Not Just Decisions, the Right Decisions; Not Just Stuff but the Right Stuff

1. Not Just Decisions, the Right Decisions; Not Just Stuff but the Right Stuff Sally Phillips, RN, PhD March 6, 2009 Emergency Management Summit

2. Tiered Response • Individual Hospital planning and response • Health care system planning and response • Regional health care system planning and response • State level planning and response • Intrastate and Interstate planning and response • Federal Response

3. Decisions and Stuff • Capabilities and Capacities( EXAMPLES) • Workforce equipment, training, increase numbers, administrative changes • Supplies- Caches (ventilators, medications, and associated space, resupply and receiving augmented support) • Beds and space expansions • Labs • Requirements to respond • Planning Scenarios • System wide expansions and policies • Home care, primary care, ambulatory services • Other facilities in system • Partners in individual hospital mission • EMS

4. AHRQ Emergency Preparedness Resource Inventory (EPRI)

5. EPRI Goals • Enable regions to compile an inventory of critical resources via a public domain database tool • Provide flexible access to inventory data via a web site • Provide ability to make emergency requests and tabulate responses • What resources do you need? • What resources can you share?

6. EPRI Inventory Structure • Resource Types, Resources • Location Types, Locations • Resources are “Assigned” to Location Types

7. EPRI Home Page

8. Inventory Data Entry and Data Quality

9. Resource Requirement Models • AHRQ Surge Model • Estimates hospital resources needed to treat casualties from nine different WMD scenarios • Mass Evacuation Transportation Model • Estimates transportation resources needed to evacuate patients from healthcare facilities

10. Models and Tools for Mass Casualty Surge Requirements Resources for WMD response

11. Surge Model Scenarios • Biological • Anthrax • Smallpox • Flu Pandemic • Food Contamination • Plague • Chemical • Chlorine • Mustard • Sarin • Nuclear / Radiological • 1 KT or 10 KT nuclear device • Radiological dispersion device (“Dirty bomb”) • Radiological point source • Conventional explosive

12. Surge Model Components Event Surge Model Casualty Module Pre-hospital management Hospital or network capacity Treated Surge arrivals Died Surge Model Hospital Module

13. Factors Considered • Attack location characteristics (e.g., population density) • Time delay between attack and when symptoms present (biological and radiological scenarios) • Optional mass prophylaxis (biological and radiological scenarios) • Condition of casualties upon arrival at the ED (e.g., mild vs. severe symptoms)

14. Durable equipment Human resources Pharmacy Consumable supplies Personal protective equipment Psychological Support Housekeeping Lab / Radiology Mortuary Nutrition Hospital Resources in the Surge Model

15. Casualty Arrivals at Hospitals (Prophylaxis reduces hospitalizations from 5,000 to 1,048)

16. Hospitalized Patients by Day and Unit

17. Resource Requirements for this Scenario

18. Resource Requirements for this Scenario

19. Comparison of Required and Available Resources • Display of staffing levels from HHS Area Resource File

21. Surge Model Treatment Paths Emergency Department Arriving Casualty Dead Or Discharged Patients Floor x1 ICU

22. Surge Model uses NIGMS MIDAS (Epicast) Flu Model Output

23. Example of Surge Model Output: Ventilator Requirement over Time

24. Calculating Patient Type-Specific Resource Consumption • First define average resource requirements per unit, per patient type, and per time interval • Calculate, based on LOS and death/transfer rates, the number of patients in any resource consumption category at any given time

25. Hospital Bed Availability and Patient Tracking System (HAvBED) • Prototype “real-time” standardized data reporting tool • Enhance system/region’s ability to care for surge of patients from public health emergency (e.g., flu) • Provides timely reporting of bed status data in an emergency (includes GIS) • Nationwide scope: prototype participants (Dec, 2005) • Standard Bed Reporting categories http://ahrq.gov/research/havbed/definitions.htm • Sustainable Bed Availability Reporting System (HAvBED2)Delivered to DHHS 12/07

26. Discharge Criteria for Creation of Hospital Surge Capacity The Grant focus was the development of: • an easy-to-apply method for pre-designating hospitalized patients suitable for early discharge in the event of a disaster. • a tool tested and evaluated in comparison with the current ad hoc method of identification of such patients. Kelen, G. Johns Hopkins University Current development of a decision support tool underway with the Disaster Alternative Care Site Project with ASPR on this topic

27. Model for Health Professional’s Cross Training for Mass Casualty Respiratory Needs Tool for assisting with mechanical ventilator staff surge Curriculum developed for ‘just in time’ training for SNS Identifies appropriate health care professionals to be trained and used in a surge situation http://ahrq.gov/prep/projxtreme/ Project Xtreme Cross Training Video

28. Mass Evacuation Transportation Model A planning tool for estimating the transportation resources required to evacuate healthcare facilities • Estimate evacuation time, given transportation constraints • Or, estimate transportation assets needed to evacuate within a time constraint

29. The Model Considers • Location of evacuating and receiving facilities • Patient transportation requirements • Availability of transport vehicles • Surge capacity of receiving facilities • Traffic congestion

30. Illustrative Hospital Evacuation

31. Illustrative Hospital Evacuation

32. Model Pilot Tests • New York City (April 2006) • Category 4 hurricane • Evacuation of 24 hospitals and 61 nursing homes in coastal areas (approximately 24,000 patients) • Planned evacuation (72 hours notice) • Los Angeles (May 2007) • Major earthquake • Evacuation of 3 hospitals (900 patients)

33. Changes to ALS Availability (Los Angeles)

34. Changes to Standard of Care (Los Angeles)

36. Provides community planners, as well as planners at the institutional, State, and Federal levels, with information to help plan for and respond to a mass casualty event Guide is written by leading experts in 6 areas related to mass casualty care: prehospital care, hospital and acute care, alternative care sites, palliative care, ethical issues, and legal considerations. http://www.ahrq.gov/research/mce/ Mass Medical Care with Scarce Resources: Community Planning Guide

37. Mass Medical Care with Scarce Resources: A Community Planning Guide Collaboration between AHRQ and ASPR • Ethical Considerations in Community Disaster Planning • Assessing the Legal Environment • Prehospital Care • Hospital/Acute Care • Alternative Care Sites • Palliative Care • Influenza Pandemic Case Study

38. Ethical Principles • Greatest good for greatest number • Ethical process requires • Openness • Explicit decisions • Transparent reporting • Political accountability • Difficult choices will have to be made; the better we plan the more ethically sound the choices will be

39. Legal Issues • Advance planning and issue identification are essential, but not sufficient • Legal Triage – planners should partner with legal community for planning and during disasters

40. Questions and Discussion

41. http://www.ahrq.gov/prep/

42. Publications & Tools • To order a copy of reports, tools, or resources: • contact the AHRQ Publications Clearinghouse at 800-358-9295 • Send an E-mail to ahrqpubs@ahrq.hhs.gov.

43. For More Information Contact: Sally Phillips, RN, PhD Email: sally.phillips@ahrq.hhs.gov