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The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega...

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Page 2: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

The Transitional Medical Model (TMM) Framework

For Pandemic Readiness and Response Plans

Paul Rega MD, FACEPChristopher Bork, PhD, EMT-B

Kelly Burkholder-Allen, RN, MSEdThe University of Toledo

College of MedicineDepartment of Public Health & Preventive Medicine

Page 3: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Pandemic

• The Enigmatic Disaster

Page 4: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Most Disasters

• Limited• Transparent

– Obvious to all• Well-defined

– Beginning– End

• Help will come from somewhere

Page 5: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Response to most disasters

• Based upon hazard analysis• Based upon risk assessment• Based upon precedent

Page 6: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Mitigation, Preparedness, Response, and Recovery• The broad strokes are sufficient for

most disasters– 40-Car Pileup– Tornado through a Trailer Park– Explosion in the Downtown district

Page 7: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Pandemics are not your typical disasters• Precedents are few

– Last major precedent (1918) before most people existed

• Not transparent– No definite beginning, middle or end

• External assistance may arrive late, if at all– Local response: Prominent

Page 8: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Pandemics: Outside of the Public’s Scope of Consciousness• Disproportional morbidity & mortality• Social distancing measures• Fractured infrastructure (schools,

businesses, places of worship, etc.)– Limited personnel– Limited resources

Page 9: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Pandemics: Outside of the Public’s Scope of Consciousness

• Prioritizing certain population subsets to receive those resources

• Depriving other subsets from receiving those resources– For example, allocation of scarce

resources• Cancellation of escapist activities

Page 10: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Potential Ramifications

• Economic chaos• Worsening and prolonged effects on

personal and communal mental health• Needless illness and death• Greater potential for violence

– Domestic– Non-domestic

• Risk of child exploitation and victimization• Prolonged interval of time to return to the

community’s baseline infrastructure

Page 11: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

What must be recognized…

• Any disaster response begins locally• Don’t depend on external agencies to

determine the fate of your jurisdiction

• Any response must be early, incremental, and temperate– Reference: 1918 response

Page 12: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Why early, incremental and temperate?

• Puts your jurisdiction ahead of events• Allows acclimatization for all citizens

– Builds public confidence• Cost-effective

– A “ramping-up or ramping-down” would ultimately be cheaper than an all-or-none action.

Page 13: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

The Transitional Medical Model (TMM)• Intermeshed with mitigation,

preparedness, response, and recovery concepts

• Incorporates a strategy that bridges the activities of normal day-to-day living with those that are employed during a potential pandemic.

Page 14: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

The Paradigm

• Traditional Medical Phase– Mitigation & planning

• The Transitional Medical Phase– Level 1– Level 2– Level 3– Level 4

• The Catastrophic Phase• The Recovery Phase

– Recovery

Response

Page 15: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Moving from Traditional to Transitional• The evolution from the Traditional

Phase to the Transitional Phase is not dependent upon external agencies, but upon the Public Health Commissioner.

• All disasters are local

Page 16: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Traditional Medical Phase • There is no evidence of an actual or imminent

disaster threatening your jurisdiction. • The principal activities: planning and education• The community’s efforts are directed towards

activities that will help that community prepare for a response to any disaster, infectious or otherwise. – identification of resources, – acquisition of resources, – education of professionals and the public, and– development, testing and refinement of

response strategies.

Page 17: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

The Transitional Medical Model

For details: http://www.ncbi.nlm.nih.gov/pubmed

Page 18: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Mission: Transitional Medical Phase • To augment, enhance, and empower a

jurisdiction’s medical infrastructure in order to provide medical care to all with skill and compassion, regardless the venue;

• To mitigate the worst medical, psychological, ethical, societal, legal consequences of a pandemic thereby minimizing the proportion of ill and dead;

• To preserve the community’s infrastructure as long as possible.

Page 19: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Transitional Phase, Level 1• Trigger: Distant outbreak• Description:

– No change in care delivery because there is no definitive pandemic.

– Information suggests a pandemic could be developing. • Principal actions:

– Place the jurisdiction on alert – Urge stakeholders and citizens to review their plans and

commence preparations to respond efficaciously.

(Please refer to TMM Quickview document for details on triggers)

Page 20: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Transitional Phase, Level 2

• Trigger: – Multiple distant outbreaks– Significant morbidity/mortality

• Description: – The possibility of a pandemic is more real than

theoretical. – Stakeholders and public should begin

activating their plans. • Principal Actions:

– Expand delivery via expanding capability of extant practices and clinics

Page 21: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Transitional Phase, Level 3

• Trigger: – Outbreak approaching jurisdiction– Outbreak repercussion felt within jurisdiction

• Description: – A significant outbreak is occurring. – It has begun to impact your jurisdiction.

• Principal Actions:– Begin activation of teams– Begin activation of Alternate Care Sites

Page 22: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Transitional Phase, Level 4 • Trigger:

– Definite outbreak occurring in your jurisdiction– Morbidity/mortality escalating

• Description: Active and passive surveillance have revealed the pandemic has arrived in the jurisdiction and surrounding regions.

• Principal Actions:– Functional teams– Functional ACSs– Public aware– Care to all, but at non-traditional venues

Page 23: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

The Catastrophic Phase• Mission: “Providing the Greatest Good for the Greatest

Number”

• Trigger: jurisdiction losing its support infrastructure

• Description: – Deterioration at all healthcare sites: patient volume, lack of

personnel, and/or inadequate resources. – Numbers of fatalities overwhelm mortuary venues. – Hospitals are inundated with critical care patients. – Disruption of infrastructural services at all levels – Prioritization of care delivery – Re-allocation of scarce resources to certain patients

• Inclusion criteria• Exclusion criteria

– Palliative care

Page 24: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

The Recovery Phase• Mission: Restoration of normalcy or “business as usual”• Triggers:

– Your jurisdiction: Drop in ILI among its citizens – Ohio: Drop in ILI among its citizens – The United States: Drop of ILI among its citizens – CDC has declared the pandemic is on the wane.

• Description: – Occurs when the Public Health Commissioner believes that

all the indicators point to an end of the outbreak. – The measures in place to mitigate the spread of disease are

not removed too quickly. – A gradual liberalization from these measures coupled with

an intense epidemiological evaluation of the jurisdiction’s health status in order to witness any adverse rise in infectious cases.

Page 25: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Major Take-Home Point of the Transitional Medical Model

• If done early and thoroughly, your jurisdiction may never experience the worst ramifications of the pandemic.

• Witness: Communities during the 1918 Pandemic who instituted early and prolonged strategies fared better than others.

Page 26: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Someone has to lead…

Why not the stakeholders in our jurisdiction?

Page 27: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Next Steps1. Identify the key stakeholders2. Compare the jurisdiction’s plans to

the sample plans in the toolkit3. Determine whether and how the

jurisdiction's plans fit with the TMM levels

4. Begin the dialog about what each stakeholder is doing during each level

Page 28: The Transitional Medical Model (TMM) Framework For Pandemic Readiness and Response Plans Paul Rega MD, FACEP Christopher Bork, PhD, EMT-B Kelly Burkholder-Allen,

Next Steps (contd.)

5. Modify response plans as needed to develop a congruence of response

6. Form an Exercise Planning Team and use the toolkit to test your plans. See “Creating Exercises Using the Transitional Medical Model” in this toolkit.


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