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Washington, DC February 5, 2008 Stephen V. Cantrill, MD Department of Emergency Medicine

Emergency Management Strategies for Identifying and Integrating Community Resources to Expand Medical Surge Capacity: Alternate Care Facilities. The National Emergency Management Summit. Washington, DC February 5, 2008 Stephen V. Cantrill, MD Department of Emergency Medicine

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Washington, DC February 5, 2008 Stephen V. Cantrill, MD Department of Emergency Medicine

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  1. Emergency Management Strategies for Identifying and Integrating Community Resources to Expand Medical Surge Capacity:Alternate Care Facilities The National Emergency Management Summit Washington, DC February 5, 2008 Stephen V. Cantrill, MD Department of Emergency Medicine Denver Health Medical Center

  2. Surge Capacity Ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system • Intrinsic: • Facility based • Community based: Alternate Care Facilities • Extrinsic: State / Federal Cantrill

  3. Community Based Surge Capacity • Requires close planning and cooperation amongst diverse groups who have traditionally not played together • Hospitals • Offices of Emergency Management • Regional planners • State Department of Health • MMRS may be a good organizing force Cantrill

  4. Where Have We Been? Cantrill

  5. Hospital Reserve Disaster Inventory • Developed in 1950’s-1960’s • Designed to deal with trauma/nuclear victims • Developed by US Dept of HEW • Hospital-based storage • Included rotated pharmacy stock items Cantrill

  6. Packaged Disaster Hospitals • Developed in 1950’s-1960’s • Designed to deal with trauma/nuclear victims • Developed by US Civil Defense Agency & Dept of HEW • 2500 deployed • Modularized for 50, 100, 200 bed units • 45,000 pounds; 7500 cubic feet Cantrill

  7. Packaged Disaster Hospitals • Last one assembled in 1962 • Adapted from Mobile Army Surgical Hospital (MASH) • Community or hospital-based storage Cantrill

  8. Pharmacy Hospital supplies / equipment Surgical supplies / equipment IV solutions / supplies Dental supplies X-ray Records/office supplies Water supplies Electrical supplies/equipment Maintenance / housekeeping supplies Limited oxygen support Packaged Disaster Hospital: Multiple Units Cantrill

  9. Packaged Disaster Hospital Cantrill

  10. Packaged Disaster Hospitals • Congress refused to supply funds needed to maintain them in 1972 • Declared surplus in 1973 • Dismantled over the 1970’s-1980’s • Many sold for $1 Cantrill

  11. The Re-Emergence of a Concept:The Alternate Care Facility • Planning Issues: • Augmentation vs Alternate Facility? • Physical space • Inclusion of actual structure • Tents, trailers, etc • Cost? Storage? Ownership? • Structure of opportunity • Private vs Public sites • Who grants permission to use? • Need for decon after use to restore to original function? Cantrill

  12. Alternate Care Facility Planning Issues • It is not a miniature hospital • “Ownership”, command and control? • HICS is a good starting structure • Who decides to open the ACF? • Scope & level of care to be delivered? • Offloaded hospital patients • Primary victim care • Nursing home replacement • Ambulatory chronic care / shelter Cantrill

  13. ACF Planning Issues • Staffing • Medical Staff • Ancillary Staff • Operational support • Meals • Sanitary needs • Infrastructure • Supplies • Pharmaceuticals • Documentation of care • Security Cantrill

  14. ACF Planning Issues • Communications • Hospitals • EMS • Emergency Management: State/Local • Relations with EMS • Rules/policies for operation • Exit strategy • Exercising the plan Cantrill

  15. Level I Cache:Hospital Augmentation • Bare-bones approach • Physical increase of 50 beds • Would rely heavily on hospital supplies • Stored in a single trailer • About $20,000 • Within the realm of institutional ownership • Readily mobile - but needs vehicle Cantrill

  16. Level I Cache:Hospital Augmentation • Trailer • Cots • Linens • IV poles • Glove, gowns, masks • BP cuffs • Stethoscopes (Developed under AHRQ Task Order: Rocky Mountain Regional Care Model for Bioterrorist Events) Cantrill

  17. Used During Katrina Evacuee Relief Cantrill

  18. Level II Cache: Regional Alternate Care Facility (ACF) • Significantly more robust in terms of supplies • Designed by one of our partners, Colorado Department of Public Health and Environment Cantrill

  19. Level II Cache: Regional Alternate Care Facility • Designed for initial support of 500 patients • Per HRSA recommendations of 500 patient surge per 1,000,000 population • Modular packaging for units of 50-100 pts • Regionally located and stored • Trailer-based for mobility • Has been implemented • Approximate price less than $100,000 per copy Cantrill

  20. Ambu bags Bed pans / Urinals Medical ID bracelets Chairs Cribs Emesis basins Forms for documentation IV sets Oxygen masks Ice packs Pillows Privacy screens Soap Tables Duct tape Adhesive tape Thermometer strips Tongue depressors (Still No Drugs) Level II: Level I Plus: Cantrill

  21. Level III Cache:Comprehensive Alternate Care Facility • Adapted from work done by US Army Soldier and Biological Chemical Command • 50 Patient modules • Most robust model • Closest to supporting non-disaster level of care, but still limited • More extensive equipment support Cantrill

  22. Work at the Federal Level • DHHS: Public Health System Contingency Station • Specified and demonstrated • 250 beds in 50 bed units • Quarantine or lower level of care • For use in existing structures • Multiple copies to be strategically placed • Owned and operated by the federal government Cantrill

  23. Basic Concept: HHS Public Health Service Contingency Stations (Federal Medical Stations) Cantrill

  24. Cantrill

  25. Station Layout Hall A Cantrill

  26. Cantrill

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  28. Possible Alternative Care Facilities Hotel Stadium Recreation Center School Church Cantrill

  29. ACF Site Selection • What is the best existing infrastructure/site in the region for delivering care? (Developed under AHRQ Task Order: Rocky Mountain Regional Care Model for Bioterrorist Events) Cantrill

  30. Cantrill

  31. ACF Site Selection Tool • ACF infrastructure factors listed on one axis of a matrix. • Potential ACF sites listed on the other axis of the matrix. • Relative weight scale for each factor using a 5-point scale comparing factor to that of a hospital. • Developed as an Excel spreadsheet. Cantrill

  32. Aircraft hangers Churches Community/recreation centers Convalescent care facilities Fairgrounds Government buildings Hotels/motels Meeting Halls Military facilities National Guard armories Same day surgical centers/clinics Schools Sports Facilities/stadiums Trailers/tents (military/other) Shuttered Hospitals Detention Facilities Potential ACF Sites (pre-selected) Cantrill

  33. Factors to Weigh in Selection of an Alternate Care Facility Site • Infrastructure • Total Space and Layout • Utilities • Communication • Other Services Cantrill

  34. Factors to Weigh in Selection of an Alternate Care Facility Site • Infrastructure • Door sizes • Floor • Loading Dock • Parking for staff/visitors • Roof • Toilet facilities/showers (#) • Ventilation • Walls Cantrill

  35. Factors to Weigh in Selection of an Alternate Care Facility Site • Total Space and Layout • Auxiliary Spaces (Rx, counselors, chapel) • Equipment/Supply storage area • Family Areas • Food supply/prep area • Lab/specimen handling area • Mortuary holding area • Patient decon areas • Pharmacy areas • Staff areas Cantrill

  36. Factors to Weigh in Selection of an Alternate Care Facility Site • Utilities • Air conditioning • Electrical power (backup) • Heating • Lighting • Refrigeration • Water Cantrill

  37. Factors to Weigh in Selection of an Alternate Care Facility Site • Communication • Communication (# phones, local/long distance, intercom) • Two-way radio capability • Wired for IT and Internet Access Cantrill

  38. Factors to Weigh in Selection of an Alternate Care Facility Site • Other Services • Ability to lock down facility • Accessibility/proximity to public transportation • Biohazard & other waste disposal • Laundry • Ownership/other uses during disaster • Oxygen delivery capability • Proximity to main hospital • Security personnel Cantrill

  39. Weighted Scale 5 = Equal to or same as a hospital. 4 = Similar to that of a hospital, but has SOME limitations (i.e. quantity/condition). 3 = Similar to that of a hospital, but has some MAJOR limitations (i.e. quantity/condition). 2 = Not similar to that of a hospital, would take modifications to provide. 1 = Not similar to that of a hospital, would take MAJOR modifications to provide. 0 = Does not exist in this facility or is not applicable to this event. Cantrill

  40. Cantrill

  41. Customizing the Site Selection Matrix Additional relevant factors or facility sites can be added to the tool based on your area or the type of event. Cantrill

  42. Issues to Consider • Is each factor of equal weight? • What if another use is already stated for the building in a disaster situation? (i.e. a church may have a valuable community role) • Are missing, critical elements able to be brought in easily to site? Cantrill

  43. WHO needs this tool? • Incident commanders • Regional planners • Planning teams including: fire, law, Red Cross, security, emergency managers, hospital personnel • Public works / hospital engineering should be involved to know what modifications are needed. Cantrill

  44. WHEN should you use this tool? • Before an actual event. • Choose best site for different scenarios so have a site in mind for each “type”. Available from: www.ahrq.gov/research/altsites.htm Cantrill

  45. Who has used this tool? • Greece, in preparation for the Olympics • California • Florida • Other states/locations • Available from: www.ahrq.gov/research/altsites.htm Cantrill

  46. The Supplemental Oxygen Dilemma • Supplemental oxygen need highly likely in a bioterrorism incident • Has been carefully researched by the Armed Forces • Most options are quite expensive with high cost/patient • Many have very high power requirements • Most require training/maintenance • All present logistical challenges • Remains an unresolved issue for civilian ACFs Cantrill

  47. And Then The “Other” Problems: • Ventilators: • Currently in US: 105,000 • In daily use: 100,000 • Projected pandemic need: 742,500 • Respiratory Therapists Cantrill

  48. Ventilators – Surge Supply • Additional full units - $32,000 each • Smaller units for $6,000 each • Many “Disposable” Units - $65 each Cantrill

  49. Respiratory Therapists:Just-In-Time Training AHRQ: Project XTREME: www.ahrq.gov/prep/projxtreme/ Cantrill

  50. Physician [1] Physician extenders (PA/NP) [1] RNs or RNs/LPNs [6] Health technicians [4] Unit secretaries [2] Respiratory Therapists [1] Case Manager [1] Social Worker [1] Housekeepers [2] Lab [1] Medical Asst/Phlebotomy [1] Food Service [2] Chaplain/Pastoral [1] Day care/Pet care Volunteers [4] Engineering/Maintenance [.25] Biomed [.25] Security [2] Patient transporters [2] ACF Ideal Staffing: 33 Per 12 Hour Shift Cantrill MEMS ACC guidelines

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