case definition with definition with symptoms/risk symptoms/risk factors/travel factors/travel

Maintaining precautionsMaintaining precautions

TreatmentTreatment

ChallengesChallenges Options limitedOptions limited

StrategiesStrategies Pharmacy Pharmacy

preparednesspreparedness Vaccination campaignVaccination campaign Increased stock of Increased stock of

antiviral medicationantiviral medication Knowledge of most Knowledge of most

current current recommendationsrecommendations

Potential for SurgePotential for Surge

ChallengesChallenges Overwhelming Overwhelming

resources of resources of health care health care system system – PPE PPE – EquipmentEquipment– StaffStaff

StrategiesStrategies Early recognitionEarly recognition Early treatmentEarly treatment Early isolationEarly isolation Stocked PPEStocked PPE Negative Negative

pressure unitspressure units Patient diversionPatient diversion

Potential for SurgePotential for Surge

ChallengesChallenges Overwhelming Overwhelming

resources of resources of health care health care system system – PPE PPE – EquipmentEquipment– StaffStaff

StrategiesStrategies Team approachTeam approach On the spot On the spot

tracking and tracking and references, Palm references, Palm Pilots Pilots

Potential for SurgePotential for Surge

ChallengesChallenges Multiple hospital Multiple hospital

CollaborationCollaboration

StrategiesStrategies Regional Resource Regional Resource

CenterCenter HEOCCHEOCC Albany County Albany County

Community Community Advisory GroupAdvisory Group

Albany County Albany County Communicable Communicable Disease WorkgroupDisease Workgroup