Health Care Delivery Model for Pandemic Influenza

1. Health Care Delivery Modelfor Pandemic Influenza Island County Health Department’s Approach Presented by: Roger S Case, MD October 2007 Thanks to Charron Plumer and staff of Tacoma-Pierce County Health Dept for making this presentation possible.

2. GOAL • Increase Health Care capacity in Island County during a medical catastrophe • Minimize morbidity & mortality

3. Island County Flu Impact A WORST CASE SCENARIO • 24,000 patients seek care (30% attack rate) • Up to 5,200 will be hospitalized (22 % of those ill) • Up to 720 will require ICU care (3% of hospitalized) • Up to 950 will die (4% of those seeking care) • Beds and staff exceeded quickly – 25 beds currently staffed

4. Pandemic Severity IndexCDC 2/07 Projected Number of Deaths in Island County Case Fatality Ratio > 2% > 480 Category 5 Category 4 1 - < 2% 240 - < 480 Category 3 120 - < 240 0.5% - < 1% Category 2 0.1 - < 0.5% 24 - < 120 < 24 < 0.1% Category 1 Based on a population estimate of 80,000 with 30% ill

5. Work Group Objectives • Engage community health care partners in developing model • Design and implement a coordinated system to deliver medical care during a medical catastrophe • Develop triage protocols to guide allocation of scarce resources, e.g. equipment, staff, supplies

6. Initial Work Group – Planning Organization Triage and Treatment Protocols Pre-Tier 1, Tier 1 & Tier 2 Community Medical Coordination Facilities Logistics Operations Started early in 2005

7. Concept of Operations • Care delivered outside of hospitals • Home • Alternate care facilities – divert pts away from ERS • Hospitals – acute/critical care • Care site based on severity of illness & resources

8. Concept of Operations • Altered Standards of Care • Insured/non-insured seen • Relax insurance limitations • Discussion elevated to state level • Legal consultant • Staff 24/7 with community medical providers and Medical Reserve Corps

9. Ethical Considerations To guide our Planning, we rely on the following principles: • To the greatest extent possible, everyone in Island County who becomes ill should be given the best care we can provide at that time, regardless of that person’s social worth. • To maximize our ability to implement this model, caregivers who work directly with patients and essential healthcare support workers should be considered a priority group for all preventive healthcare resources. • If resources become so scarce that we cannot provide all patients with the care they need, care should be given to the patients likely to receive the most benefit from those resources. • If it should become necessary to restrict individual liberties for the sake of the public health, the least restrictive interventions likely to be effective should be employed.

10. Four Tiered System* • Pre-Tier 1 – EMS (including 911) and Health Care Information lines • Tier 2 – Neighborhood Emergency Help Centers • Triage, Outpatient Treatment and Referral function • Tier 3 – Alternate Care Facilities • Expanded bed capacity with limited care • Tier 4 – Hospitals • Higher acuity, lower census *Adapted Based on Modular Emergency Medical System Developed for mass casualty bioterrorism eventsUS Army Soldier and Biological Chemical Command 6/1/02

11. Facilities • ?? NEHC Tier 1 sites identified • ?? ACFS Tier 2 sites identified • Memoranda of Agreements • Facilities will be standardized

12. Pre-Tier 1 • EMS - 911 medical dispatching protocols developed • Not all calls will get an ambulance • EMS empowered to triage patients to appropriate levels • Including care and comfort at home • Nurse Triage Lines • Similar protocols to 911 • Can refer patients to Tier 1 or send EMS

13. Pre-Hospital Straw PersonPre-Tier 1/Phone Triage Tx to Tier 3 Y Y EMS sent Require Transport? Hypoxic, Hypertensive Y Tx to Tier 2 Call to 911 or other public safety answer point Unstable? N N Evaluated by Nurse line N Refer to Tier 1 NEHC*** Call to Nurse line* Y Arrange for AVM Needs in-person evaluation? Y Consideration: special access phone # for high priority personnel to access nurse line AVM** eligible Refer patients to Tier 1 location to p/u AVM N N Create mechanism for nurse to communicate with Tier 1 = nurse phone order AVM Info only *Nurse lines are run by multiple health care organizations, will require standardization between organizations and agencies. May also require standardization across counties. **Antiviral medications***Neighborhood Emergency Help Center

14. Tier 1 - Triage & Neighborhood Emergency Help Center (NEHC) • Triage and basic evaluation • dispense antiviral medications • Patient receiving area; separate pts by severity of illness • Flu kits and home care information • Holding areas - Pts waiting on transport to higher tier

15. Tier 2 • For patients referred from Tier 1, or step down from Tier 3 • Persons not sick enough for hospital, need care that cannot be provided in home, or palliative care • Short stay (I.e. dehydrated) • Limited testing capability • O2 saturations, Chemistry/glucose • Oxygen, IV fluids • Antiviral medications, abx for secondary bacterial pneumonia

16. Tier 3 Alternate Care Facilities • Pre-id sites for surge capacity medical care • Mostly high schools • Geographically located around Island County • Facility set up in 50 bed units • Continue to expand until full capacity

17. Tier 3 (continued) • Rest area for family care givers • Palliative care area • Occupational Health office • Functioning cafeteria – 24/7 • Staff break and sleeping area • Chapel & morgue • Children under 3 y/o receive care at Tier 3 – eliminates need for cribs • Posters, videos w/ care instructions & infection control

18. Patient Tracking Systems • Tracking system – “Iris” • Bar coded wrist band • Tracks from first physical contact until disposition • Can be used to track staff as well

19. Joint Information Center Risk Messaging • Switch to alternate care system • Home health care information • How to contact health information line • When to enter the system and go to Tier 1 • How to get to nearest Tier 1 Site • What to bring: clean linens/pillow, personal hygiene products, routine meds, one family caregiver

20. Staffing • Medical Coordination and Recruiting • Medical Reserve Corps • Registration • JITT - Safety training, Triage and treatment protocols, Job Action Sheets, Infection Control, PPE

21. Medical Reserve Corps • A group of community based medical volunteers called upon to serve in large-scale emergency, natural disaster, or public health incident

22. Liability Concerns • Liability concerns permeate the discussion • Pandemic or mass casualty event creates uncertainty and unpredictability as to how courts will interpret the legal standards in medical malpractice actions

23. Liability • WA State assumes considerable liability for damage to property, injury or death that might occur during an emergency or medical disaster for registered worker • Generally, Emergency workers, including state and local employees are indemnified by the State; state will pay judgment for public employee who is found liable (if not due to gross negligence or willful misconduct) • Covered (Registered) Volunteer emergency workers are immune from liability

24. Liability • In order for an emergency worker to be protected, emergency management must have assigned a mission number to approved missions and other emergency activities • Citizens who are commandeered into service are entitled to the same privileges, benefits and immunities • Covered volunteer emergency workers are granted immunity only when engaged in a covered activity and acting within the scope of his/her duties, under the direction of a local emergency management or law enforcement

25. Worker Registration • Critical to register emergency workers • Registered workers receive training on medical disaster system • Statewide medical disaster system standard of care is implemented (proposed)

26. Emergency Workers vs. Covered Volunteer Emergency Worker • Emergency Worker = Any person who is registered with a local emergency management organization or the state military dept • Holds an ID card issued by the above for the purpose of engaging in authorized emergency management activities • Or is an employee of WA State or any political subdivision called upon to perform emergency management activities

27. Covered Volunteer Emergency Worker • An Emergency Worker, such as an MRC volunteer, not receiving compensation as an emergency worker from the state or local government. • Is not a state or local government employee • Registration critical

28. Altered Standards of Care • Community clinical decision makers will be identified who will assess the evolution of the illness and coordinate existing and changing standards of care within PC and the State

29. Altered Standards of Care Principles • Goal of an organized and coordinated response to a mass casualty event should be to maximize the number of lives saved • Rather than doing everything possible to save every life, it will be necessary to allocate scarce resources in a different manner to save as many lives as possible • Process must be fair and clinically sound, transparent and judged by public to be fair • Triage protocols need to be flexible as event grows

30. Statewide Standards • Suggested that WA approach the issue of Altered Standards of Care in a Statewide manner • Seek approval of proposed altered standards by professional organizations • Submit to accreditation organizations for review • Adoption of statewide standard of care would give medical providers increased guidance and increased likelihood of liability protection

31. Tier 3 Work Group Goals • Increase hospital capacity to care for acutely ill during a pandemic flu • Identify patient type categories to facilitate triage during a pandemic flu • Develop triage guidelines to guide allocation of scare hospital/ICU resources • Develop Response Matrix outlining triage guidelines Hospitals PH, EMS Military DEM Participants Work started early January 2007

32. Assumptions • Pandemic severity index, WHO Phases and Federal Response Stages will be the triggers guiding response and implementing the tiered triage protocols • Standards of Care will be altered as incident progresses and emergency declared • Focus on keeping health care systems functioning

33. Patient Types A matrix has been developed that outlines and defines patient types. Four types have been identified: RED, YELLOW, GREEN, and BLUE RED – very poor prognosis, expected to die within 2-3 days • Massive respiratory failure – overwhelming entry of inflammatory cells (Cytokine storm) • Rapid onset of SOB, cyanosis, tachypnea • This type of response likely to occur in the younger, healthier persons – 15-40 years old • If treated in ICU/ventilators – survival rate – 50% • Ref: Grattan Woodson, M.D. 2/13/07

34. Patient Types YELLOW – Very ill, survival past 3 days • Pulmonary and/or cardiovascular complications • Elderly, very young, adults with chronic medical condition • Significant co-morbidities, e.g. diabetes, heart disease, HTN, asthma • Pregnant women at high risk • Survival rate is 85% if treated with IV abx, ICU and ventilator when needed • 50% mortality rate if left at home • Ref: Grattan Woodson, M.D. 2/13/07

35. Patient Types GREEN – greatest chance of survival • Majority of those ill with pan flu • Dependent upon others (household members) to care for them • Fever, cough, malaise • No cyanosis, hypoxia, or hemorrhage • Co-morbidities under control • Survival rate – 99% if admitted to hospital when needed; 95% if treated at home • Death primarily due to dehydration • Ref: Grattan Woods, M.D. 2/13/07

36. Patient Types • May be unconscious • Will receive palliative care BLUE – near death

37. TIER 3 (HOSPITAL): PATIENT TRIAGE DURING PANDEMIC INFLUENZA Tier 3 Patient Typing Definitions RED (Type 1 Patient) Prognosis: Poor: die within 2-3 days of onset of symptoms Age: 15-40 year -olds due to cytokine storm Clinical signs: rapid onset SOB, cyanosis, tachypnea, bleeding from sites YELLOW (Type 2 Patient) Prognosis: Very ill, survival past 3 days; pulmonary and/or cardiovascular complications. Age: All elderly, very young, or adults with chronic medical disorders Clinical Signs: Often improve then relapse with malaise, aches, pains and then fever. Significant co-morbidities: Emphysema, chronic bronchitis, children with asthma, diabetes, coronary heart disease, high BP. Ppregnant women are at high risk Survival: 85% survival rate with IV antibiotics, diagnostic testing, ICU, vent when needed. 50% mortality rate if left at home GREEN (Type 3 Patient) Prognosis: Greatest chance of survival; majority of those ill with flu; dependent on others for care. Clinical Signs: Fever, cough, malaise, no cyanosis, hypoxia or hemorrhage. None or controlled co-morbidities. Survival: 99% survival rate if admitted to hospital when needed; 95 % survival rate if treated at home. *Death is primarily due to dehydration. Survival: 50% survival rate w/ access to ICU/Vents; 95% mortality if left at home BLUE (Patients in extremis) Near death Unconscious Supportive care only

38. WHO (World) Phases Phase 6 – Pandemic Phase: increased and sustained transmission in general population Fed Govt Response Stages Stage 3 – Widespread human outbreak in multiple locations overseas Stage 4 – First human case in N. America Stage 5 – Spread throughout U.S. Stage 6 – Recovery & prep for subsequent waves Triggers: Phases and Stages of a Pandemic

39. Triggers Fed Govt Stage 4 First human cases in North America 1-2 ICU cases in Is. Co. Full hospital resources Category 1 – Usual Standards of Care Actions Alert and Standby Tiers 1 & 2 Conduct JITT of staff Admit all patient types Refer Green patients for home health monitoring Normal Critical care admission Elective procedures continue Response Guidelines

40. Triggers Fed Govt Stage 5 Spread throughout U.S. Pan Flu in W. WA Up to 10 ICU cases in IC Diminished Hospital capacity Emergency Declaration Category II – Altered Standards of Care Actions Triage ED patients to Tier 1, as appropriate Refer GREEN patients to Tier 1 Admit to CC based on ventilator, homodynamic support needs Admit YELLOW and RED when ICU beds available Once ICU beds filled, YELLOW patients receive priority Response Guidelines

41. Response GuidelinesCategory II Actions (continued) • Lift EMTALA by decree of Declaration of Emergency • Activate surge capacity and emergency response plans • ACFS – operational • Hospital Command Centers communicate on patient triage and movement • Elective procedures decreased • Implement early discharge protocols

42. Triggers Fed Govt Stage 5: Community Spread ICU cases greater than 10 Hospital resources are nearly or completely diminished Category III– Altered Standards of Care Actions Implement criteria for inclusion or exclusion to CC Admit YELLOW patients with greater chance of survivability Assess RED patients case by case (if ICU bed is available and no YELLOW patient is waiting, admit RED) Refer RED patients to hospice, Home Health, Tier 2 Palliative care Exclude elective surgeries Emergency surgeries – traumas, appendectomies will be continued Response GuidelinesCategory III– Altered Standards of Care

43. Response GuidelinesCategory III Actions (continued) • Activate resource conservation, conversion • Convert surgical suites, day surgery, recovery suites in CC beds • Shift human resources from OR and Recovery to CC • Cancel elective procedures • Hospital Command Center coordinates movement of patients between hospitals

44. Critical Care Inclusion Requires ventilator support Requires homodynamic support Critical Care Exclusion Severe trauma, severe burns, cardiac arrest Severe baseline cognitive impairment Advanced untreatable neuromuscular disease Metastatic malignant disease Advanced immunocompromised Advanced/irreversible neurologic event End-stage organ failure Elective palliative surgery Response GuidelinesCategory III – Critical Care Inclusion/Exclusion Guidelines Ref: CMAJ 11/21/06: Development of a triage protocol for critical care during an influenza pandemic

45. Category Triggers Available Resources Admission & Triage Guidelines Action Fed Govt Stage 4: First human cases in North America 1-2 ICU cases in Island County Full Resources Admit all Patient types: RED, YELLOW, & GREEN, if able. GREEN patients: assess home environment; identify family members that can provide care; assess ability to take oral fluids; refer to home health monitoring as appropriate (guidelines to be developed) Critical Care Admission: Normal triage Continue Elective procedures Increase surveillance (tool to be developed) Alert and Standby Tier 1 & 2 Sites Conduct Just-in-time Training of staff for Tier 1, 2 Acquire anticipated resources (pre-planning needs identified) Activate Facility Emergency Plans Activate EOC & ESF 8 Alert Home Health/Hospice/LTCF to activate Emergency Plans Alert status: activation of hospitals’ surge capacity I Usual Standard Of Care Tier 3 – Triage & Admission Guidelines Tier 3 Response Matrix

46. Category Triggers Available Resources Admission and Triage Guidelines Action Fed Govt. Stage 5: Community spread Greater than 20 ICU cases in County Note: gradual transition from Category II to II. Hospitals maxed out Limited equipment, supplies, staff • Admit YELLOW patients – those identified as having greater survivability. • Critical Care Inclusion: (ref: 1) • - Require ventilator support • Require homodynamic support • Critical Care Exclusion: (ref 1) • - Severe trauma • - Severe burns • - Cardiac arrest • - Severe baseline cognitive impairment • - Advanced untreatable neuromuscular disease • - Metastatic malignant disease • - Advanced/irreversible immunocompromised • - Advanced/irreversible neurologic event or condition • End-stage organ failure • Age > 85 • - Elective palliative surgery • RED Patients: assess case by case – if bed available, and no Yellow patient is waiting, admit to ICU; when ICU beds not available, refer RED patients to hospice, home-health, Tier 2 Palliative Care • Continue emergent surgical, non-flu procedures (traumas, appendectomies, stent replacement) Activate Critical Care Inclusion/Exclusion Criteria. Assess function and effectiveness of Community Tier 1 & 2 sites (develop assessment tool). Activate resource conservation/conversion: surgical suites, day surgery, recovery suites into CC units. Shift of human resources, i.e. from OR, Recovery to CC. Cancel all elective procedures Implement established withdrawal of Critical Care guidelines for patients with non-survivability conditions. (Clarify ??) Hospitals’ ECO coordinate between hospitals transfers of yellow patients where beds available. II  & III Altered Standard of Care Tier 3 – Response Matrix

47. Pediatric Triage & TreatmentCurrent workgroup • Expand Tier 1 and Tier 2 protocols • Incorporate pediatric protocols into Tier 3 matrix • Pediatric modifiers for Patient Type descriptions • Admission Guidelines of pediatric patients to adult hospitals

48. Little available in literature re clinical presentation or historical models of peds during pan flu Additional complexity: family treatment modality – makes social distancing more difficult Pediatric ModifiersPatient Types

49. Red (very poor prognosis, expected to die within 2-3 days) Peds: robust immune system, primary flu, suspected high inflammatory response, young adults in good health < 15 y.o not likely to be categorized as Red Type >15 y.o likely to have higher immune system response, therefore thought to be at higher risk Pediatric Patient Types

50. Pediatric Patient Types • Yellow (very ill, survival past 3 days) • Peds: Main risk is secondary infection creating compromised health • Green (greatest chance of survival) • Peds: Very ill and symptomatic, but with a high survival rate • Blue (near death) – very ill, routed to holding area