Surge Capacity: Preparing for the worst-case scenario

John L. Hick, MD

Hamilton, Ontario

May 29, 2006

What defines a disaster?

Demand for critical resources outstrips availability thus putting patients or staff in danger

Goal is to plan ahead to ensure: More effective use of available resources Mobilization of additional resources

Outcome: ‘special incident’ doesn’t become a ‘disaster’

May depend on time / day / facility

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

Surge Capacity Partners EMS (and other patient transportation resources) Emergency Management Public Health Public Safety/Law enforcement Healthcare Systems

Hospitals and hospital associations Red Cross Behavioral health Jurisdictional legal authorities Professional associations inc pharmacy, medical,

nursing, mental health

Concepts and Principles

Standardization Incident Management System Multi-Agency Coordination System Public Information Systems Interoperability (eg: personnel and resource

typing) Scalability Flexibility Tiers of capacity (spillover to next level)

Off-Site Care Facilitiese.g., Procedure Centers,

Churches, Hotels, Community/Recreation Centers, Warehouses

Home

Clinics and/orPrivate MDs

Treatment/Triage

In-Home Family Care

LTC Facilities

Urgent Care Centers

Neighborhood Emergency Help

CentersMass Dispensing Clinics

Screening Centers

Homecare

Hospitals

Surge Capacity Coordination

HCF A HCF CHCF B Healthcare Facility 1st Tier

2nd TierHealthcare “Coalition”

Jurisdiction I

(PH/EM/Public Safety)

Non-HCF Providers

Medical Support

3rd TierJurisdiction Incident

Management

4th Tier

Jurisdiction II

(PH/EM/Public Safety)

Regional Coordination

5th Tier

National Response 6th Tier

Provincial CoordinationProvince A Province B

Provincial and National Response

Tiers of Response – Patient Care

Cap

ab

ilit

ies

and

Res

ou

rces

National Response

Regional / Mutual Response Systems

Provincial Response

Increasing magnitude and severity

Local Response

Tiered Response Strategy

Minimal Low Medium High Catastrophic

Facility / Community Planning Emergency

Management Plan HVA Command, control,

communications Community partners Regional partners Training Drills Review / modify

Functional Planning MCI Security Event Fire Chemical exposure Radiologic Event Infectious Disease Evacuation

Local Attractions...

Emergencies Present Themselves In 2 Ways…

Oklahoma City Bombing

September 11, 2001

Hurricane Katrina

Midwest Floods

Pandemic InfluenzaNorthridge Earthquake

The Amount of Time We’re GivenTo Pre-Organize People and Pre-Stage Equipment

Can Drastically Change Our Response Effectiveness

Anticipatedand/or

With Warning

Anticipatedand/or

With Warning

Unanticipatedand/or

Without Warning

Unanticipatedand/or

Without Warning

‘C’ first and foremost

CommandControlCommunicationCoordination

Command / Control

Who is in charge? Who has authority to declare a special

incident, evacuate, etc? Where is the EOC/Command Post? How does the EOC/CP interact with:

Community resources Other hospitals/public health

Tiered, scalable, flexible plans Use of Hospital Incident Command System

Getting Organized…

INCIDENT BRIEFING

• Date/time of start of incident

• Type of incident

• Services involved

• Current incident status

• Current resource status

• Current strategy/objectives

• Communications systems being used

• Special problems/issues

NatureNature

SizeSize

LocationLocation Time of DayTime of Day

Day of the WeekDay of the Week

InitiallyInitially

MobilizationChecklist

MobilizationChecklist

What ?Where ?When ?Who’s Involved ?Where Is It Going ?

What ?Where ?When ?Who’s Involved ?Where Is It Going ?

EmergencyOperations

Center

IncidentAction

Planning

Communication

Within ED / hospital Phone (redundant?), local cellular Paging Portable radios Alpha pagers, SMS, email, VOIP Runners

Outside facility – phone, cell, HEAR, amateur radio, internet – VOIP, email, net-based

Coordination

Within facility (for ICU, CT, etc.) Outside facility:

Transfers (including ambulances, helos) Resource requests Outside agencies

Regional Hospital Resource Center (RHRC) Coordinates hospital response and requests

within region

‘S’ - Logistics

SpaceStaffStuff

Space Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home)

Discharge holding area

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) Alternative ambulatory care areas (lobbies, clinics, etc.)

Staff

Different events = different staff needs Eg: HAZMAT vs. trauma vs. monkeypox

Scope of event = scope of staff call-in Mechanism to reach staff Support staff – eg: central supply, food,

psychosocial Labor pool unit leader Assign staff to specific areas when possible Nursing staff often limiting factor

Staffing

Personnel Augmentation

Hospital personnel Clinic personnel Non-clinical practice professionals Retired professionals (eg: HC Medical Society) Trainees in health professions Service organizations Lay public / faith-based / family members Government personnel

Stuff

Patient care supplies – look at by type of event

Pharmacy – analgesia, sedation, dT, abx PPE – masks, barrier gowns Supply and staffing issues (72h ahead) Logistics and planning sections

Surge Capability

Pharmaceuticals

Personal Protective Equipment

HCMC Security

HCMC Security

‘T’ - Operations

TriageTreatmentTransport

Triage

Primary – immediate, often scene-based (eg: EMS)

Secondary – at hospital or for in-hospital resources, re-assessment Location Supplies Personnel

Tertiary – after admission / initial care

Treatment

Where provided? (eg: will certain patients be cohorted in certain areas?)

What treatment will be provided? (resource limitations?)

What are the limiting factors? Staff Supplies Space

Transportation

Ground assets (including buses and out-of-area EMS)

Rotor-wing “Loading zones” for both ground and air units Receiving facilities Coordination of patients, records Prioritization for evacuation and method

Transportation Capacity/Capability

IN-HOUSEIN-HOUSEDistressed StaffDistressed Staff

INPATIENTINPATIENTDistressed InpatientsDistressed Inpatients Family MembersFamily Membersof Inpatientsof Inpatients

INCOMINGINCOMING

Behavioral Health Surge

MediaMedia VolunteersVolunteers OnlookersOnlookers

PsychologicalPsychologicalCasualtiesCasualties

EMS-EMS-ProcessedProcessed

MedicalMedical

Self-TransportedSelf-TransportedMedical CasualtiesMedical Casualties

Bystanders orBystanders orFamilyFamily

Members,Members,Friends,Friends,

Co-workersCo-workersof Incomingof IncomingCasualtiesCasualties

Family MembersFamily MembersSearchingSearchingfor Missingfor MissingLoved OnesLoved Ones

Injured,Injured,Exposed,Exposed,

DistressedDistressedDisaster/Disaster/

EmergencyEmergencyWorkersWorkers

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

Influenza calls to MDH December 2003

0

500

1000

1500

2000

2500

3000

Visits to MDH home and Flu Clinic web pages - Dec 2003

0

2,000

4,000

6,000

8,000

10,000

12,000

12/3 12/6 12/9 12/12 12/15 12/18 12/21

MDH Home Page

Flu Clinic Page

Hospital Metro Resources Routinely staffed beds 4857 Avg. daily census 4143 Surge Capacity

Census vs. staffed variance 714 Unstaffed but available beds 1068 15% of total beds staffed = 728 PACU/procedure rooms 536 Convertible rooms single to double 473 Total average overall surge capacity 2500-3519 Adjusted standard of care surge capacity 500-

1000

Metro Hospital Resources

Stepdown beds 501 (surge 190 addtl) ICU beds 416 (surge 192 addtl) PICU beds 64 (surge 20-39 addtl) ED beds 460 OR suites 295 Ventilators 533 Tabs of doxycycline 76,881

Regional Hospital Resource Center

Hospital A

Hospital B

Hospital C

Clinic coord

Healthsystem

Multi-Agency CoordinationCenter

EM EMS PH

Public HealthAgenciesEMS Agencies

JurisdictionEmergency Management

AA

B

C A

B

C C

B

Hospital Resources Metro Population 2,600,000 10% population affected by ‘pandemic’ =

260,000 patients 20% of affected patients too sick to care for

selves = 52,000 20% of those patients lack family members

that can care for them or are too sick for homecare (require IV fluids, etc.) = 10,400

Requires off-site care facilities and triage of resources

Off-site hospital Incident recognized, regional coordination

established, need for off-site care recognized Primary and secondary sites pre-selected and

screened Public health authority is authorizing/controlling entity Compact provides for first 48h:

Teams of providers (RN, MD, HCA/NA/EMT) <200 beds – 1 team >200 beds – 2 teams Each 6-8 person team has up to 50 patients

May be required when hospital infrastructure damaged, especially in smaller community

Sample Site

Sample Site Food Restrooms Staff rehab areas Secure HVAC system specs Paging /messaging

/radio Power Phone, T1 lines, etc. City owned!

Adjusting Standards of Care

The last resort ‘What do you do when you can’t surge any

more’ Gracefully, systematically change your

standard of care to one appropriate for the resources available

Staffing and staff roles / responsibilities Policy changes (eg: documentation) Resource triage decisions

Overarching Goal

Do the greatest good for the greatest number of persons you can based upon the resources available…

What are the goals? Understanding by the community of the limits of

resources and the plans when they are exhausted Evidence-based strategy for triage of resources

(based upon chance of survival, not subjective factors)

Regional, not facility-based criteria Provide support and framework for physician

decisions Provide governmental support for response efforts

including liability protection

Restrictions on Mechanical Ventilation

Do not offer or withdraw ventilator support for: Tier 1 – multi-organ failure Tier 2 – severe underlying disease conditions Tier 3 – other criteria (event driven) possible:

Sequential Organ Failure Assessment Score Age related? Other markers for poor outcomes?

What can I do?

Know your role in your institutional plan Work with your emergency preparedness committee Look at your C, S, T - have you optimized your

preparedness? Ask questions, run scenarios… KISS Job action sheets / task cards Extension of daily tasks / responsibilities Education where these differ from your plan Start small, grow big