Jenny Atas MD Associate Professor Wayne State University Medical Director Region 2 South Medical

1. Emergency Management Strategies:Lessons Learned in Developing Specifications, Procuring, Housing and Maintaining a 100-Bed Mobile Hospital Jenny Atas MD Associate Professor Wayne State University Medical Director Region 2 South Medical Bio-Defense Network Mark Sparks Logistics/Planning Officer Region 2 South Medical Bio-Defense Network

2. Presentation Overview • Project Background • Acquisition Process and Specifications • Durable and Non-Durable Equipment Acquisition Process • Storage & Deployment Considerations

3. PROJECTBACKGROUND~ Organization ~

4. Project Background ~ OrganizationPre 9-11: District Organization • 8Emergency Management Districts covering 83 Counties • 45 Public Health Departments • 65 Medical Control Authorities (oversight of pre-hospital system) with no seat at the table

5. Project Background ~ OrganizationPost 9-11: New Paradigm of Planning Emergency Management Public Health Health Care

6. Project Background ~ OrganizationPost 9-11: HHS Grant Programs HRSA (now HHS ASPR) CDC Medical Control Authorities Hospital/Pre-hospital Local Health Departments Other Local/Regional Partners Coordinated State/Local/Regional Planning

7. Project Background - OrganizationPost 9-11: Regional Organization • 8 Medical Bio-Defense Regions • Mirror of 8 E.M. Districts • Incorporates 65 MCAs • Bioterrorism Coordinator • Medical Director • Emergency Preparedness Coordinator (Local Health Department) • Epidemiologist • SNS Technical Advisor • Seat at the table

8. Project Background ~ OrganizationRegion 2 South (R2S) Overview • 3 Counties; 97 local political jurisdictions; 2.6 million people • 14 P.A. 390 Emergency Management/Homeland Security Programs (4 with Public Health authority) • 6 Public safety mutual aid organizations • 4 Public Health Authorities • 4 Medical Control Authorities • 37 Hospitals • 69 Fire/EMS agencies • 11 Private/EMS agencies

9. Project Background ~ OrganizationLessons Learned • Regional Partnership with Emergency Management is Critical • Development of surge plans, procedures and resources must involve all disciplines • Take full advantage in the ability to leverage other federal funding streams (restrictions / allowances) • Allows you to mitigate duplication of effort on all fronts

10. PROJECTBACKGROUND~ Foundation ~ DHHS NBHPP Program Guidance for Fiscal 2006 dictates that states have the ability to surge outside hospitals and healthcare systems

11. Project Background ~ FoundationSituation • Hospitals in Michigan have incorporated the ability tosurge 20% above the average daily census. • Even with these additional 7,000 beds there stillexists insufficient surge response capability to address the needs that a medium level pandemic • MEMS remains the primary method of addressing Medical Surge Capacity and Capability (MSCC) • Hurricane Katrina demonstrated the utility of surge facilities

12. Project Background ~ FoundationSituation • Pandemic Flu • Outbreak of a moderately severe pandemic flu would exhaust surge capacity within the first two weeks • Natural and Man-Made Disasters • Trauma victims immediately exhaust surge capacity • Non-urgent health problems are exacerbated and further increase healthcare demands • Local Healthcare Emergencies • International air-traveler quarantine • 2003 SARS: 3,017,496 international passengers thru DTW • “All hazards” response capability

13. Project Background ~ FoundationSituation • In light of these factors a decision was made to utilize HRSA/ASPR funding to develop two self-contained all-weather mobile field hospitals or “surge facilities” • Initially develop and equip a 100-bed unit • Lay the groundwork • Based on available funding, develop a 50-bed unit • Extension of 100-bed unit • Rapid acquisition; rely on established specifications

14. Project Background ~ Foundation Patient and Staff Planning Assumptions • The Mobile Field Hospital would be designed… • For patients suffering from COPD, asthma, congestive heart failure (no C-PAP or vent), chronic pain syndrome, and behavioral conditions, and needing IV hydration and IV antibiotic therapy • With a 4:1 ratio of adult to pediatric patients • With a planned admission/discharge rate of 23 hours • To be operated by a core team of medical professionals augmented by volunteers (Michigan Volunteer Registry)

15. Project Background ~ FoundationLessons Learned • Don’t recreate the wheel • Patient profile from the Katrina disaster experience • Patient demographics from Michigan Census • Staff profile from existing Michigan plans for Alternate Care Facilities/MEMS Model

16. Transportable Emergency Surge Assistance Medical Unit( TESA)~ Facility Acquisition Process ~

17. TESA Project ~ Facility Acquisition ProcessGrant Application • Region 2 South was selected to develop the 100-Bed TESA Unit • The project was outlined in Region 2 South’s FY 06-07 HRSA Grant Application • Statewide resource; housed in S.E. Michigan and operated by “strike teams” from across the state • Complete project within the grant year • Establish a Task Force to: • Research the different platforms and associated planning, operational, administrative and logistical considerations • Recommend how to best configure and develop the facility within budgetary constraints

18. TESA Project ~ Facility Acquisition ProcessGrant Approval / Initial Steps • Project was approved; $1,000,000 budget • Task Force formed in October 2006. • Agencies represented: • Region 2 South Medical Bio-Defense Network • Michigan Department of Community Health, Office of Public Health Preparedness • Michigan Department of State Police, Emergency Management/Homeland Security Division • Michigan-1 Disaster Medical Assistance Team

19. TESA Project - Facility Acquisition ProcessTask Force Determinations • The recommended basic platform for the facility would be a “soft-walled” shelter structure. • To account for cost uncertainties, the platform (and invitation to submit proposals) would be designed around: • A core 50-bed facility (to include areas for triage, supply, admin, and staff support) • 25-bed add-on patient wards.

20. TESA Project - Facility Acquisition Process Task Force Requirements • Basic Requirements for the 50-Bed Core • Separate staff and patient entrances • Separate areas for facility administration, facility supplies, staff lounge and staff hygiene, and patient care wards a. Staff hygiene must have a changing area, sink, shower and toilet, cold and hot water, an on-board potable water supply with a water distribution system and a gray water containment system • Each patient ward must be equipped with a private field toilet (the Brief ReliefTM system, or equivalent)

21. TESA Project – Facility Acquisition ProcessTask Force Requirements • Basic Requirements for the Entire Shelter System • Completely self-contained • Trailer-mounted generators • Maximum component size (98”w, 50”d, 50”h) • Man-portablecomponents (maximum 75lb per worker) • Rapidly erected without the use of tools or equipment • Must provide all-weather climate controlled environment • Materials must meet NFPA Standards • Must be interoperable with existing FEMA-NDMS assets

22. TESA Project - Facility Acquisition ProcessTask ForceDeterminations • Proposal/Bid Quotation Requirements • Must provide a comprehensive description of: • Proposed system components • Warranties, manuals, parts availability guarantees • Where requirements are met or exceeded • Where requirements are not met and why a variance should be considered • How it will be packaged w/container dimensions • Must include diagrams (50-bed core, 75-bed and 100-bed configurations) • Must identify single POC for notices and inquires • Must be submitted by e-mail (formatted in MS Word and Adobe PDF.

23. TESA Project - Facility Acquisition Process Task ForceDeterminations • Parameters established to select potential shelter sources: • Identify potential sources known by the Task Force to manufacture shelters that • Generally met platform requirements • Were in common use as mobile medical facilities • To maximize practical competition, limit the minimum number of potential sources to 3 • To minimize the procurement process, limit the maximum number of potential sources to 6

24. TESA Project - Facility Acquisition ProcessTask Force Determinations • Six potential platform sources were identified • 4 that generally met shelter requirements and had been used by members of the Task Force • 1 that generally met shelter requirements but was unknown to members of the Task Force • 1 that manufactured “hard-walled” shelters, was unknown to members of the Task Force but was a Michigan-based company • These 6 potential vendors were e-mailed the Invitation to Submit a Combined Proposal/Bid Quotation

25. TESA Project - Facility Acquisition ProcessThe RFP/RFQ Package • Task Force determinations were reduced to a 3-page invitation to submit a combined Proposal/Bid Quotation… • …that would be e-mailed to pre-selected vendors.

26. TESA Project - Facility Acquisition ProcessThe RFP/RFQ Package • Task Force determinations were reduced to a 3-page invitation to submit a combined Proposal/Bid Quotation… • …that would be e-mailed to pre-selected vendors.

27. Vendor 1 Vendor 2 Vendor 3 Vendor 4 Vendor 5 Vendor 6 TESA Project - Facility Acquisition ProcessEvaluating Proposals/Quotes • All invitees responded • Hundreds of pages • Each with unique format • Some highly detailed and well organized • Some lacked detail and organization • All were printed, bound and distributed to each member of the Task Force

28. Vendor 1 Vendor 2 Vendor 3 Vendor 4 Vendor5 Vendor 6 TESA Project - Facility Acquisition ProcessEvaluating Proposals/Quotes COMPARABLES • Quote Duration • Cost • Max Size Container • Assembly • # Basic Units • Access Doors • Area (sq. ft.) • Furniture • Power • Lighting • Outlets • HVAC • NDMS Interop? • Trailer Boot • Warranty • Framing • Fabric • Insulation • Hygiene Center • Flooring • Training THE EVALUATION MATRIX

29. TESA Project - Facility Acquisition ProcessAwarding the Contract • 2 vendor’s RFP/RFQ met specs, the other 4 were eliminated from competition • Task Force members to NDMS conference to inspect both shelter systems • Gained experience - revised specifications • Requested final quote on revised specifications • Reviewed final quotes • Unanimous agreement to award contract

30. TESA Project - Facility Acquisition ProcessLessons Learned • Need experienced and knowledgeable team to avoid pitfalls when expediting a complex project • Need comparison matrix to efficiently deal with variable specifications • No substitute for getting your hands dirty (in-person inspection and assembly) • No substitute for face-to-face discussion with vendor representatives

31. TESAPROJECT~ Facility Specifications ~

32. 10,000 Sq. Ft. Enclosed Area 20,000 Sq. Ft. Footprint (125’ x 158’) 5 Generators (4 @ 36kW and 1 @ 56 kW) 16 HVAC 15 @ 42K BTU heat/3.5 ton cool/29K heat strip 1 @ 60K BTU heat/cool/HEPA positive or negative pressure) 4 Hygiene Centers Each with sink, shower, toilet, hot H2O, 500-gallon fresh and gray water holding tanks 16 Interconnected Shelters 1 each for Administration, Staff, Supply (w/boot) and Intake/Triage/Treat 1 ten-bed Patient Ward (isolation) 7 ten-bed Patient Wards 4 five-bed Patient Wards Design 4:1 ratio of adult to pediatric patients Admit/Discharge Rate: 23 hours (= 100 patients per day) Over 1,000 Separate Pieces TESA Project – Facility SpecificationsQuick Specs

33. TESA Project – Facility SpecificationsThe Design

34. TESA Project – Facility SpecificationsTactical Labeling • The components of each individual shelter are: • Color-coded & labeled • Packaged together

35. TESA Project - Facility SpecificationsTactical Storage

36. TESA Project – Facility SpecificationsAs Built (40-Bed Unit)

37. TESA Project – Facility SpecificationsLessons Learned • Color-code and label individual shelter components • Facilitates handling • Has limitations • Only so many distinct colors • Correlates only to complete 100-bed layout • Because it is a white vinyl tent labor intensive for cleaning before repackaging • Setup and tear down takes expertise • Requires the development of specialized teams

38. TESAPROJECT~ Equipment & Supply Acquisition~

39. TESA Project ~ Equipment/Supply Acquisition ProcessPatient & Staff Profile • The Mobile Field Hospital would be designed… • Forpatients suffering from COPD, asthma, congestive heart failure (no C-PAP or vent), chronic pain syndrome, and behavioral conditions, and needing IV hydration and IV antibiotic therapy • With a4:1 ratio of adult to pediatric patients • With aplanned admission/discharge rate of 23 hours • To be operated by a core team of medical professionalsaugmented by volunteers (Michigan Volunteer Registry)

40. TESA Project ~ Equipment/Supply Acquisition ProcessTask Force Determinations • The stakeholder Task Force determined to utilize sole-source provider of medical supplies and equipment to outfit the facility • Previously qualified source • Current source of ACC and NEHC facilities for MEMS components. • Demonstrated ability • Medical expertise to identify and meet needs (based on expected patients and healthcare staff) • Professional packaging • Competitive pricing

41. TESA Project ~ Equipment/Supply Acquisition ProcessPatient Profile Questionnaire • Comprehensive questionnaire was used to refine the patient profile and then determine what level of service would be provided over a given period of time

42. TESA Project ~ Equipment/Supply Acquisition ProcessCapability Worksheet

43. TESA Project ~ Equipment/Supply Acquisition Process Master Template • Master Template was used to generate the type of treatment which could be offered and the type and quantity of equipment and supplies needed.

44. TESA Project – Equipment/Supply Acquisition Process The Design

45. TESA Project – Equipment/Supply Acquisition Process The Design

46. TESA Project – Equipment/Supply Acquisition Process The Design

47. TESA Project – Equipment/Supply Acquisition Process The Design

48. TESA Project – Equipment/Supply Acquisition Process The Design

49. TESA Project – Equipment/Supply Acquisition Process The Design

50. TESA Project – Equipment/Supply Acquisition Process The Design