new england society for health care material management preparing for pandemic surge march 22, 2006
TRANSCRIPT
New England Society for Health Care Material Management
Preparing for Pandemic Surge
March 22, 2006
3/21/2006 R. Paone
New England Society for Health Care Material Management
Robert P. Paone, B.S., Pharm. D.
Statewide Strategic National Stockpile Coordinator
Center for Emergency Preparedness
Massachusetts Department of Public Health
(508) 820-2011 (desk)
(617) 438-8249 (cell)
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Objectives
Review current impact projections of a Pandemic Flu in Massachusetts
Describe Pandemic Response Plans at state and local levels
Discuss surge preparations
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Potential Impact of Next Pandemic In Massachusetts: Planning Assumptions Outbreaks will occur simultaneously
throughout the US
Up to 40% absenteeism in all sectors at all levels
Order and security disrupted for several months, not just hours or days
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Pandemic v. Usual Surge Event Likely to happen across Commonwealth and
affect all regions simultaneously Expected to occur in at least 2 waves of
approximately 8 weeks duration each Projected numbers are spread across the
wave, with a peak occurring mid-wave High attack rate among healthcare workers
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Hospital Admissions for 30% Attack Rate, 8 Week Wave
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
1 2 3 4 5 6 7 8 9 10
Example of an Epidemic Curve
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MDPH FLU SURGE ASSUMPTIONS
Attack rate: 30% Hospitalization rate: 4% of ill Death rate: 1% of ill Duration of epidemic wave: 8 weeks Avg. length of non-ICU stay for flu related illness: 5 days Avg. length of ICU stay for flu related illness: 10 days Avg. length of vent usage for flu related illness: 10 days Flu admissions requiring ICU care: 50% Flu admissions requiring mechanical ventilation: 15% Flu deaths assumed to be hospitalized: 70% Daily increase of cases compared to previous day: 3%
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Surge Bed Definitions Level 1: Staffed and available Level 2: Licensed, Staffed
Two types Beds made available through patient discharge and transfers.
These beds are NOT additive – they are within the Level 1 bed number, but are vacated and made available for surge.
Beds made available through canceling of elective surgery, such as day surgery or endoscopies. Both the beds and the staff for those beds can be redirected for general hospital patients. These beds ADD to overall capacity. (Redirected level 2 beds, or 2R)
Level 3: Licensed but not staffed Generally equipped, including wall gases
Level 4: Overflow beds in non-traditional patient care areas Cafeterias, lobbies, etc. Require purchase of equipment (including beds), supplies and in
need of staff
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Hospital Surge Capacity
Level I 13,067 Current staffed beds
Level II 2,000* Re-directed
Level III 3,568 Un-staffed beds
Level IV 5,071 Non-trad. space
Total: 23,706*
*Adjusted number reflects omission of beds that had been double counted through transfers out to other hospitals. This number will decrease over time as the “elective” admissions become non-elective. All beds are ultimately dependent on available staffing, so maximum number may not always be attainable.
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Comparison of Pandemic Planning Numbers
1957/68-like MDPH Surge
Planning*
1918-like
# Ill 2 M (30%) 2M (30%) 2 M (30%)
Hospitalizations 20,000 (1%) 80,000 (4%) 220,000 (11%)
Deaths 4,600 (0.23%) 20,000 (1%) 42,000 (2.1%)
*Based on 3X 1968 projections (Trust For America’s health report: A Killer Flu, www.healthyamericans.org, June 2005)
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outbreak 30% attack rate
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Surge Bed Capacity vs. Need
Levels 1 and 2
Level 3 Level 4 *
Total Bed
Capacity
Total Beds
Needed
Variance
1 (West.) 2,122 277 1,026 3,425 3,284 141
2 (Central)
1,948 460 579 2,987 2,867 120
3 (N.E.) 2,663 788 1,286 4,737 4,022 715
4AB (128)
2,879 740 915 4,534 5,096 (562)
4C (Bos.) 3,013 978 748 4,739 4,014 725
5 (S.E.) 2,761 324 517 3,283 4,277 (994)
STATE 15,061 3,567 5,071 23,705 23,560 145
* Requires Purchase of Beds & Supplies
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State: Need 23,560out of 23,705 Beds
0
500
1,000
1,500
2,000
2,500
3,000
3,500
1 2 3 4 5 6 7 8
Nonflu Flu
Levels 1 and 2
Level 3
Level 4
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128 Crescent (4AB):Need 562 more beds than available
0
1,000
2,000
3,000
4,000
5,000
6,000
1 2 3 4 5 6 7 8
Nonflu Flu
Levels 1 and 2
Level 3
Level 4
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Southeast (5): Need 994 more level 4 beds than available
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
1 2 3 4 5 6 7 8
Nonflu Flu
Level 1 and 2
Level 3
Level 4
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Gaps in Bed Capacity
All 6 regions expected to fill 100% of level 3 beds (licensed but unstaffed)
All regions will need to open some level 4 beds (overflow areas)
Two regions will exceed their surge capacity (Regions 4AB and 5)
Staffing and supplies required for ALL level 3 and 4 beds
Equipment, supplies, and staffing needed for level 4 beds
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Hospital Surge Capacity
Despite operational changes, hospitals may become overwhelmed depending on usage in communities served
Alternate care spaces will need to be identified to expand hospital capacity
Pre-hospital triage will be needed to relieve pressure on hospital operations
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Alternate Care Sites (ACS)
Hospitals: flu patients requiring mechanical ventilation, or those with complex medical management needs
ACS: Sickest flu patients not meeting the criteria for hospital admission but for whom home care is not possible
Location and number to be determined by local hospital bed availability.
Federal Medical Station Federal Medical Station Type III (Basic)Type III (Basic)(FMS TIII)(FMS TIII)
SNS Stakeholders ConferenceSNS Stakeholders Conference
February 21, 2006
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FMS Goal
Address the nation’s potential shortfall in all-hazard mass casualty care events and create a federal-level contingency care program as
directed in HSPD 10.
Deploy a surge capability throughout the Nation, pre-positioned and configured to respond rapidly and effectively to all types of public health emergencies, from significant incidents to large-scale catastrophic disasters
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FMS TypesStandardized Capabilities Across Agencies Type I (Advanced): Has capability to care for severely ill or injured
patients, equivalent to conventional operating room, ICU, and basic laboratory (Lead: DHS) (DHS uses “FMCS”)
Type II (Specialized): Configured for specific clinical scenarios, such as respiratory isolation and burn care. Future prototypes to be developed. (Lead: DHHS)
Type III (Basic): Low to mid-level acuity of care to provide platform for DMAT teams, special needs shelters, quarantine function, alternate care facility to augment community hospital capability (Lead: DHHS)
Type IV (FMS): Special Needs Shelter (Lead: DHHS)
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FMS TIII (Basic)FMS TIII (Basic)ConceptConcept
A Federal, deployable medical asset designed to support regional, state, and local healthcare agencies responding to catastrophic events. It provides two critical capabilities:
- Inpatient, non-acute treatment capability for areas where hospital bed capacity has been exceeded.- A quarantine capability to isolate persons suspected of being exposed to or affected by a highly contagious disease.
Features:- Consists of three core modules and bed expansion module- Very few recoverable items in the FMCS kit- Easily adapted to meet a range of mass medical care needs following disaster- Deploys with SNS technical team to facilitate FMCS set up and transfer to Federal Health Care Professionals
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FMS TIII 250 Bed Module FMS TIII 250 Bed Module Configuration e ConfigurationType III Basic
Base SupportWith
Quarantine
• Administration• Support• Feeding• Quarantine• Beds(50)• Housekeeping• First Aid Equipment• Pediatric Care• Adult Care• Personal Protective Equipment
Type III BasicTreatment
Type III BasicPharmaceutical
•Pharmaceutical•Special Medications• Prophylaxis
Type III BasicBed Aug
(50)
•Beds• Bedding• Bedside Equipment
• Primary Care• Non-acute Treatment • Special Needs• Non-acute Treatment • Special Needs
FMS
Current Pack
•634 items - 3 days supply
•170 pallets (uni-pacs and pallets)
• 4 tractor trailer (53 ft) loads
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Staffing
Remains biggest challenge we face Legal protections are key to recruiting personnel Large number of non-clinical personnel also needed Potential sources of clinical surge personnel:
Internal Hospital Strategies MSAR volunteers Medical Reserve Corps that are not included in hospital staff Retired, inactive health professionals Students (medical, nursing, pharmacy)
Connect and Serve (www.mass.gov)
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Health Care Professionals
Professional qualifications must be checked and verified ahead of time
Volunteers cannot be assigned to take care of patients until their specific knowledge and skills are understood
It takes time to do this – volunteers who have not been pre-registered and pre-credentialed may be delayed in receiving an assignment
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3/21/2006 R. Paone WHO recommendation November 2005, *FDA
Masks v. Respiratorshttp://www.fda.gov/cdrh/ppe/masksrespirators.html*
•Viruses spread primarily by droplet spray therefore surgical mask is appropriate protection if working within three feet of infected patients. (Upon entering the patient’s room)
•Respirators (i.e. N-95 masks, properly fitted*) should be worn by HCWs who are involved with patients undergoing procedures in which aerosolized particles may be generated. (endotracheal intubation, suctioning, nebulizer therapy, etc.)
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Oxygen Needs
Model presumes that patients in Level IV and ACS who require oxygen will require oxygen therapy at 4-6 liters/minute (l.p.m.) flow.
Level IV and ACS model is based on 50 patients being treated for 10 day period.
Assumption is that at any given time, 25 patients will require constant oxygen.
Cost estimates derived from preliminary survey of local vendors.
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Delivery Systems
Oxygen Gaseous Cylinder Oxygen Concentrator Liquid Oxygen Stockpile/Cache Planning
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Gaseous Cylinder
H tank cylinder being used at 4-6 l.p.m. will last approximately 1 day per patient.
Therefore, each ACS will need a minimum of 250 H cylinders worth of oxygen.
Most oxygen vendors lease H cylinders to end users and recycle the empties replacing them with full tanks (similar to bottled water cooler set ups used in offices)
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Oxygen Concentrators
Different models can be used at 1 to 6 liters per minute.
Each patient would need their own concentrator. Primarily used for lower flow (1-2 l.p.m.)
applications, however units do exist that do 6 l.p.m. and more expensive units could provide oxygen up to 10 l.p.m.
Concentrators produce oxygen from room air and therefore do not require any gaseous or liquid oxygen to be supplied.
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Liquid Oxygen
Based on cryogenic technology. Most hospitals have liquid oxygen tanks on
their premises used to supply oxygen throughout facility.
Cost is based on pounds. It is estimated that at approx. 6 l.p.m., each
patient would probably use approx. 280 pounds for a 10 day period
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Oxygen Stockpile/Cache Planning MDPH representatives have started to
conduct outreach such as attending New England Medical Equipment Dealers quarterly meeting Dec. 8th in Boxboro, MA.
MDPH will contact major medical supply vendors/distributors including local and regional oxygen suppliers to explore the topic of securing adequate oxygen supplies during a regional, statewide and national pandemic surge situations.
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Ventilators
Hospital Ventilators cost approx. $25,000/unit.
Portable ventilator contained within SNS stock costs approx.$7,900/unit.
Looking into prices for portable ventilators. MDPH will work with ventilator suppliers and
manufacturers to explore state and nationwide ventilator availability.
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Ventilators
Massachusetts Department of Public Health is currently in the process of evaluating ventilators and O2-concentrators.
DPH is considering purchasing 1000-2000 vents and O2-concentrators for our state wide stockpile.
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Surge Supply Caches: Total Cost for 50 Bed ACS: $250,000 Approx. $5000 per patient Approx. $20,000 Oxygen and Suction
supplies Approx. $40,500 durable medical supplies Approx $17,600 for Intravenous related
supplies Approx. $78,800 for
infrastructure/administrative supplies
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Alternate Care Site Costs (cont.)
Approx $28,000 for support service costs (laundry, food, lab-work etc.)
Approx. $46,600 Pandemic related medicines Approx $7500 for acute/non-emergent
maintenance meds Approx. $13,000 for stocked Crash Cart
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Maximizing the Supply Chain
Identify items for surge Increase par levels for on site cache For pharmaceuticals, distributors maintain
~21 day inventory Work with suppliers Place orders early in pandemic
Identify alternate sources
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Maximizing the Supply Chain (cont.) What else? All suggestions are welcomed!
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Time
Provide quality medical care
Infection control in medical & long term care settings
Antiviral treatment & prophylaxisIm
pact
Pandemic influenza disease
Pandemic Response Actions:Timing and Potential Impacts
Vaccination
Interventions to decrease transmission
Maintain essential community services/emergency response activities
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Most of the impact and most of the response
will be local.
Local Infectious Disease Emergency Planning