No Vacancy: Healthcare Surge Capacity in Disasters

1. No Vacancy: Healthcare Surge Capacity in Disasters John L. Hick, MD MDH/HCMC July 22, 2004

2. Capacity vs. Capability • Surge Capacity – ‘the ability to manage increased patient care volume that otherwise would severely challenge or exceed the existing medical infrastructure’ • Surge Capability – ‘the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions’ • Barbera and Macintyre

3. Different types of ‘surge’ • Unexpected vs. expected • Timeline and potential for secondary cases (anthrax vs. plague) • Static vs. dynamic • Triage / field treatment • Healthcare facility-based • Community-based

4. Concepts and Principles • Standardization • Incident Management System • Multiagency Coordination System • Public Information Systems • Interoperability (eg: personnel and resource typing) • Scalability • Flexibility • Tiers of capacity (spillover to next level)

5. Tiers of Response – Patient Care Federal Response (Regional & National) 6th Tier Federal Response 5th Tier State / Interstate Coordination (MDH) State A State B 4th Tier Coordination of Intrastate Regions (MDH) Jurisdiction I (PH/EM/Public Safety) Jurisdiction II (PH/EM/Public Safety) 3rd Tier Jurisdiction Incident Management (County) Medical Support 2nd Tier Healthcare “Coalition” (Compact) HCF A HCF B HCF C Non-HCF Providers 1st Tier Healthcare Facility

6. HRSAGrant Minnesota Local Public Health Regions

7. Minnesota Hospital Resources • 140 acute care hospitals • State total 16,414 licensed beds • Less than 50% of these operating • Loss of 36 hospitals, 3000 beds in past 20 yrs • Nearly half of MN hospitals are either ‘critical access’ or considering such designation • Staff shortages, particularly nursing staff

8. Metropolitan Hospital Compact • Since April 9, 2002 • 27 hospitals, approximately 4800 operating beds • 7 counties • Agreement provides for: • Staff and supply sharing • Staffing off-site facilities for first 48h • Communications, JPIC • Regional Hospital Resource Center (HCMC)

9. Regional Coordination • Regional Hospital Resource Center (RHRC) • Acts as ‘broker’ for patient transfers • Coordinates hospital response and requests within region • Represents hospital needs and issues to RCC • Regional Coordination Center (RCC or MAC) • Multi-agency coordination center for policy and strategic guidance • NO jurisdictional authority • Functions and scope determined by incident

10. Hospital Response • At least 50% arrive self-referred • On average, 67% of patients in any given disaster are cared for at the hospital nearest the event (range 41-97%) • Redistribution from the hospital closest to the incident scene to other facilities may be as (or more) important than transport from the scene

11. Facility-based Surge • Usually can free up 15% of beds at a given facility • Get ‘em up and get ‘em out (ED, clinics) • Discharges and transfers (eg: nursing home) • Board patients in halls • Cancel elective procedures • Convert procedure/PACU areas to patient care • Accommodate vents on floor (or BVM or austere O2 flow powered ventilators) • Supply and staffing issues (72h ahead)

12. Per 1000 patients injured • 250 dead at scene • 750 seek medical care • 188 admitted • 47 to ICU • ‘Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11

13. Community-Based Surge • Clinics • Homecare • Nursing homes • Procedure centers • Family-based care • Off-site hospitals (Acute Care Center) • Off-site clinics (Neighborhood Emergency Help Centers) (assessment and clinic level care) • Local / Regional referral / NDMS

14. Aircraft hangers Military facilities Churches National Guard armories Community/recreation centers Surgical centers / medical clinics Convalescent care facilities Sports facilities / stadiums Fairgrounds Trailers Government buildings Tents Hotels/motels Warehouses Meeting halls Potential Alternative Care Sites

15. Ability to lock down/Security HVAC Lab/specimen handling Lighting Laundry Loading Dock Equipment storage Oxygen delivery capability Waste disposal Parking Communications capability Patient decon Door size Pharmacy areas Electrical power with backup Proximity to hospital Family areas Toilets/showers/waste Food supply / prep area Water supply Wired for IT/Internet access Factors to consider

16. Off-site hospital • Triage / admission criteria • Level of care – basic nursing, drip meds, IVs, NG feeds • Medications • Documentation / order management • Laboratory • Food / water / sanitary • Linen and medical waste handling • Oxygen?

17. Personnel Augmentation • Hospital personnel • Clinic personnel • Medical Reserve Corps • Non-clinical practice professionals • Retired professionals (eg: HC Medical Society) • Trainees in health professions • Ski patrol, civil air patrol, other service organizations • Lay public (CERT teams, etc) • Federal / interstate personnel

18. Sample Site

19. Food Restrooms Staff rehab areas Secure HVAC system specs Paging /messaging /radio Power Phone, T1 lines, etc. City owned! Sample Site

20. Resources • Off-site matrix: www.denverhealth.org/bioterror/tools • MaHIM: www.gwu.edu/~icdrm • Model hospital planning: www.er1.org • Off-site facilities and community planning: www2.sbccom.army.mil/hld/bwirp/ • Annals of Emergency Medicine www.mosby.com/aem ‘articles in press’ (left side)