Welcome & Introductions

1. Welcome & Introductions March 28, 2012 (10am – Noon)

2. Altered Standard of Care Preplanning Guide Exercise

3. Purpose To introduce local Health Officers, Public Health Directors, LEMSA Administrator, and LEMSA Medical Director and other staff to the Altered Standard of Care Pre-Planning Guide.

4. Altered Standard of Care Pre-Planning Guide What is it?

5. Altered Standard of Care Pre-Planning Guide The Altered Standard of Care Pre-Planning Guide is designed as a tool to assist local emergency planners with modifying the current EMS delivery system in response to a catastrophic incident.

6. Altered Standard of Care Pre-Planning Guide • Developed with HPP Year 8 grant funds • Based upon best practices and source documents including: • Santa Clara County Altered Standards Tool, • San Francisco County Altered EMS Protocols, • CDC and NHTSA guidelines

7. Altered Standard of Care Pre-Planning Guide • Designed as an all-hazards tool for any type of disaster, including: • Severe flooding • Earthquakes • Pandemic Outbreak • Other catastrophic incidents

8. Exercise ScenarioPandemic Outbreak(Week 6)*Worldwide, National, and State data is based upon actual response information from the H1N1 outbreak

9. World wide impact

10. Worldwide Impact • In early February, confirmed reports from the U.S. Centers for Disease Control revealed a novel strain of the influenza virus.

11. Worldwide Impact The World Health Organization declared a global pandemic alert as more than 214 countries and overseas territories or communities worldwide have reported laboratory confirmed cases of the novel virus.

12. Worldwide Impact As of last week, most developed countries reported widespread infection, including at least 18,449 deaths.

13. Worldwide Impact Community Mitigation measures include school closures, cancellation of mass gatherings, isolation and quarantine, and other social distancing measures.

14. Worldwide Impact • Health care systems experiencing significant stress; reporting regional surges in hospital, emergency department, and outpatient visits. • Some countries reporting hospital bed, equipment and medication shortages.

15. National Impact

16. National Impact CDC is reporting that the most impacted populations include: • Children and young adults • Persons with underlying chronic medical conditions (e.g. chronic lung disease, heart disease, immunosuppression, neurological and neurodevelopment diseases) • Pregnant women • Indigenous populations • Possible risk groups: Obesity (Body Mass Index ≥35), Extreme/Morbid obesity (Body Mass Index ≥40)

17. National Impact Oseltamivir (Tamiflu) and zanamivir are the only FDA-approved antiviral drugs effective against this virus.

18. Presidential Proclamation President Obama has signed a proclamation declaring this influenza pandemic a National Emergency to facilitate our ability to respond to the pandemic by enabling – if warranted – the waiver of certain statutory Federal requirements for medical treatment facilities.

19. Presidential Proclamation In particular, this proclamation is aimed at providing HHS the ability to waive legal requirements that could otherwise limit the ability of our nation’s health care system to respond to the surge of patients with the novel influenza virus.

20. HHS has approved: • Hospitals request to set up an alternative screening location for patients away from the hospital’s main campus (requiring waiver of sanctions for certain directions, relocations or transfers under EMTALA). • Hospitals request to facilitate transfer of patients from ERs and inpatient wards between hospitals (requiring waiver of sanctions under EMTALA regulations).

21. HHS has approved: • Critical Access Hospitals requesting waiver of 42 CFR 485.620, which requires a 25-bed limit and average patient stays less than 96 hours. • Skilled Nursing Facilities requesting a waiver of 42 CFR 483.5, which requires CMS approval prior to increasing the number of the facility’s certified beds.

22. State Impact

23. State Impact Gubernatorial Declaration NOW, THEREFORE, I, EDMUND G. BROWN JR., Governor of the State of California, in accordance with the authority vested in me by the California Constitution and the California Emergency Services Act, and in particular California Government Code sections 8558(b) and 8625, find that conditions of extreme peril to the safety of person and property exists within the State of California and HEREBY PROCLAIM A STATE OF EMERGENCY in California.

24. State Impact Gubernatorial Declaration (Cont.) IT IS HEREBY ORDERED that all agencies and departments of state government utilize and employ state personnel, equipment, and facilities as necessary to assist the State Department of Public Health and the Emergency Medical Services Authority in immediately performing any and all activities designed to prevent or alleviate illness and death due to the emergency, consistent with the State Emergency Plan as coordinated by the California Emergency Management Agency.

25. Local Impact

26. Local Impact Butte: Both Oroville Hospital and Feather River Hospital reporting >100% capacity. Ambulance turn-around times greatly delayed (60 - 90 minutes).

27. Local Impact Colusa: Colusa Regional Medical Center has converted the Physical therapy and Outpatient areas into additional inpatient beds, and also reports significant delays in ambulance response.

28. Local Impact • Nevada: Tahoe Forest and Sierra Nevada Memorial Hospital are both using surge tents and have created surge beds within their facilities. Dispatch is complaining about lack of available ambulances and lack of mutual-aid resources.

29. Local Impact • Placer: All three hospitals have implemented internal surge plans. Kaiser and Sutter Roseville have been in discussions with Public Health to convert a portion of the Maidu Center into an ACS for additional inpatient beds.

30. Local Impact • Shasta: Fire personnel in Redding reported an incident in which they performed CPR on-scene for 29 minutes before ambulance arrival. 5 ambulances are currently being held at Shasta Regional Medical Center with patients on their gurneys, 2 of these have been waiting more than 90 minutes.

31. Local Impact • Siskiyou: Mercy Medical Center Mt, Shasta and Fairchild Medical Center are reporting zero inpatient beds, and are holding multiple admissions in the ED. 911 callers are complaining of being put on hold, and ambulances have delayed turnaround times.

32. Local Impact • Sutter: Fremont Medical Center has a full census, and is reported no available beds. Bi-county ambulance has staffed two additional units, and are complaining about the ED status and turnaround times at Rideout.

33. Local Impact • Tehama: Due to the recent MCI at the Red Bluff Airport, St Elizabeth Hospital has been dealing with several trauma patients, and has no inpatient beds available. Fire personnel have been unavailable to assist on medical calls due to the MCI and fire.

34. Local Impact • Yolo: The Yolo Emergency Communications Agency has implemented their Emergency Rule Stage 3 for suspending pre-arrival instructions to attempt to respond to the increased 911 medical-aid requests. Sutter Davis and Woodland Memorial have both activated internal surge plans, and are holding admits in the ED. AMR Yolo is reporting significant delays at the ERs, and are unable to staff additional units due to sick calls.

35. Local Impact Yuba: Rideout is reporting a significant staffing crisis due to sick call-ins. The HERT team has set up surge tents in the parking lot to receive/triage patients. However, ambulance personnel are reporting that there are no nurses staffing the triage area, and there are three ambulances waiting outside for more than an hour.

36. S-SV EMS Agency • In response to overwhelming numbers of local requests from MHOACs, Public Health Departments, ambulances, and hospitals; S-SV has been in contact with EMSA and the RDMHSs in Region III and Region IV regarding ambulance mutual-aid, and no additional resources are available at this time.

37. S-SV EMS Agency • Since outside resources are unavailable, each operational area must determine how to continue to support the 911 system with the current local resources.

38. “How can the EMS System Continue to sustain this demand?”

39. Altered Standard Orders Form

40. Altered Standard Order Form

41. Public Access

42. Control Facility

43. EMS Providers

44. ASO Form Summary • It’s a tool…not a policy • Once reviewed, and signed by the MHOAC or EMS Agency Medical Director it becomes an Emergency Policy and Protocol EMERGENCY Policy and Protocol

45. System Changes • In response to this Pandemic Outbreak, the EMS Agency staff has met, and would like to present their proposal to the Health Officers to get feedback and consensus.

46. System Changes • We are going to review those proposals in two segments: • Public Access Changes, and • Field Protocol Changes • Followingeach segment, there will be a time for open discussion.

47. Prioritizing the Needs IMMEDIATE DELAYED MINOR DECEASED

48. Proposed Changes to the Public Access System • Public Access Number/ Website • Scheduled Transport Center • Altered 911/EMD triage

49. Scheduled Transport Center By establishing a Scheduled Transport Center the stress on the 911 system will be significantly decreased, and will allow dispatchers to manage a higher call volume and improve call turn-around times.

50. Scheduled Transport Center Activating this separate center will allow the Transport Center staff to explore all the alternatives for the transportation needs of the calling party.