Healthcare Surge Capacity in Disasters

Healthcare Surge Capacity in Disasters
Barbara Dodge Virginia Helget Sharon Medcalf This slideset is designed to be presented over a three-hour period to healthcare professionals interested in advancing the preparedness of their institution for mass casualty events. It is not to be copyrighted or presented for profit, but may be used for educational purposes without additional permissions as long as these conditions are met. Adapted from a presentation by John L. Hick, MD. Used with permission

Overview Section 1 – Incidents and Incident Management
Section 2 – Healthcare Facility and Community Surge Section 3 – Selected Surge Situations and Special Topics This three hour course is designed to introduce you to some of the issues and concepts of healthcare surge capacity. These materials are also NOT designed to be a course in incident management or emergency management, those these are critical to the success of surge capacity and will be touched on. Every institution will have different resources and needs, and slightly different partners to work with. However, the general foundations are the same.

Section 1: Incidents and Incident Management

Overview Define disaster
Incident management and its importance in surge capacity The CST of surge Getting all C’s – Command, control, communications and coordination

Discuss impact on community – what if takes out the hospital or local nursing home? What if it takes out a school? Is the expected effect on the healthcare system brief, or prolonged? (brief – some delayed injuries during clean-up, etc but impact is usually immediate). No specialized responses aside from search and rescue, good availability of support resources. Disasters can be natural, etc. Incorporate slides 6-9. Rule of 85-15: Natural Disasters: 85% minor injuries. 15% major and require care. Most deaths occur at the scene Most injuries after a tornado are related to clean up. What structure if taken out can be the most troublesome? A Hospital

What is a disaster? Demand for resources acutely outstrips supply
May depend on day / time / facility Internal / External events Static vs. dynamic - timeline Contagious events special sub-category ‘Complex Incidents’ A multiple-vehicle collision with 10 victims is easily absorbed by a urban trauma center but may be a disaster for a small rural facility. Even the urban trauma center may have problems accommodating this number of patients at 3am. Example of static (car crash) vs. dynamic (civil unrest, smallpox). Complex incidents refer to longer-term disasters involving the basic structure of society and often political issues (eg: Asian tsunami). Where the demand for resources exceeds the supply

Key goal of planning and incident management:
Get the… Right resources…to the Right place…at the Right time…to prevent A ‘special incident’ from becoming a… DISASTER The main goal of our planning is to avoid a ‘disaster’ – it’s fine to have ‘special incidents’ or ‘multiple casualty incidents’ but you don’t want to get to a point where you have inadequate resources if that could have been avoided with some proactive planning, resource procurement, or resource requests. Don’t let the need outsource the resources

Disasters – Reality Check
Only 7 disasters in U.S. history have resulted in > 1000 fatalities Only incidents per year result in more than 40 injured victims

Historic Disasters 1865 Steamship explosion 1,547 deaths
1871 Peshtigo, WI fire 1,182 1889 Jonestown, PA flood > 2,200 1904 Steamship fire, NYC 1,021 1928 FL Okeechobee Hurricane 2,000 2001 NYC WTC disaster 2,795 (inexact) 2005 Hurricane Katrina (inexact) NYC toll as of – NYC woman and FL man found alive >1yr later, former wife reported him missing, thought convention was in NYC but was in Indianapolis! (they are divorced now, not surprisingly). Katrina death toll per AP October 28, 2006 – high variability in this number due to inclusion/exclusion criteria for considering deaths ‘storm-related’ (for example, heart attack caused by stress of the evacuation are not counted).

Tiered Response Strategy
Capabilities and Resources Federal Response State Response Regional / Mutual Response Systems Local Response, Municipal and County Note that you are on your own for the first hours and that Federal response is NOT ‘first response’ – assume it will be days before there is a Federal resource presence. In some cases, there will be no assets coming (pan flu) You may actually get more than you bargained for in the Federal response As you go up the scale, resources get farther and farther away and take longer to reach you. Minimal Low Medium High Catastrophic Increasing magnitude and severity

Now, let’s think about Planning

What is most likely? Moderate sized disaster
> 120 injured is threshold for chaos Plan for victims Tie planning to Hazard Vulnerability Analysis Citation: Aufderheide, Erik – Disaster Response Best to plan for these types of disasters victims will cover 95% of all disasters 10 for small communities Regardless of size… one of the biggest problems will be families and media It is not realistic to prepare for severe disasters.

Planning Documents Hazard Vulnerability Analysis
Emergency Management Plan Emergency Operations Plan Departmental Plans This slide summarizes the entire ‘to-do’ list for hospitals and healthcare facilities (minus all the time-consuming details!) that want to prepare for emergencies. If you are doing this you are in good shape. It is like an onion, as you peel off layers you find more to be done. Emergency Management Plan is often incorrectly confused with the EOP. EMP details the role and goals of the facility, the IMS that will be used, assigns responsibility and oversight, training/drilling and corrective actions. Outlines the policy and responsibilities of the institution and its staff Outlines an expectation for incident management Assigns a person to be responsible for the plan’s content and it’s regular review Outlines training and drilling expectations/requirements Emergency Operations Plan EOP is the operational side of the planning. This is the detailed IMS, the general response and notification plan, and the functional annexes that describe specifics for selected situations. What the hospital and employees will actually DO in an incident Incident management General plan Functional annexes Fire, HAZMAT, MCI, Systems/Utility Failure, Weather, Security Emergency, Infectious Disease Emergency, Continuity of Operations Plan, etc. Department Plans These should be tailored to the work area and directed to the line employees and their supervisors. They should be BRIEF and very operational (not policy language!). If possible, they should describe some scalability (for example – on the triage unit leader card a suggestion to use the admissions lobby for triage if the ED capacity is exceeded). If you are doing all this you are in good shape but…it’s like an onion and as you peel off the layers, you see more

A sample HVA. All the possible events are listed on the left side, then these are ranked numerically for their probability, which is multiplied by the severity (impact plus preparedness) to generate a ‘priority list’ for planning. Model HVA are available from a number of sources including Joint Commission Resources and ASHE. Everyone should be familiar with this!

Don’t expect employees to do this when an incident occurs – they won’t
Don’t expect employees to do this when an incident occurs – they won’t. They need to be familiar with the basic tenets of your plan and have a job aid that they can grab and refer to while they do their duties. The more familiar staff is with plan and the more bulleted it is, the more they will use it.

What is Surge Capacity?

Surge Capacity C S T The 4 S’s The 4 C’s The 3 T’s Space Staff Command
Stuff Special The 3 T’s Triage Treat Transport The 4 C’s Command Control Communications Coordination * Surge capacity CANNOT occur if you don’t ‘get all C’s’ This is the core of surge capacity planning – not Central Standard Time mind you, but acronyms that help us organize our thinking about surge capacity. Getting all C’s may not be good in school, but it’s the first thing that needs to be done when an incident occurs – we’ll be talking about each of these in turn as we go through the modules. Need to make assignments early and firmly to get control of the situation early. Get the Cs nailed right away in a disaster. Special= special considerations

Command What is Incident Command? Standard language
Incident Management System Multi-agency Coordination System Public Information Systems Standard language Standardized job duties Scalable and flexible Firescope… If we don’t use standard language, it’s very difficult to communicate with other facilities or outside agencies. It’s very rare for a hospital to be an ‘island’ in a disaster – we depend on public safety, EMS, emergency management, and others to help us in the response. We also must standardize processes and terms for resource requests – some of this is happening at the Federal level. During tropical storm Alison a few years ago a request went to the state for 20 ambulances to help with hospital evacuations. They arrived the next day – on flatbed trailers without supplies or staff… Scalablity and flexibility is also critical – we need to tailor the response to the size of the event. A ‘binary’ response whereby either the facility is in daily operations or everyone is called in and disaster procedures implemented is not helpful as such a response is rarely needed. Why call a dermatologist in if you don’t need the help? The system also depends upon making resource requests to the next tier of capacity when your resources are exceeded (next slide). Let PIO know when to come in and when not Scalability: you will not need everyone at once Flexibility: Should be able to expand and contract Tiers of capacity: Where is the next level of resources when yours run our Interoperability: example of Texas Hurricane: they asked for ambulances and got them on flatbed trailers

Basic HICS Structure This is the basic structure common to ALL IMS. Note that there may be a ‘unified command’ if there are several agencies equally in charge with a representative from each at the top – even in this situation there is usually a ‘first among equals’ – early in an incident fire may be in charge, followed by police as a transition from rescue to crime investigation occurs. There must always be a safety officer, regardless of the event type. The liaison officer keeps partner agencies informed about the actions being taken. Information officer provides public and internal information about the event as approved by the IC.

HICS IV org chart – note NIMS compliant terms… Command boxes should always be filled (except technical specialists), section chiefs, always filled, the rest based on personnel available and event demands / complexity. If you DON’T assign a sub-box then the section chief is responsible for those responsibilities however (for example, ops is in charge of HAZMAT unless delegates). Make this a handout

Tools in the new HICS Job action sheets Position recommendations
Incident Planning Guides Incident Response Guides Forms – consistent with FEMA requirements NIMS (compliance activities)

Use it often Incident Command must be used as frequently as possible (daily responses) Employee familiarity and comfort with system is dependent on exposure / practice Need to use IMS for ALL incidents – even minor ones – otherwise never get comfortable with it – fire service uses IMS on EVERY call. Another argument against a ‘binary’ response plan – use IMS so you can practice with it, expand it, collapse it… Where is this? A: Carnegie Hall How do you get there? Practice, practice, practice

Surge Capacity Partners
EMS Emergency Management Public Health Public Safety/Law enforcement Hospitals and Healthcare Systems American Red Cross Behavioral health Jurisdictional legal authorities Looking OUTSIDE your facility for partners. These will vary by community, you don’t need to read them all, just realize there are LOTS of partners that you need to engage – a process to engage them that results in constructive dialog and efforts is critical. Think about who you are forgetting and what they might bring to the table to help you – also consider private partners that may be able to contribute lots of help (85% of US infrastructure is private) – example might include local college, local warehouse. Perhaps public works could help with transportation or even decontamination? Lots of possibilities…

Regional Coordination
Medical Response Systems Trauma System Public Health Districts Regional Hospital Resource Center (RHRC) Multi-Agency Coordination In order to coordinate surge capacity across more than one institution some regional ‘trusted source’ should be identified that can represent hospital needs and, when necessary, be the broker for transfers so that the facilities don’t have to do this in isolation, duplicating efforts and consuming valuable time. This regional source is then the hospital conduit into Multi-Agency Coordination (MAC) where other agencies come together to determine problems and needs. Comment about bed availability training. How does the trauma system play into this? Broker Example of ND floods Local Hospitals had to make all the calls themselves to place their patients

Federal Assets National Disaster Medical System (NDMS)
Urban Search and Rescue (eg: Nebraska TF-1) Commissioned Corps Readiness Force Military (NORTHCOM) Federal Medical Stations CDC SNS and VMI Though Federal resources will not be immediately available, they are very important, and may be available within hours (strategic national stockpile 12 hour push-pack) to days (DMAT teams). NDMS provides assistance at many levels. FEMA Urban Search and Rescue Task Forces provide victim rescue in collapse situations and can provide overall search capabilities. The commissioned corps readiness force is public health service personnel that are pulled from their duties to go to disaster areas to provide medical care. Federal Medical Stations will be addressed on a later slide. Most people are familiar with the Strategic National Stockpile, which includes the rapid response ‘push packs’ deployed around the nation and the somewhat later response vendor-managed inventory (VMI) which is comprised of much larger stocks of items such as antibiotics, ventilators, and the like that can be requested and delivered within a few days time. Any active duty (note does not include national guard, as these are under state control) military support would be coordinated via the North American Command of the military (NORTHCOM).

Section 2: Healthcare Facility and Community Surge

Overview Initial Actions Facility-based surge
Space, staff, stuff, special Triage, treatment, and transport Community-based surge capacity Partners and players Alternate care sites

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 This distinction is important – capacity is about volume, capability is about the ability to manage specialized patients – for example burn patient or smallpox, or chemical contamination. A much smaller volume of patients can overwhelm ‘capability’ even when the institutional ‘capacity’ is large. Both must be accounted for in planning. Example: Smallpox vs trauma patients

Example of capability planning – hospital hazmat preparedness.

Example of capacity planning (though some might argue capability for diarrheal illnesses) – right down to the lowest level of the institution! Just because you have the capacity, doesn’t mean you have the capability.

Initial Actions – Notification and Communication
Facility notified of event / recognizes event Advisory Alert Declaring an emergency – Activation Mobilize adequate resources based on intel Plan for next operational period (action planning cycles) Notifying Staff Patients and their families General public Ongoing communications / information cycle Advisories generally do not require action, but monitoring is necessary, and you may want to begin to ‘prepare to mobilize’ (example – tornado watch). Alerts mean something is happening – may require you to stand up resources to assess the situation (example - tornado warning). Activation means you are affected and have to respond (tornado hits your house / hospital / sends multiple victims to your facility). Size-up the Incident and Mobilize Resources Incident commander appointed Resource requirements Time course of event Plan for next operational period – staffing and resource needs This is a very common source of errors – based on incomplete information sometimes too many (or less often) too few resources are mobilized based upon an inaccurate assessment of the situation. Get as much information as you can from as many sources (including media! – often your best source – picture is worth a 1000 words). As soon as possible, appoint somebody (a talented somebody!) to planning and begin to get into an action planning cycle. Get your information officer working on initial internal and external communications. If these things are done well in the first few minutes of an event, you’ll have a lot less headaches later! Don’t forget that some of the resources you need to mobilize may be transport resources from a LONG way away – the sooner you get them coming, the sooner they will be there for you… Must make sure at each point that there is a protocol and process for notifying staff including supervisory/admin. Patients and family members may also need information (for example – don’t let family members leave facility and walk out into chemical cloud / tornado). General public needs to know when to seek care, what to do. Establish a cycle for information as part of the incident action plan so that you get these communications scheduled into the routine (both for press and employees, etc).

Different types of ‘surge’
Pre-event surge (eg: pandemic, hurricane) Healthcare facility-based Discharges Admissions Community-based Ambulatory care Existing sites Field treatment sites Non-ambulatory care (acute care center / off-site) EMS Surge capacity comes in a variety of ‘flavors’. We’ll discuss these in detail in subsequent slides. Pre-event surge: A lot can be done ahead of time i.e. get prescriptions written or filled for 3 or 6 months, pre-natal, Well Baby Discharges: Event: 1. Can go home (can be put in hallway or dialysis recliner until discharge arrangements made) 2. Can go home with help 3. Can’t go home Non Ambulatory care: Can be used for high level of inpatient care EMS plays a huge role: they shouldn’t be bringing you patients that you can’t take

Pre-event surge /actions
If short warning time present: Determine what service lines will be maintained Mobilize staff and resources If longer warning time: Consider expanding services to take care of as much elective business as possible (eg; evening operative cases, expanded clinic hours) A process must be in place to look at facility services and decide what will be maintained / augmented / eliminated during a response. If adequate warning time consider expanded clinic hours to take care of all possible elective business - e.g.: in advance of pandemic get all med refills, OB checks, well baby checks and other appointments done that will not be able to be handled or will reduce pressure on the system after the pandemic arrives. Maintain services: Can probably cancel sleep studies Mobilize staff. If services will not be provided, what will those staff do? Discharges: Event: 1. Can go home (can be put in hallway or dialysis recliner until discharge arrangements made) 2. Can go home with help 3. Can’t go home

Facility-based Surge Hospitals may use HRSA dollars to purchase cots, lab equipment, and other supplies Nearly always preferred to off-site Comfort of staff Expertise Off-site: designate what equipment can be taken and who can operate it No alternate care site can provide what a hospital provides. You would much rather be on a cot in a hospital hallway than a church hallway if you are a patient. USE of supplies assures that personnel are comfortable operating them, this is important with things like vents and lab equipment. If an alternate care site is required it should be clear what materials can be moved to this site vs. kept at the hospital. Some alternate care sites may be within (conference room, gym) a hospital, adjacent (next door clinic building or tenting) to the hospital, or distant to (armory) the facility. If you move off-site, you also move away from expertise and equipment you need. Durable supplies: Be careful. Some vendors will only start warranty when they are first used. Buy several brands in case there is a recall Q: Who is going to operate the vents? A: need to figure out what an RT absolutely needs to do

Reality Check Very rare to be overwhelmed in a disaster
Only 6% of hospitals in 29 disasters experienced supply issues, and 2% had staffing shortages . . . Most had too many! Date from Erik Aufderheide - Disaster Response. This is the good news - bad news is that there are definitely disasters (such as Katrina, pan flu, etc) that we will clearly overwhelm staff and resources. Prepare and plan for what to do with additional help. Ask. People will typically show up even before the squads arrive. Upside down triage will occur, meaning the first to arrive will probably be walking

In the Real World . . . At least 50% arrive self-referred
‘Upside down triage’ – least wounded arrive first On average, 67% of patients in any given disaster are cared for at the hospital nearest the event (range 41-97%) Don’t expect majority by EMS and in fact, usually you will have victims walking in prior to any notification from the field. The closer you are to the scene, the more walk-ins and carry-ins you will have. The initial arrivals will tend to be less injured than the later arrivals - consider this so that you don’t fill up your critical care / ED areas with minor injuries prior to the true criticals arriving. Need to have a mechanism to divert people

Rule of Thumb Per 100 patients injured:
25 dead at scene 75 seek medical care 63 minor 12 serious ‘Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11 (minor vs. serious) In every catastrophic disaster, sustained pressure on the healthcare system is seen following the incident General rule of thumb - 85% minor injuries and 15% serious - very helpful if you hear about a 50 person incident in your area! These numbers per the CDC mass casualty / bomb and blast injury website. The more severe the disaster, the more prolonged the effects on the system - in most cases ERs see sustained increases in volume for days to weeks after an event - this is worse when the event is chemical or biologic in nature (invisible agent, or nonspecific symptoms = big problems separating out anxiety vs. illness) Good for planning when to “pull the switch” for more resources.

Critical Hospital Resources
Physical Plant Personnel Supervision Supplies and Equipment Communication Transportation Koenig K et al. Acad Emerg Med 1996:3;723-7 Supervision = both personnel and system of supervision (ie: incident management). If we take out supervision (command) and communication, and leave transportation until later we can talk about… We have been talking about what we will need to do, now we need to talk about what we have.

The "Space"

Space ED and clinic triage protocols (evolve with event)
Discharges and transfers (eg: nursing home) Discharge holding area Treat patients in halls / flat space areas (cots) Cancel elective procedures Convert procedure/OR/PACU areas to ICU space Accommodate vents on floor Alternative ambulatory care areas / triage areas Triage protocols - who will you see based on the event? Can the clinics cancel elective and some other appointments? Is there some criteria that the ED and clinic could agree upon in advance about patients that the clinic could take in referral from the ED? (small soft tissue injuries, sprains/strains, etc). A discharge holding area is important since you won’t have time to go through the normal process (getting meds, arranging transport, etc) and they will need somewhere to be that is quiet and supervised prior to their actual discharge. No time? Then put them in chairs in the hall while you fill beds with victims. Identify areas of the building that could be used for patient care (eg: lobby areas for triage, flat space gym or conference rooms for cots, procedure center for trauma care/isolation area). Convert your step-down beds to ‘ICU’ beds by allowing more stable ICU patients to be on vents or med drips there. Procedure rooms and OR space / PACU space can serve as temporary ICU areas as well. Communicate well as you plan, you don’t want to designate the same space for a morgue and family room, for example. Evolve with the incident: set aside schedule for the day. PACU: can provide ICU care there Vents on the floor: use monitored beds. Most patients in monitored units don’t really need to be there--only for our security. Move patients in ICUs to monitored beds as a step down unit. Don’t put new, unstable patients here. Cafeteria or school could be triage area.

Space Don’t forget surge space for:
Family members / Family support center Tracking system (badge) Media in separate space Consider traffic patterns and satellite space Behavioral health area Staff respite Labor pool Staff housing / sleeping (family members?) Patient care needs come first, but a huge part of a successful response is managing the family members and media - be ready for this! Also realize that many ‘family members’ won’t actually have a patient in the hospital - they are just looking for that person. So you may want your family center near, but not on the hospital premises. Same thing for your media staging - make sure there’s plenty of parking for the satellite trucks at the location, or they will be moving - perhaps somewhere you don’t want them. In some cases (blizzard, etc) staff sheltering at the hospital may wish to have family stay with them - establish a policy on this, as well as on the situation when a staff member does not want to go home (due to the risk of exposing his/her family to some nasty infection encountered at work - eg: SARS). Red Cross is very good at family support centers. Example of Madrid: They weren’t prepared to deal with the family members. Poor tracking system with many people with the same name Q: what about parents and kids? A: If kids major and parents minor….MOU to treat parents at children’s hospital to keep families together Have a visitor policy during disasters – how many do you let in. Consider a badge so they can pass the torch to other family.

Example of Surge Windswept Hospital
Let’s look at surge capacity and planning at a typical community hospital (which means that it won’t be like anybody’s in the room - but that’s ok, it’s all pretend). 50 beds – avg occupancy 40 Skilled nursing facility 25 beds total – avg occupancy 23 5 daily admissions for minor surgery Assume 15% appropriate for ‘early discharge’ = 7 patients - holding area in conference room Flat space areas – classrooms and cafeteria, lobby – 50 cots available Surge capacity (average) = __74____ Only 10 hospitals in NE have associated LTCFs. Handout and activity

The "Staff"

Staff Different events = different staff needs
Eg: HAZMAT vs. trauma vs. monkeypox Appropriate specialties Scope of event = scope of staff call-in Mechanism to reach staff Obligations of the staff Contract staff What are they required to do? Don’t call in the dermatologist for a burn incident (unless you are really desperate for all-hands-on-deck - very rare). Do your staff know about their obligations? Are they reachable off-hours? As much as possible free up clinical staff for assessments. Consider what work they normally do that could be done by other people. In a pandemic 90% of care will be done by a family member, whether in hospital or not

Staff Assign staff to specific areas when possible
Don’t forget the support staff Nursing staff often limiting factor Team nursing Involve family in care What do specialists “have” to do? Staff extenders / Staff roles Mentoring and supervision of extra staff Just in time training Don’t forget the support staff! Disaster response can’t happen without food! How can you extend your staff? - by changing their roles - nurses don’t have to feed/bathe/provide personal cares or even do vitals. Change from individual nursing to team nursing. Find non-healthcare providers or family members to do the personal cares / feeding. Make sure if you do bring in outside staff to assist that they are paired with an appropriate mentor from your facility that can orient and supervise them. Systems don’t allow others to help i.e. Pixus is passworded so others can’t help give meds. What does a nurse HAVE to do? What does a respiratory therapist HAVE to do? Have guest “staff” paired with someone from the facility. Don’t forget the support staff! Extend staff by changing their roles. Look at contracts of staff (i.e. anesthesia, central supply, etc) Are they under any obligation to come in during off hours?

Staff Augmentation Hospital personnel Clinic personnel
Medical Reserve Corps Non-clinical practice professionals Retired professionals (eg: via Medical Society) Trainees in health professions Civil Support Team, Civil Air Patrol Lay public (CERT teams, etc) Federal / interstate personnel In somewhat preferenced order (federal and interstate is last due to timeframe, not preference, and the fact that during some incidents such as pan flu you cannot call on them). Non-clinical practice might include nurses doing quality review audits, etc. Retired may not be that old - for example real estate work is the #1 occupation for retired nurses. Trainees - make sure there are appropriate policies for use of trainees / expectations in place. In some disasters, we can make do without help - in others we’ll need all the help we can get. Trainees in health professions: Agreements in advance like work comp Lay Public: identify special needs folks in neighborhoods and provide home care, meds to them. Fed/interstate: If run out specialty areas i.e. burns…can request more but make sure they get a good orientation to the facility and the community. Permission from HHSS is enough to get these resources BUT make sure you know who is paying. Need disaster declaration to tap federal funds.

The "Stuff"

Stuff Provider protection General patient care supplies
Specialty patient care supplies Support supplies Let’s talk about supplies now - 4 basic categories.

Stuff – Provider Protection
Personal Protective Equipment Medications – antidotes?, anti-virals? Consider: re-use duration of use other risk-reducing strategies (UV light, ventilation, etc) Mask type may vary depending upon event. Patients may also require masking. Will the facility stockpile antidotes (probably should have some additional atropine around for pesticide poisoning as well as nerve agent) or have a cache of anti-virals for their staff should a pandemic occur? Slides 56-8 are handouts and discussion

Stuff – General Patient Care
Airway – disposable intubation blades, bag/masks Surgical – chest tube trays Medications – Morphine, Valium, Atropine Other disposables – catheters, dressings, linens Durable – beds, vents, IV pumps, BP cuffs Simple things can make all the difference for patient care. In the Station nightclub fire response, Warwick hospital ran out of intubation blades almost immediately and had to bag/mask ventilate patients in hallways. Are you prepared to do this? Plastic, disposable blades are really cheap, and bag/masks inexpensive also. Morphine is needed in EVERY disaster and is very inexpensive - have lots available. 2PAM = pralidoxime - nerve agent antidote. How many chest tube trays do you have available? Should you have more? Handout

Stuff – Specialty Patient Care
Example – burn Adaptic dressings Bacitracin Kerlix dressings 50% BSA burn needs 14 liters LR/NS in 1st 24h, MS 250mg/24h) Standard adult 50% BSA burn requires these supplies per 24h period. Very inexpensive, no good substitutes - so why not have these supplies for 5 patients at every hospital? Note the large amount of IV fluids used. Handout

Ventilator re-allocated Patient keeps ventilator
Persistent SBP < 90mmHg or age-appropriate hypotension unresponsive to fluids Occasional hypotension or other signs of poor perfusion No signs of shock Laboratory or clinical evidence of multiple (> 4) organ system failure* Laboratory evidence of 2-3 organ system failure Respiratory failure only Severe underlying disease with poor short-term prognosis** Severe underlying disease with poor long-term prognosis and/or ongoing resource demand No severe underlying disease Long duration – ARDS, infectious causes of respiratory failure, (estimate > 7 days on ventilator) Moderate duration – ARDS or infectious cause in healthy patient (estimate 3-7 days on ventilator) Short duration – flash pulmonary edema, chest trauma, other anticipating < 3 days on ventilator Worsening oxygenation index*** Stable oxygenation index over time (failure to improve after adequate disease-specific trial of mechanical ventilation) Improving oxygenation index Poor prognosis based upon epidemiology of specific disease (eg; pandemic influenza) for patient group. Indeterminate / intermediate prognosis based upon epidemiology of specific disease process Good prognosis based upon epidemiology of specific disease High potential for death according to predictive model Intermediate potential for death according to predictive model Low potential for death according to predictive model Example of ventilator triage matrix – multiple factors inform decision to withdraw support and give the ventilator to another patient with a better prognosis. Rows are: signs of shock, organ system failure, underlying disease, expected time on ventilator, oxygenation index (for ventilated patients), disease-specific prognostic factors (for example, perhaps the pandemic ALWAYS kills left handed flute players regardless of intervention – this would need to be incorporated – more likely it will have disproportionate mortality in certain age groups, or with certain underlying diseases), finally a predictive model (scoring system) such as the sequential organ failure assessment (SOFA) score may be used to predict mortality. (Hick, in press 2007) Handout

Stuff – Support Supplies
Food Water Office supplies Utilities Communications Oxygen supply In addition to clinical care supplies, don’t neglect support supplies! Food and drinkable water are not optional. Oxygen – not only amount of O2, but what is capacity for drain on the system. Use of o2 tanks is not practical except for short-term. Meds – always stock Morphine. You need it for all disasters. Also Valium. Atropine you can get in crystalline form for$30 and pharmacy can reconstitute it.

"Special Areas"

Surge Capability / Specialty
Burn Chemical / Decontamination Isolation Pediatric Blast injury / mass trauma Behavioral Health In addition to burn a few other categories that you should consider the need for specific supplies / training / preparation. Amer Acad Pediatrics has issued guidelines for pediatric preparedness which you may wish to reference.

‘T’ - Operations Triage Treatment Transport
Now that we have our C’s and S’s down (command and logistics/planning), let’s look at the operations side (yes, there’s some overlap with transportation to logistics, but bear with us).

Triage Hospital triage: The most critical patients first
Mass Casualty triage: The greatest amount of good for the largest number of people. Resources used on the victims that have the best chance of survival 2 types of triage - most of the time we think of triage as ‘where should they go’ in the department not whether they should live or die. Almost none of us are comfortable with those sorts of decisions, though in a disaster we may have to make them. Exercise: Use Flip chart and ask about the difference

Triage Location? Triage officer
Triage tags / initial registration or tracking Locations of care – where are patients triaged TO? Key bottlenecks – decontamination, radiology (eg; CT), transportation, OR, ICU Triage officer should be relatively experienced RN or MD, perhaps EMT-P - overtriage (triage to a higher level of acuity) is common. What sort of tags does your EMS agency use? Do you use tags? If so, are they the same as EMS? How do you keep them separate (don’t remove them - there may be a tracking number or identifiers on there that need to be saved. What are the triage officer’s options? (ie: can he triage certain cases to clinics, to the lobby, to the ED waiting area, into the ED). What’s the process for registration (and then sharing this information)? Traige Officer example: isreal= Surgeon Bottlenecks: Have triage at all of these areas. And in PPE Have you thought about when (triggers) you may need to triage outside of the hospital

Treatment What patients may be safely treated in what areas:
ED, clinics, lobby areas, etc Deal with life-threats only initially Defer definitive wound closures, fracture reductions Defer most xrays and labs until demand eases Use your clinical skills! What is the expectation for documentation / nursing orders during disaster? When you’re getting crushed, take a different approach: examples - splint fractures for now, (no xrays), bandage (don’t suture) the wound, get a chest xray only to rule out the life-threats but defer additional imaging in stable patients. Once you get caught up, start filling in the gaps. Worry about the unstable and those that have potentially life-threatening injury. Also, figure out ahead of time how you do nursing orders and medical record-keeping during a disaster - these are areas that will fall apart if there’s not a plan. Keep all greens in the lobby

Transportation Capacity/Capability
1930s pierce arrow ambulances x3 and one GM ambulance. Hopefully your local system is a little more up-to-date, but many of you work in communities that have nicer ambulances, but fewer! Rhode Island: Talking to transport and the hospitals at the same time. Things got confusing

Transport Internal External
Transportation from ED to other in-hospital locations (CT, OR, etc) Personnel and resources (beds and wheelchairs, etc) External Transport resources – ground, rotor and fixed wing, alternative ground (WC vans, etc) Referral centers – what’s your backup when usual partners are full / unable to receive? Look for alternatives to ambulances - wheelchair vans, buses, other alternatives as ambulances in short supply. Again from the Station nightclub fire, confusion occurred when the ‘usual’ referral hospital for burns was at capacity. An additional problem was that there were two hospitals that received burn patients directly from the scene - both of these hospitals were calling the same burn centers and helicopter services for assistance - problematic since there wasn’t a good way to determine how best to use the resources. Make due internally with wheelchairs. What about fabric stretchers? Alternative ground: school buses with boards across the aisle

Transport EMS issues Few communities have adequate EMS resources
Many EMS personnel have competing demands during disaster (fire department, hospital, family) and may not be available Few communities have process for allocation of scarce EMS resources Depending upon the system, requests for EMS may be taken by medically trained dispatchers - in this case, the dispatchers may be able to determine based on the resources if the call can be answered or deferred. If the dispatcher has no medical training, this gets more difficult - good medical direction and ambulance operation supervisor input is needed to assure that a safe process is instituted. If EMS personnel are scarce, consider non-medical driver (eg: public works). Also, consider ‘single agency’ response to some calls (police only to accidents until confirmed injuries, etc) when resources are tight. Further information is available in the AHRQ document ‘Mass Casualty Events: Providing mass medical care with scarce resources’ at

Surge Capacity Coordination
This illustration is shown again to remind you that though the hospital may have ‘surge capacity’ unless we increase capacity across the other disciplines we will fail. If outpatient and homecare surge is not optimized, the patients will fall back on the hospitals for care. Also, the hospitals are stressing aspect of the system (homecare, for example) by early discharges that may have more unmet home health needs than usual.

Community- Based Surge
Clinics Procedure centers (i.e. dialysis centers) Long Term Care Facilities (LTCFs) Homecare Family-based care Alternative care sites Local / Regional referral / NDMS Having a planned approach to the involvement / activation of community resources is critical to the successful use of these partners. Without their assistance, considerable patient volumes may fall back onto the hospital, causing a ‘disaster within a disaster’. As with the hospital process, look at the resources available, how they might be used during a disaster, and open communications with them as partners – a good thing to discuss is pandemic influenza or SARS / suspect highly infectious cases where there are mutual needs from the clinic (should a patient present there for care) and from the hospital (during a pandemic encouraging those with minor symptoms to be seen at a clinic OR a designated screening site for suspect cases only). Again, the importance of MAC here in making decisions about continuing clinic operations, opening special sites, etc. is critical, as is public communication. For example – if there is Tamiflu for the public during a pandemic, a patient must get in and be seen / given Tamiflu at the first sign of illness (and do they go to their clinic for this, or to a special site designated by public health?). If there is no Tamiflu, the patient should not seek medical care until they are too ill for home care. Who can activate alternate sites? If extending hospital - JCAHO issues If extending shelters – PH issues Alternate care sites don’t always have to be for the walking wounded

Clinic surge capacity Rural – scant ability to increase capacity
Urban – larger ability to increase capacity Sub-specialty clinics Surgical centers Cancellation of elective appointments Changes in hours / staffing Receiving referrals from hospital? Criteria Supplies Challenges to surge capacity vary by population density and the size of the facility. In densely populated areas, very large numbers of victims may be generated by terrorist or natural disasters which is not typical for rural areas. Rural areas cannot increase capacity much, but can face situations in which even limited surge capacity is tremendously valuable in a ‘small’ mass casualty event when their distance from partner hospitals is great. Clinics can support the hospital mission greatly by changing schedules, staffing (including contributing staff to the hospital response in appropriate circumstances) and by receiving appropriate referrals from hospitals that are overloaded (clinics may also have to send selected patients to the hospital that are beyond their capacity). Clinics may wish to have some supplies for basic emergency care available dependent upon their proximity to known hazards and what agreements they have with the hospital(s). MMRS areas are incorporating clinics in their regional planning Easier to do in urban areas

Professional Homecare
Homecare agencies Social workers Durable equipment suppliers Are agencies prepared to prioritize services to accommodate increased demands? Do homecare nurses have other commitments? Homecare agencies may wish to categorize services provided (1 highest acuity, 5 lowest or similar) in order to prioritize services during a disaster. Homecare nurses may have to use appropriate PPE during epidemics. Durable equipment suppliers may be needed to supply oxygen generators and other equipment – it is helpful to know what their abilities are prior to an incident. Social workers should also be involved with these discussions with homecare agencies. Can homecare withdraw services?

Family-based care Will be focus of most care in pandemics and
General emergency preparedness critical Specific information and are excellent resources for employees and general public. A good family plan is a huge asset during an incident, allowing employees to feel safer. When family care becomes critical (eg: pandemic) it is critical to make sure that accurate, helpful, and concise information is provided to families to help them. They may also need appropriate PPE for themselves depending upon the circumstances and available supplies. Specific Information: When to seek care, and where How to provide homecare for bed-ridden Managing dehydration and common complications Infection control in the home Home palliative care and managing deaths at home If we don’t give specific information they will come back to the hospital!

Alternate Care Sites / Community Action
Neighborhood Emergency Help Center Screening and minimal care (for example – early pandemic symptoms requiring anti-virals) Population-based interventions Acute Care Center / Off-site care facility Non-ambulatory care (may also have role as special needs shelter – NH fire, widespread disaster) Hospital overflow –allows hospitals to focus on critical care Many models – adjacent hospital, regional, self-supporting infrastructure vs. existing NEHC’s may be initiated or organized by public health – they would help decompress clinics or hospitals or evaluate persons not ill enough to be seen in the healthcare system but with symptoms that require early treatment. NEHCs are generally NOT points of distribution of vaccine or prophylaxis though they may be established at the same venues depending upon community plans. Acute care centers may provide only non-ambulatory care, but in some areas they may combine features of the NEHCs or see ambulatory patients in addition to their austere non-ambulatory care role. Neighborhood sites: where we want the sniffles to present for their Tamiflu

Potential Alternative Care Sites
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 Many, many possibilities – preferably city/public owned, one of the key disadvantages of hotels is that it is difficult for small teams of providers to monitor patients in a hotel environment and patient movement and environmental issues (soiling, vomiting, diarrhea) can be difficult. Best solution is what works best for the community. Schools are a possibility but may not be out after an MCI – which may be an issue with their use. Some facilities can provide more advanced levels of care (surgical centers for example). Handout Motels are not as good as one can’t observe patients as well as in an armory. They are good for quarantine.

Factors to consider 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 Primary and Secondary sites Controlled access Many, many factors – one that also needs to be considered is ability to observe multiple patients at a time (open area) which may be desirable in some situations (and thus make hotels less attractive options). This is a summary of an AHRQ tool on site selection for ACS available on the AHRQ website. Handout

What will Happen at the Acute Care Alternate Sites?
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? After site selection comes a process to outline what will actually HAPPEN at the site. Who will be candidates for care there (ie: what level of care – IV fluids, NG feeds, IV meds ok but not high-flow oxygen / critical care, etc). Determine age restrictions, if any. Develop a medication list for the on-site pharmacy, determine documentation / order management (keep it REALLY simple!), lab services that will be provided on-site (eg: glucose monitoring, urine testing, consider portable digital radiography and basic labs using iSTAT or similar equipment). Environmental issues are critical – may have enough bathrooms but may need to contract showers, etc. Oxygen provision is extremely difficult at this type of facility. Portable oxygen concentrators have some utility, but use significant amounts of electricity and are expensive. Sequenced H cylinders can supply up to 25 persons / 24h but are bulky, dangerous, and require frequent refilling – in general, ongoing provision of oxygen at these facilities is NOT advised. Triage: Exactly who are you going to treat Meds: will you have controlled substances? Lab: will you do some blood i.e. CBC Sanitary: Many large armories have poor toilet facilities Linen and waste: Are there contractors willing to pick up and drop off? Oxygen: No more than 20 people – more is not feasible Although these are not hospitals, documentation should capture what is happening with each patient. Will need to bill supplies back to fed gov

Ames IA, 1918 influenza pandemic (old University of IA fieldhouse)
Ames IA, 1918 influenza pandemic (old University of IA fieldhouse). Honestly, the type of facility and care provided might not be much different today.

Sample Site 5000 sq feet per 50 patients thus 1000 patients per hall roughly at 3 feet between cot head/feet, 6 foot aisles. Again, every community will have different needs and resources – this meets the regional needs of a large metropolitan area (note that other sites are planned for as back-up). Hospital acts as a agent of the state to open the center. Allows flexibility and broad liability protection.

Sample Site Food Restrooms Staff rehab areas Secure HVAC system specs
Paging /messaging /radio Power Phone, T1 lines, etc. City owned! On-site catering / kitchen, ability to alter ventilation to each of the domes is nice. Note back-up power does NOT power the HVAC system – need supplemental generators if this occurs. Check the emergency power carefully at your shelter / ACS sites!

2x2 zip-tied to folding chairs, shim across top
HEAD COT CHAIR HEAD A12 2x2 zip-tied to folding chairs, shim across top Nails for chart, IV bag Cards show team color/letter (eg: green A) Other cards show pending orders (red = stat) Clothespins/rubber bands hold cards Simple camping cots can be used, though they are not good for obese patients and it is much nicer if the head tilts up so the patient does not always lay flat. Slightly more money buys heavier duty cots that allow a head-up position and are much more durable and suitable for patients up to 300 lbs. Knee pads a must for providers due to how low the cots are! Illustration shows possible layout and inexpensive system for IV ‘pole’ and order/bed tracking system. Cheap and easy is good, but every community / region can determine what they wish to do.

Denver, January 4-7, 2005 – first trial of the Federal Medical Station – many of these (as prior discussed) were used in Hurricane Katrina as special needs shelters and for austere care. Note that heads of beds are together, perhaps not ideal for infectious situations.

Ongoing Issues Clinic / outpatient care roles Legal and Regulatory
Reimbursement Workforce coordination with public health Credentials / HR issues Many issues remain to be solved. Do not wait for legal, reimbursement, regulatory issues to settle before planning to do what you feel is right and will work best for your community. These barriers have a way of falling down in an incident and moving forward on a planning process will help give the issues greater clarity and urgency. We’ll discuss standard of care in our next section.

Section 3: Selected Surge Situations and Special Topics
Note that the person seems to be appropriately parked. (or that the penalty for mis-use of the spot was particularly severe). This is the last section! Homestretch!

Overview – Section 3 Event-specific Behavioral health Security
Education and training In this section we’ll apply some of what we’ve learned to some incident-specific snapshots and then discuss some of the other issues associated with surge capacity planning including what to do when you have no surge capacity left and demand for services remains high.

Scenario 23 year old presents to ED – just arrived from Africa
Bleeding from everywhere – sclera, gums, GI tract, genitourinary tract, bruising skin noted Febrile to 101 Sister who traveled with her is also feeling ill but has no signs yet of her sister’s illness What do you do? 23 year old presents to ED – just arrived from Africa Bleeding from everywhere – sclera, gums, GI tract, genitourinary tract, bruising skin noted Febrile to 101 Sister who traveled with her is also feeling ill but has no signs yet of her sister’s illness What do you do? ISOLATE, full barrier precautions. Limit HCPs and track them. Notify Public Health This case actually happened at a hospital (HCMC) in Minneapolis. Patient was vomiting blood at the airport baggage carousel, 911 called, EMS used NO protection aside from gloves in her care. Her sister became ill the next day. Fortunately, she did not have a viral hemorrhagic fever – both she and her sister apparently had a very severe and unusual reaction to anti-malarial medications that they were on. Patient was immediately put in negative flow isolation room in ED, masked, providers used ‘special pathogens’ PPE (think smallpox) for care. Sister was initially home quarantined, then became febrile and was admitted (increasing angst about infectious cause).

Isolation Space Triage and screening – location, process Treatment areas – iso rooms, cohorting Staff - training, call-in, monitor compliance with PPE, communications Stuff – antibiotics, anti-virals, analgesia / sedation, ventilators, PPE supplies Special – security, communications, family issues Transport – internal and external issues - process These bullets are generic for ANY isolation case / suspect unusual pathogen case – you need to have this sort of plan rather than specific plans for smallpox, sars, etc. as you never know when monkeypox is going to wander in – and the patients don’t have labels on their shirt when the first present. Hopefully, the cases don’t start in your community and you have time to put protocols in place and do some just-in-time training. Biggest problems with the prior case: CDC, MN DOH, multiple agencies involved and no liaison officer, so lots of mis-communications. Lab handling did not go as smoothly as it should have. Isolation plan worked well, but family members did not cooperate with PPE requests (they felt they were already exposed) and led to many issues. Consider when you have to move patients how you reduce exposure. What happens when you use the elevator to move this patient? (air currents may cause exposure to others standing by elevators). Lots to think about – start with ONE patient and then think about 5/10/25, etc. If you need to screen visitors / patients / staff where will you do this? How will you do it? Maintaining isolation while moving Security on each floor to keep people 30 feet away Designate the IC right away for one point of contact Handout

Scenario Workers at construction site unearth large jar of clear liquid – they pick the jar up and it shatters Both workers are splashed and have immediate respiratory distress as well. Much of the liquid vaporizes. EMS removes clothing and transports as no decon available and respiratory distress What do you do? Workers at construction site unearth large jar of clear liquid – the pick the jar up and it shatters Both workers are splashed and have immediate respiratory distress as well. Much of the liquid vaporizes. EMS removes clothing and transports as no decon available and respiratory distress What do you do? DECON AGAIN AND GET A pH Again, an actual case – the gentlemen were excavating at the site of an old university chemistry research building. Both suffered some areas of significant burns. pH paper was applied and the substance determined to be a very strong acid (thus causing airway irritation). Based upon this, and the fact that their airway symptoms stabilized after nebulizer treatments, soap and water decontamination was provided for contact exposure to a strong acid. The patients did fine (alkali would have been a much different story!). Minnesota put together a “Bad Bug Kit” that has all the PPE (except N-95) with a poster on how to don equipment. Cardinal did it for them for about $5.00 each.

Chemical Space – decontamination, triage, treatment space
Staff – trained for decontamination, ED staff, ICU (if applicable), monitoring of PPE use / duties Stuff – antidotes (particularly atropine and 2PAM), analgesia, sedation, PPE, vents / ICU Special – decontamination equipment, runoff issues Biggest problem is to get staff to don PPE! Also, ventilation of decon area can be an issue. Major threat to providers and that requires antidote are organophosphate agents (either pesticide or terrorist/military). Nurses in two cases of suicidal ingestions of pesticide have required intubation or intensive care due to their exposure to the patient’s secretions and vomitus and off-gassing of same.

Scenario Tornado watch issued at noon for your city
Tornado warning at 4pm – staff and patients shelter in place Severe damage to large neighborhood in community, hospital multiple windows broken, reports of leaking roof in one unit, electricity out except emergency power What do you do? Tornado watch issued at noon for your city Tornado warning at 4pm – staff and patients shelter in place Severe damage to large neighborhood in community, hospital multiple windows broken, reports of leaking roof in one unit, electricity out except emergency power What do you do? What do you do when a watch is issued? A warning? Here the hospital is a victim, but must carry on its role in the community – should generate discussion about assessing safety of facility, assuring patients moved to safe areas. First Priority: Appoint an IC Damage Assessment: Life Safety: Can we stay or do we need to go Structural integrity Electrical Gas leaks? Measure with a meter, not your nose. What services are we going to provide both internal and external

Tornado Command – assess impact on facility / staff
Space – triage areas, treatment areas – expand capacity especially outpatient Staff – shift staffing Stuff – Tdap boosters, analgesia, sedation, local anesthetics, suture trays Special – debris removal, utilities support, staff transportation Transportation – EMS resources Life safety first – quick search. Damage assessment and systems assessment should be next priority (HICS has standard form for this), do NOT forget to assess for gas leaks! Many patients walking in with shrapnel type injuries – remember upside down triage – get these patients to an area where they will not take up critical care resources. Can EMS get around with the structural damage and wires down, etc? Can your personnel get in for the next shift? What supplies, assistance, resources do you need? Remember that helicopters can still get in. Look for open spaces Refer them back to the hazard Vulnerability Assessment

Scenario Office building explodes
Several persons trapped in rubble, at least 2 fatalities – 2 of injured dragged out and brought by private car to hospital Multiple walking wounded including some people walking on the street / in cars and hit by debris Few windows broken in hospital complex Office building explodes Several persons trapped in rubble, at least 2 fatalities – 2 of injured dragged out and brought by private car to hospital Multiple walking wounded including some people walking on the street / in cars and hit by debris Few windows broken in hospital complex This scenario was not terrorist in origin, a natural gas leak outside the building allowed gas to build up in the basement and when an office worker went to the basement for supplies and flipped the light switch, the building was destroyed instantly (actually happened – as with all these cases). Because the leak was outside the basement, the soil filtered out the usual NG ‘smell’ but did not reduce it’s destructive potential. Whenever there is a blast consider where it occurred, the date (9-11 anyone?), etc. to try to determine if it’s likely to be terrorist or not. Secondary devices or secondary explosions are ALWAYS a consideration.

Bomb / Blast injury Command – facility assessment?
Space – triage area, treatment, OR Staff – including specialty – ENT, eye, surgery Stuff – analgesia, sedation, Tdap, burn supplies (adaptic, narcotics, ibuprofen, bacitracin), surgical supplies (suture trays, chest tube) Special – security, behavioral health, family Eye injuries and ear injuries VERY common with blasts. Burns less likely but depends on what exploded. If potentially terrorist in origin, consider threat to facility if victims brought there OR if perpetrator is one of the victims in your facility. Especially in criminal cases will have liaison with multiple agencies and behavioral health implications are significant. Assess life safety issues Could hospital be a secondary target? What about passive radiological detection Lockdown to visitors and screen staff

Other Surge Challenges
‘Upside down triage’ Family members Communications / information Media Psychological casualties We’ve discussed many of these already, but they are worth noting again in relation to the Madrid bombings. Sometimes even the EMS triage is ‘upside down’ for unusual reasons. E2 nightclub in Chicago – pepper spray used by patron, panic ensued, many people tried to evacuate down locked stairwell and several crushed at bottom. EMS providers were forced at gunpoint to transport victims in cardiac arrest (obviously not the priority with multiple victims). Toughest in the psychological casualty area are chemical exposures, where victims are all complaining of throat tightness, anxiety, shortness of breath – these symptoms have been shown to be highly associated with mass hysteria (usually triggered by some odor or small release) in addition to being symptoms of airway effects of chemical agents – only time and observation are going to sort these patients out.

Behavioral Health Surge Demands
EMS- Processed Medical Casualties Self-Transported Medical Casualties Bystanders or Family Members, Friends, Co-workers of Incoming Casualties Family Members Searching for Missing Loved Ones Injured, Exposed, Distressed Disaster/ Emergency Workers INCOMING Psychological Casualties Media Volunteers Onlookers We often think about victim and provider needs for BH support, but there’s a much larger pool that may need support (courtesy of Jim Shultz – University of Miami DEEP Center – Surge, Sort, and Support – Behavioral health response to disasters) INPATIENT Distressed Inpatients Family Members of Inpatients IN-HOUSE Distressed Staff

Behavioral Health Surge
Sorting Triage psychological (or likely) to observation area Supporting Quiet area Food and liquids Family support area as well Services Chaplaincy, social work, psychology/psychiatry, CISM, psychological first aid Observe, screen, refer as needed Observation area should be quiet and as relaxing as possible. Both medical and psychological support personnel should be available in the area and observing patients. Given that there are NEVER enough behavioral health professionals, consider broader training within the facility in Psychological First Aid (PFA) techniques which can be used by many providers in their daily jobs as well as in disasters.

Aftereffects Continued high ER and clinic volumes
Psychological stressors Unique hazards may affect health after the event At least 25% of NY firefighters working at ground zero have developed significant respiratory symptoms (ground zero cough) at least will be on permanent disability due to resp damage (mainly reactive airways dz) – asbestos, propylene, benzene, powdered glass and cement. Also, many persons with non-disaster related health problems will defer visits to ER / clinics during the time they feel the victims will be presenting, and then come the subsequent day/days.

NYC post 22.5% increase in asthma over 5-9 weeks younger patients, 44% > 54 yrs 75% in random phone survey reported adverse psychological effects MMWR Sept. 6, 2002

Security Lockdown Ingress / egress control Staff:
Hospital Contract Public Safety Community sources Policies and procedures – weapons, crowd control, use of force Although none of the scenarios that we covered warranted a faciity lockdown.. Let’s think of some examples of when that may be the case How fast (and how) can you lock your facility down? What are the policies? What security staff (if any) do you have? How do you get more? Do your security guards have other jobs (eg: police officer) that would drag them away in a disaster or disable your ‘security surge capacity’? How do you control staff / visitor access? If you bring in community law enforcement during a disaster for support, are there policies on what they can and cannot do? Do you have policies for your security staff about the last bullet contents? What if you had to issue them additional measures during an event (eg: TASER, batons, etc)? Consider augmenting your staff with local bar bouncers and weight lifters if all you need is physical presence (pair them with an employee or public safety officer!). If someone comes in when someone goes out Security will be important in a pandemic. Metal detectors may be used due to scarce resource protection (vents/meds) Most hospital security are not law enforcement and do not carry weapons.

Can your security personnel operate while in PPE
Can your security personnel operate while in PPE? If you have a team providing decontamination in a vulnerable area (eg: outside) after a chemical exposure where tensions may be high, you MUST have a security presence in the ‘warm zone’. Consider having zip cuffs that can be operated with gloves on and batons for body control. Make sure that you have a way to communicate (PA, etc) with those outside, as communication while in PPE is difficult.

Education and Training
Hospital Incident Command Training Just-in-Time Training Drills Tabletop Functional Discussion of surge situations and problem-solving (such as we’ve done here in this module) greatly help employees to reason their way through scenarios. Tabletop = ‘tell what you would do’. Functional = ‘do what you would do’ (to a point). 5 minute teachable moments with people under you.

Transition to the” next steps”
Transition to the” next steps”. We’ve just unloaded a tremendous amount of information on you. You are no doubt wondering…where do I start? Barb is going to help you with that as we close this training with what we call “NEXT STEPS” Collect and read some of the questions

What do I do now? Next Steps Review Your Emergency Operations Plan
Incorporate Incident Command Clearly define what a hospital employee will DO Have current job actions sheets and reporting forms Request more training in Incident Command if needed Imbed Incident Command in daily operations

Next Steps to Surge Define your Surge Capacity Partners
Make sure they know what you expect of them. Identify federal assets Acquire the needed bed-tracking program & training Create a Pre-surge plan If time allows:

Surge “Capacity” Space Evaluate your physical facility
Space for cots, family, media, staff respite BH … Evaluate near-by external facilities Create guidelines for early dismissals

Surging Personnel Staff
Determine ways to reallocate internal staff roles Determine external staffing options Determine process for assigning mentors/preceptors Plan Staff Extenders Just-In-Time Training

Considering Supplies Stuff Create a plan for a quick inventory
PPE General Patient Care Supplies – include medications Specialty Patient Supplies Support Supplies Food, water, office, communication Create a plan to begin stockpiling

Planning for the T’s Triage Treatment Train in Mass-Casualty Triage
Plan triage areas, internal and external Locate Vests and Tags Treatment Discuss and plan for temporary treatment of non-life-threatening injuries. Discuss alternative record-keeping

Transportation Internal External
Determine number and location of wheelchairs/gurneys Plan for alternate modes of transportation External Know your local transport resources

Community Based Surge Coordinate with local Public Health
Determine your role Identify existing plans

Revisit Parking Lot Issues

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Healthcare Surge Capacity in Disasters

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