May 2, 2006 VI. HEALTHCARE PLANNING The following is a plan addressing “Surge Capacity” corresponding to Health and Human Services “HHS Pandemic Influenza Plan” Part 2, Supplement 3, Healthcare Planning, S3-III.A. Planning for provision of care in hospitals. 2.h) Surge capacity. The plan consists of an overall “umbrella” plan for the County at the Health Department level as well as the individual plans for each hospital in San Mateo County. Supplement 3 contains a number of additional elements that need still to be developed for the hospital pandemic flu plans including hospital surveillance, communications, education and training, triage, clinical evaluation, admission procedures, facility access, occupational health, use and administration of vaccines and antiviral drugs, security, and mortuary issues. Additionally plans for provision of care in non-hospital healthcare settings and alternative sites need to be developed. Work on the above elements should begin in early 2006 and will need to involve the Health Department, all hospitals in San Mateo County, the Office of Emergency, the fire service, and local law enforcement. The plan below will be divided into categories for strategies to be undertaken and notifications within each element for the “Stage” of the event (Green, Yellow, Red, and Black). Introduction In California, and across the nation, over the last decade health care cost containment measures have resulted in narrowing the margin of excess staff and available patient care beds. Hospital downsizing and hospital closures have been common strategies. In most areas there is little “surge” capacity to meet periods of exceptionally high patient volume. This was demonstrated in 1997-98 when an unusually severe flu season caused serious hospital overcrowding. San Mateo County Pandemic Flu Plan Page 79
Transcript
May 2, 2006
VI. HEALTHCARE PLANNING
The following is a plan addressing “Surge Capacity” corresponding to Health and Human Services “HHS Pandemic Influenza Plan” Part 2, Supplement 3, Healthcare Planning, S3-III.A. Planning for provision of care in hospitals. 2.h) Surge capacity. The plan consists of an overall “umbrella” plan for the County at the Health Department level as well as the individual plans for each hospital in San Mateo County. Supplement 3 contains a number of additional elements that need still to be developed for the hospital pandemic flu plans including hospital surveillance, communications, education and training, triage, clinical evaluation, admission procedures, facility access, occupational health, use and administration of vaccines and antiviral drugs, security, and mortuary issues. Additionally plans for provision of care in non-hospital healthcare settings and alternative sites need to be developed. Work on the above elements should begin in early 2006 and will need to involve the Health Department, all hospitals in San Mateo County, the Office of Emergency, the fire service, and local law enforcement. The plan below will be divided into categories for strategies to be undertaken and notifications within each element for the “Stage” of the event (Green, Yellow, Red, and Black).
Introduction In California, and across the nation, over the last decade health care cost containment measures have resulted in narrowing the margin of excess staff and available patient care beds. Hospital downsizing and hospital closures have been common strategies. In most areas there is little “surge” capacity to meet periods of exceptionally high patient volume. This was demonstrated in 1997-98 when an unusually severe flu season caused serious hospital overcrowding.
San Mateo County Pandemic Flu Plan Page 79
May 2, 2006
Fortunately, San Mateo County was able to handle the increased patient load with less difficulty than some other areas of the State, such as Los Angeles County which has been particularly hard hit by hospital closures. During “every day” operations, hospitals serving our community are able to provide hospital services without difficulty. Such services include emergency department care, in-patient hospitalization including critical and acute care, elective non-emergency surgery and other interventions, emergency surgery and other interventions, diagnostic services, and on-going treatment of chronic conditions. The hospitals’ capacity to provide these services is dependent upon each hospital’s physical plant, bed capacity, staffing, and equipment and supplies. Generally the number of people needing hospital services is fairly constant and the normal capacity of our local hospitals is able to meet the community’s needs without difficulty. There is some seasonal variation such as the flu in winter months. In some years the increased volume of seriously ill flu patients has stretched our local resources so that measures have been taken to be able to accommodate a greater volume of patients needing hospitalization; one example is canceling elective surgeries. In a disaster event, such as large mass casualty incident, our local hospitals would not be able to accommodate a large number of casualties and we would need to use strategies such as transferring patients to locations outside the affected area and bringing resources into San Mateo County from outside our Region. In a flu pandemic these strategies would likely be unavailable, as all areas of the nation would likely be affected. In a flu pandemic it will be important to stretch our local resources in order to meet the healthcare needs of our community as much as possible. In order to do this we will try to use our available resources as efficiently as possible. This will mean curtailing non-essential services, using staff in non-traditional ways, providing services in places not used in ordinary times, anticipating the services that will be needed, and building capacity for equipment and supplies. In the event that a flu pandemic occurs similar to the 1918 event, our local hospitals will not be able to provide healthcare sufficient to meet demand. Current projections for San Mateo County in such an event are that 14,470 people would require hospitalization for the nine to twelve month pandemic period. These patient cases would not be evenly distributed over this period and cases would occur in several waves. Planning for such an event should improve our ability to respond but there should not be an expectation that there will be “healthcare as usual.” It is possible that at some point the hospitals may no longer be able to provide anything but austere care and that ill persons will need to be cared for in the home or other
San Mateo County Pandemic Flu Plan Page 80
May 2, 2006
non-hospital setting. We believe that planning for a pandemic will improve our ability to respond to a flu pandemic event but there should be no assumption that this planning will keep such an event from being catastrophic in San Mateo County. Implementing our County flu pandemic hospital surge plan, and each hospital’s individual surge plan, will be a stepped-approach. This stepped approach will include those strategies to be undertaken early in the event (such as discharging in-patients early) through those strategies that would be taken as a last ditch effort late in a catastrophic situation (e.g., limiting to austere care, closing hospitals). In the later stages of the pandemic it will likely be necessary to ration healthcare. Examples would be determining which patients should have priority for ventilators. A plan for such rationing should be undertaken early in the planning process.
Essential Hospital Surge Strategies Surge strategies are aimed at increasing capacity to provide the most important healthcare services to patients in most need. The strategies focus on four elements:
1. Staffing 2. Acute care bed capacity 3. Consumable and durable supplies 4. Continuation of essential medical services
San Mateo County Pandemic Flu Plan Page 81
May 2, 2006
Alert Levels As per the previous “Concept of Operation” section, alert levels have been established to activate responses. The County Health Officer will be responsible for determining when to change alert levels. The County plan will identify general strategies based upon the various alert levels. Each hospital will undertake its own strategies, as outlined in its plan, based upon the countywide alert level.
Alert Level Hospital Conditions Green - little or no human transmission Plan for bed capacity, staffing, supplies
during an outbreak of pandemic influenza
Yellow - limited to moderate human transmission
Hospitals are receiving H5 patients on a limited basis; PPE issued; isolation of patients; prepare for essential services only;
Red - extensive human transmission Receiving H5 patients on a large scale; conduct essential services only; vacation leaves cancelled; all ventilators in use; inter-hospital transfers; request for DMATs to staff non-hospital facilities
Black - controlled and uncontrollable human transmission
Staff shortages; patient to staff ratio is huge; city services limited – sporadic trash collection; laundry shortages; morgue overflow; care is austere
San Mateo County Pandemic Flu Plan Page 82
May 2, 2006
Element 1. Staffing
Considerations Staffing will be a major challenge for hospitals during a flu pandemic for the some of the following reasons:
• There will be large numbers of seriously ill patients (possibly 14,470 over a nine to twelve month period).
• Since the pandemic will probably be universal we will likely be “on our own” for the duration of the event; mutual aid will not be an option.
• There are very few healthcare workers currently not employed in health care that would be able to (or willing to) return to the local healthcare workforce.
• Whereas historically large numbers of volunteer health care workers respond to disasters this may not be the case in a pandemic
• It is probable that many healthcare workers will become ill • Some healthcare workers will opt to stay home to care for ill family
member or to care for children/dependents whose normal day care provider is now unavailable
• Childcare may be very limited and possibly prohibited by the Health Officer
• While we may be able to augment the healthcare workforce with other personnel who do not traditionally provide healthcare, labor pools of available and willing personnel are probably limited.
• Early notification that flu pandemic is beginning will help hospitals prepare to implement their plans.
San Mateo County Pandemic Flu Plan Page 83
May 2, 2006
Hospital Strategies for Staffing Recruiting/Processing Staff Strategies Hospitals should establish process for rapid employment processes. Develop rapid credentialing process for healthcare professionals Develop rapid screening process for public volunteers Establish dialogue with local healthcare professions education programs (e.g. medicine, nursing, technicians) regarding use of trainees in hospitals during pandemic. Develop list of local non-hospital healthcare providers as resources for staffing and assets Identify Mass Care Sites in event that sufficient staff is available during peak periods of pandemic. Training Strategies Develop education/training content and materials for “just in time” training of:
• hospital personnel (that normally provide non-essential services) in functions needed for essential services during pandemic.
• healthcare personnel not normally working in the hospital setting (e.g., paramedics, emergency medical technicians, clinic staff).
• currently licensed health care providers (e.g., physicians, nurses) returning
to work force. • lay public volunteers
Administrative Strategies Establish policies for administrative personnel to maintain professional licenses Identify essential-support personnel titles needed to provide essential healthcare and hospital services (e.g., respiratory therapist, pharmacists, environmental and engineering services, food and nutrition services, clerical, medical records, information technology, laboratory, administration). Create lists of non-essential positions that could be reassigned during pandemic that could be cross-trained for essential positions during pandemic. Develop strategies to support staff during pandemic (e.g., providing psychological support, occupational health support, resources for families). Develop processes for utilizing health care trainees to assist in providing essential hospital services (e.g., nursing and medical students). Set up process ahead of time for “just in time” training, procedures, job action sheets, etc. Develop procedures/processes for orienting new staff (including physicians, nurses, other health professionals, auxiliary staff, paramedics, emergency medical technicians, lay public volunteers). Develop methods for identification of staff during pandemic. Identify potential housing for out-of-area staff during pandemic. Work with various groups who may be able to provide lay public patient care (e.g.,
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Administrative Strategies faith-based community groups, ethnic community groups, senior centers). Legal Strategies Identify insurance and liability issues related to use of non-hospital staff. Meet with unions and agree on staffing issues for pandemic. Develop MOUs between local hospitals to permit sharing of staff, waiving credentialing for staff of other local hospitals, and determine how salary issues will be addressed for shared employees. Identify liability issues related to using lay public and families to assist in staffing hospitals in late stages of pandemic. Recruiting/Processing Staff Strategies Implement rapid employment processes. Contact out-of-hospital health care entities and seek to recruit staff to provide in-hospital essential services during pandemic. Training Strategies Conduct education/training training to personnel:
• hospital personnel (that normally provide non-essential services) in functions needed for essential services during pandemic.
• “just-in-time” training for healthcare personnel not normally working in the hospital setting (e.g., paramedics, emergency medical technicians, clinic staff).
• currently licensed health care providers (e.g., physicians, nurses) returning to work force.
Administrative Strategies Prepare to reassign staff providing non-essential services to function in essential services. Review processes for utilizing non-hospital staff to assist in providing essential hospital services to include:
• nursing students • medical students • other healthcare students • paramedics • emergency medical technicians • lay public volunteers
Legal Strategies Implement any processes that were identified as needed during Green planning process for insurance and liability issues related to use of non-
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Legal Strategies hospital staff. Notify unions and implement agreed upon staffing procedures for pandemic.
Continue all above Yellow strategies. Strategies for Recruiting/Processing Staff Truncate credentialing process to allow qualified volunteers to serve in hospital Develop strategies to support staff during pandemic (e.g., providing psychological support, occupational health support, resources for families).
Training Strategies Conduct “just in time” training of for:
• healthcare personnel not normally working in the hospital setting (e.g., paramedics, emergency medical technicians, clinic staff).
• lay public volunteers willing to assist in staffing hospitals • families and lay public to use to care for flu patients at home, in non-
hospital facilities, or within a hospital if staff is unavailable.
Administrative Strategies Reassign staff providing non-essential services to function in essential services. Institute processes for utilizing non-hospital staff to assist in providing essential hospital services to include:
• nursing students • medical students • other healthcare students • paramedics • emergency medical technicians • lay public volunteers
Obtain housing for out-of-county staff (if needed). Responsible: Hospitals Implement strategies to support staff during pandemic (e.g., providing psychological support, occupational health support, resources for families).
Legal Strategies Implement any processes that were identified as needed during Green planning process for insurance and liability issues related to use of lay public.
San Mateo County Pandemic Flu Plan Page 86
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2. Continue to use all above Yellow and Red strategies.
Strategies for Recruiting/Processing
State of emergency in effect; able bodied volunteers accepted and assigned to needed duties based on short interview
If sufficient staff available (e.g., DMATs) open Mass Care Site.
San Mateo County Pandemic Flu Plan Page 87
May 2, 2006
Element 2. Acute Care Bed Capacity Considerations Bed capacity will be a major challenge for hospitals during a pandemic for the some of the following reasons:
• There will be large numbers of seriously ill patients (possibly 14,470 over a nine to twelve month period with).
• Because of the anticipation of limitations on the availability of staff as discussed above it will not be possible to provide mass care in non-hospital locations. In localized disasters (e.g., earthquake, hurricane) mass care in non-hospital locations is possible. This will likely not be possible in a pandemic flu event although we will include it as a contingency in the event that staff can be procured e.g., Disaster Medical Assistance Teams.
• With such large numbers of patients needing hospitalization and so few staff available, caring for patients would be easier in multi-patient locations (e.g., large wards) but modern hospitals do not have these type of patient accommodations.
• Home healthcare agencies may also be very short staffed during a pandemic so it may not be possible to arrange at-home care for patients who have been discharged early from hospitals.
• Note: Not related to hospitals – County should work with various groups who may be able to provide lay public patient care (e.g., faith-based community groups, ethnic community groups, senior centers).
Primary Strategies to increase capacity: There are two basic strategies:
1. Open additional beds or patient treatment spaces. 2. Curtail non-essential healthcare services so that all available beds (and
patient spaces) will be available for essential healthcare services. Types of beds Licensed: The maximum number of beds for which a hospital holds a license to operate. Many hospitals do not operate all of the beds for which they are licensed. They may be physically available or physically unavailable.
Physically available: Beds that are licensed and physically set up, and available for use. These are beds regularly maintained in the hospital for the use of patients. These beds may be staffed or un-staffed.
Staffed: Beds licensed and physically available; staff are on hand to attend to the patient who occupies or might occupy the bed.
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Staffed beds include beds that are occupied and those that are vacant.
Occupied: Beds with patients. Vacant: Beds that are vacant and to which patients can be transported immediately. These beds are licensed, physically available, and have staff on hand to attend to a patient who will occupy the bed.
Un-staffed: Beds that are licensed and physically available but have no current staff on hand to attend to a patient who would occupy that bed.
Physically unavailable: These are beds included in the license that may be in the repair shop or in storage. They are not immediately available for a patient.
Unlicensed: These are beds that exist but are not currently licensed. They may be physically available, such as recovery room beds, or physically unavailable, such as those in storage. Other Patient Spaces: This refers to physical spaces that could be used for patient care activities during a disaster and that have been identified in the hospital’s surge plan. Examples include surge tents or large vacant spaces where stretchers or cots could be placed.
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Our local hospitals, based on their Flu Surge Plans, have identified the following total acute care bed/patient space capacity.
Acute Care Patient Space Type CountyMIL & PEN KRC SET SMC STC SEQ KSS
Bed Capacity Strategies Green Strategies to Conserve Resources Develop plans for identifying patients that could be discharged early in late Yellow stage of pandemic event. Establish dialogue with home healthcare agencies regarding need for home healthcare agencies to increase capacity during pandemic to care for:
• early patient discharges (non-flu patients) in pandemic • seriously ill non-flu patients unable to be admitted to hospital • seriously ill flu patients unable to be admitted to hospital and without
access to family/friends to care for them. Develop policies and procedures for accelerating hospital discharge of patients (e.g., ensuring physician cooperation). Develop policies, procedures, processes for curtailing non-essential admissions and services. Develop plans and procedures for cohorting flu patients. Develop process for identifying need to request waivers from regulators on bed use and nursing ratios. Develop policies and procedures for shifting patients between nursing units to free up bed space in critical care areas and to cohort influenza patients. Strategies to Increase Bed/Patient Space Capacity Identify beds for each “category” – licensed, unlicensed, patient space. Identify “patient space” areas that could be used for patients. Identify patient rooms that could accommodate more than one bed. Identify process to rapidly identify licensed beds, physically available beds, staffed beds (vacant, occupied). Determine number of isolation rooms. Develop cohorting protocols based on patient’ stage of recovery and infectivity. Yellow
Strategies to Conserve Resources Early Yellow: Begin to identify patients for early discharge and begin planning for their discharge (e.g., arrange for in-home care). Late Yellow: Discharge patients who have been identified as able to be discharged early. Work with home healthcare agencies regarding need for home healthcare agencies to increase capacity during pandemic to care for:
• early patient discharges (non-flu patients) in pandemic Implement policies and procedures for accelerating hospital discharge of patients
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Strategies to Conserve Resources (e.g., ensuring physician cooperation). Take steps necessary to curtail non-essential admissions and services. Implement cohorting of flu patients. Strategies to Increase Bed/Patient Space Capacity Prepare to utilize all beds (licensed and unlicensed).
Red Continue Yellow Strategies Strategies to Conserve Resources Work with home healthcare agencies regarding need for home healthcare agencies to increase capacity during pandemic to care for:
• seriously ill non-flu patients unable to be admitted to hospital • seriously ill flu patients unable to be admitted to hospital and without
access to family/friends to care for them. Shift patients between nursing units to free up bed space in critical care areas and to cohort influenza patients. Black Continue Yellow and Red Strategies As Much As Possible Strategies to Conserve Resources Discharge patients as many inpatients as possible. Curtail admission for all patients whose care is not essential at this time. Implement plan for rationing medical care (e.g., ventilators, admissions).
San Mateo County Pandemic Flu Plan Page 92
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Element 3. Consumable and Durable Supplies
Considerations
• Normal hospital operations and budget requirements dictate “Just In Time” (JIT) inventory strategies; very limited inventory on hand and reliance on vendor efficiency
• There are a limited number of vendors and these vendors supply many hospitals.
• Inventory space is limited • The strategic national stockpile (SNS) will be insufficient to supply the
nation. • Past experience shows the first resource to be depleted during a flu
epidemic is ventilators • Consumable and durable supplies that will be needed during a flu
pandemic can be anticipated. The primary categories are: • Personal protective equipment
o N-95 masks o Surgical masks o Face shields/eye protection o Gowns o Gloves
• Patient Treatment/Support o Ventilators o Portable oxygen o Compressed air o Respiratory care equipment o Anti-virals o Antibiotics to treat bacterial complications
vancomycin ceftriaxone levofloxacin or moxifloxicin azithromycin doxycyline imepenem
(A local pharmaceutical stockpile exists and contains some doxycycline.)
o IV supplies and IV pumps o Central line kits o Beds/cots o Morgue packs o Facial tissues o Linen o Tympanic thermometers
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• Other o Temperature o Additional power supply for patient spaces o Cleaning and disinfecting supplies o Hand cleaner o Stethoscopes o Morgue packs
• Issues relative to droplet vs. airborne spread of flu virus. o Flu is spread by droplet. o A well-fitting surgical mask is adequate protection in most situations
involving close contact between health care workers and flu patients. o Some procedures may generate increased small-particle aerosols of
respiratory sections (e.g., endotracheal intubation, nebulizer treatment, bronchoscopy, suctioning). For these procedures healthcare workers should wear a N-95 mask.
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Consumable and Durable Supplies Strategies GREEN Strategies Re: Consumable and Durable Supplies Develop inventory and location of all ventilators. Consider stockpiling enough consumable supplies for a pandemic wave (6-8 weeks). Review procedures for tracking consumable and durable supplies and establish revisions to procedure to implement during pandemic. Determine triggers for ordering more supplies. Develop a strategy for acquiring additional equipment. Develop SEMS/NIMS processes to communicate need for additional consumable and durable supplies. Establish contingency plans for situations in which primary sources of medical supplies become limited. Yellow Strategies Re: Consumable and Durable Supplies Use triggers for ordering more supplies. Acquire additional equipment as needed. Red Continue to use all Yellow strategies above. Strategies Re: Consumable and Durable Supplies Using SEMS/NIMS procedures request needed consumable and durable supplies by contacting Regional Disaster Medical Health Coordinator Region 2. Procure durable medical equipment as needed and available from local businesses that rent medical equipment. 3. BLACK Continue to use all Yellow and Red strategies above. Strategies Re: Consumable and Durable Supplies Using SEMS/NIMS procedures request Strategic National Stockpile by contacting Regional Disaster Medical Health Coordinator Region 2.
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Element 4. Continuation of Essential Medical Services Considerations:
• Essential medical services will need to continue. Examples include, but are not limited to: o Trauma o Acute medical conditions such as acute coronary syndrome, stroke,
malignancy, internal bleeding, respiratory failure, etc. o Obstetrics & neonatal o On-going treatment for chronic conditions such as hemodialysis,
infusion centers for chemotherapy, parenteral nutrition o Provision for essential medications for patients who cannot, or should
not travel to pharmacies • At some point during the pandemic it may be necessary to ration certain
services. There should be a thoughtful plan for rationing care that is developed with input from ethicists and the medical community.
GREEN Strategies for Continuation of Essential Medical Services Develop plans for how essential care areas will continue to be staffed and supplied during pandemic. Develop training materials and supplies that can be used to train and supply families for certain home care procedures (e.g., peritoneal dialysis, parenteral nutrition). YELLOW Strategies for Continuation of Essential Medical Services Implement plans for maintaining essential healthcare services. RED Continue Yellow strategies as above. Strategies for Continuation of Essential Medical Services Begin rationing care in accordance with plan. BLACK Continue Yellow and Red strategies as above.
