2. Mass Medical Care During an Influenza Pandemic: Establishing Influenza Care Centers PRESENTATION AND WORKBOOK
NACCHO Advanced Practice Center (APC) Road Shows Albuquerque, New Mexico August 11-12, 2009

3. APC Toolkit

4. Toolkit Sections Concept of Operations Fatalities and Morgue
Command and Control
Communications
Staffing and Training
Clinical Standards, Protocols and Operations
Infection Control
Fatalities and Morgue
Facilities
Equipment and Supplies
Security
Transportation

5. Toolkit Tools

6. Today’s Objectives Present highlights of the toolkit.
Focus on your local area requirements for mass medical care.
Use the workbook to start your planning.

7. What Are Expectations or Requirements?
In California:
Hospitals surge to care for seriously ill or injured.
Public health activates ACS/ICCs to care for moderately acute ill or injured patients, thereby taking the load off hospitals.
(Originally, hospitals were expected to set up and run the ACS...).
What are State-wide expectations or requirements for ACS activation?

8. What’s the Status of Current Planning ?
Healthcare Surge Plan (area-wide)?
Hospital surge plans?
Mass dispensing site (s) operational plan?
Alternate Care Site (ACS) operational plan?

9. ACS Planning Resources
APC Toolkit – based on SCC’s ICC h%20Department%20(DEP)%2FAdvanced%20Practice%20Center%20(APC)
CA Dept Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume /0/volume2_ACS_FINAL.pdf
CA Government-Authorized Alternate Care Site Operational Tools Manual. F781-4D8C-B A1C2C6F0C/0/Operational_ACS_Ops_Tool_FINAL.pdf
Seattle-King County APC Video ia/health/publichealth/documents/hccoalition/AltCareVideo.ashx

10. Elements of Planning: Interconnected Decisions
ALTERNATE CARE SITE
PATIENT CARE & PROTOCOLS
PATIENT “FLOW”
FACILITY LAYOUT
STAFFING
NUMBER OF PATIENTS

11. Influenza Care Centers (ICC)
For pandemic planning, Santa Clara County established the concept of Influenza Care Centers (ICC).
ICCs are alternative care sites designed to address the needs of moderate acuity patients in a pandemic.

12. ICC Pandemic Planning Assumptions:
Local hospital capacity will not meet hospitalization demand:
Bed capacity limits (adult and pediatric acute care, adult critical care, pediatric & neonatal critical care).
Ventilator limits (all ventilators, including disposable, mass casualty ventilators).

13. ICC Pandemic Planning Assumptions:
Illness, hospitalizations, fatalities
25-35% popn clinically ill
13-22% require hospitalization
% fatalities
12 months w/illness, hospitalizations, fatalities evenly distributed each quarter.

14. Surge and Capacity Challenges
With hospital interventions to expand capacity, assume 50% of beds in any one hospital available for flu patients (other variables include: ill staff, other illnesses/trauma, waiving of license requirements)
These charts show that by the third week of a pandemic, there will be a need for 461 beds for the sick that will not be available.
10% of hospitalizations require ICU
Average stay is 7 days in hospital or 10 days in ICU

15. Estimate # Patients, Sample – Albuquerque, New Mexico
Estimated (Albuquerque) population 600,000
600,000 x .25 = 150,000 = # clinically ill
150,000 (# clinically ill) x .22 = 33,000 = # require hospitalization
33,000 (# require hospitalization) / 4 = 8,250 pts / quarter = (12-week pandemic “wave”)

16. Estimate # Beds for Flu Patients Sample – Albuquerque, New Mexico
# of local area (Albuquerque) hospital beds
University of New Mexico Hospital
Heart Hospital of New Mexico - 55
Presbyterian Hospital - 453
The Children's Center at Presbyterian Hospital - 81
Lovelace Women's Hospital - 185
Kaseman Presbyterian Hospital – 252
Specialty Hospital of Albuquerque - 82
Kindred Hospital-Albuquerque – 61
Total = 1,519 beds
In hospital surge, 50% for flu patients = 760 beds (total includes ICU beds).

17. Estimate # of ACS Patients, Sample – Albuquerque, New Mexico

18. Workbook – Estimate # Patients
Estimated population: ________
_____ x .25 = ______ = # clinically ill
_______ (# clinically ill) x .22 = ________ = # require hospitalization
_______ (# require hospitalization) / 4 = ______ pts / quarter = (12-week pandemic “wave”)

19. Workbook: Estimate # Patients
# of local area hospital beds __________
In hospital surge, 50% for flu patients
= _________ beds (total includes ICU beds).

20. Workbook: Estimate # ACS/ICC Patients
# beds available for flu patients _______________
# patients / quarter = __________
Figure % of pts/qtr for each week. (Use %’s shown).
Identify peak weeks.
Subtract # beds available from the #hospitalized (cumulative – add the weeks up to and including the peak week).
This is the number to plan for at the ACS/ICC.

21. Toolkit Sections Concept of Operations Fatalities and Morgue
Command and Control
Communications
Staffing and Training
Clinical Standards, Protocols and Operations
Infection Control
Fatalities and Morgue
Facilities
Equipment and Supplies
Security
Transportation

22. Concept of Operations Step 1 – Describe the ICC, Objectives
Standard of Care
Level of Care
Step 2 – Operational Periods
Step 3 – Activation
Step 4 – De-activation

23. ICC Objectives
Primary objectives for the establishment of an ICC include, but are not limited to, the following:
Decompression of acute care hospital inpatient beds (receiving site for hospital discharge patients who are not able to be cared for at home)
Used instead of acute care hospital inpatient beds (inpatient care for moderate-acuity patients and palliative care)

24. Standard of Care
Standard of care during a healthcare surge is the utilization of skills, diligence and reasonable exercise of judgment in furtherance of optimizing population outcomes that a reasonably prudent person or entity with comparable training, experience or capacity would have used under the circumstances. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes*.
California Department of Public Health (CA DPH)

25. Pandemic Levels of Care
At Home Care
Isolation
Oral Hydration
Oral Antibiotics
Influenza Care Centers
Intermediate Care
IV & Oral Hydration
Oxygen
Nursing Services
MD on call
Hospital Admissions
Critical Care
Ventilators
Ancillary Services

26. Level of Care Planning Decisions
Patient Referrals
Are patients transferred from hospitals?
Can patients be referred by physicians?
Can patients self refer?
Transportation
Do patients arrive by ambulance?
Do patients arrive on their own?
Care
Acute Care Palliative Care
Screened and Admitted?
Outpatient Care?

27. Workbook: Level of Care Planning Decisions
Estimated # patients_______
Level of Care at hospital (s) _________________
Level of Care at the ACS/ICC ________________

28. Operational Periods
Define and describe the Operational Periods in terms of a likely pandemic cycle and daily operation.
It is anticipated that an ICC will be operational from eight to fourteen weeks for the first wave of a pandemic influenza event and then for an additional eight to twelve weeks during the second wave.
Operational periods = 12 hours.
Staffing

29. ACS Activation
Follows area’s event/emergency activation procedures per NIMs.
Authority to activate/operational policy:
The Health Officer will notify the local officials of the intent to activate and then coordinate implementation through the Medical-Health Branch of the Operational Area Emergency Operations Center. Positions in the ICC are filled according to National Incident Management System (NIMS). Once ICCs have been activated, only patients routed to ICCs or those triaged on-site for admission will be accepted. Patients that are admitted to an acute care hospital at the time the ICC is activated will remain in the acute care facility and will not be transferred to an ICC.

30. Workbook: Activation
Describe how emergency operations are activated per NIMS.
Who has authority to activate the ACS?
What patients are admitted upon activation?

31. Deactivation Authority to de-activate.
NIMS position to oversee deactivation.
Exit strategy in catastrophic failure:
Facility fire
Civil unrest, gun fire
Government, societal failure

32. Workbook: Deactivation
Who has authority to deactivate the ACS?
Which NIMS position oversees deactivation?
Describe catastrophic failures that might occur:

33. 2. Command/Control ICC organization Hospital Incident Command (HICS)
USE TOOL #2
ICC organization
Hospital Incident Command (HICS)
Planning with:
Hospital representatives
Emergency management representatives
Fire and Law enforcement
Inventory managers

34. 2. Command/Control
USE TOOL #2
Step 1 – Describe relationship of ICC to Public Health
Step 2 – Describe relationship between ICC to the EOC – Medical Health Branch
Step 3 – Prepare organizational charts

35. ICC Organizational Chart
General Staff
ICC Division Manager
Safety Officer
Operations Section Chief
Finance/Admin Section Chief
(See below)
Medical Care Branch Director
Infrastructure Branch Director
Security Branch Director
Logistics Section Chief
Planning Section Chief

36. County EOC - Operations Section Medical/Health Branch Director
ACS Site Incident Commander*
Safety Officer
Operations Section Chief
Medical Care Branch Director
Clinical Support Branch Director
Site Security Branch Director
Logistics Section Chief
Services Branch Director
Support Branch Director
Planning Section Chief
Resource Unit Leader
Situation Unit Leader
Documentation Unit Leader
Demobilization Unit Leader
Finance/Admin Section Chief
Time Unit Leader
Compensation Claims Unit Leader
Facility Liaison

37. Workbook – ICC Organization Chart
USE TOOL #2 and TOOL #5
The ACS/ICC is a field operation of __________________.
The ACS/ICC Incident Commander reports to ____________.
Logistics and support is provided by: __________________________

38. 3. Communications Step 1 – Determine ICC needs.
USE TOOL #3 TOOL #18
Step 1 – Determine ICC needs.
Step 2 – Describe methods.
Step 3 – Consider communications:
Within the ICC
Between the ICC and other ICCs
Between the ICC and hospitals/healthcare providers
Between the ICC and the EOC

39. 3. Communications Wireless Laptop Computer
USE TOOL #3 TOOL #18
Wireless Laptop Computer
(5) Portable 800 MHz radios (EMS Frequencies)
Access to existing landline fax machines
Access to existing landline phones
Access to internet-accessible computers
Access to a television with cable or satellite service
Access to a radio
Handheld Patient Tracking Devices
Wireless router

40. 4. Staffing and Training Step 1 – Determine staff ratios.
USE TOOLS #4 and #5
Step 1 – Determine staff ratios.
Step 2 – Describe functional roles. (Tool 4 – Functional Roles Matrix)
Step 3 – Determine training requirements for categories of positions.
Step 4 – Identify types of support staff needed.

41. 4. Staffing and Training
USE TOOLS #4 and #5
Local public health agency employees will not be sufficient for staffing the ICCs. The broader health care community, city governments, and community volunteers must provide human resources to ensure adequate staffing of the ICCs.

42. 4. Staffing and Training
USE TOOLS #4 and #5
The recommended staffing patterns are based on the following scenario for Santa Clara:
Total number of patients per ICC = 450
12-hour shifts for all staff
Patient population includes 50% patients on IV fluids (n=225) and 60% on Oxygen via nasal cannula (n=270)
Each ICC is divided into sections (treatment units) of up to 40 patients each.

43. 4. Staffing the ICC
USE TOOLS #4 and #5

44. Workbook: Staffing Number of patients (beds) in the ICC = (#)
USE TOOLS #4 and #5
Number of patients (beds) in the ICC = (#)
Using staffing ratio chart, determine staffing ratios to be used.
Review and revise Tool #5 Job Action Sheets
Identify community support for staffing.

45. Workbook: Staffing USE TOOLS #4 and #5 ACS Staffing Ratios Position
Staff-Pt Ratio
ICC (450) Santa Clara (Toolkit Example SCC needs twelve bed ICCs )
ICC (100) (22% of SCC ICC)
(Any town, USA Example)
ICC (___) = ___ % of SCC ICC (450)
Staff Ratio as % of SCC’s Staff-Patient Ratio
Medical Doctors
1: 50-60
8-9 per ICC
1-2
Registered Nurses
1: 15-20
23-30 per ICC
5-7
Respiratory Therapists
1: 20-30
15-23 per ICC
3-5
Care Givers (Health Technicians)
1: 5
90 per ICC 20
Clerical
1: 20
23 per ICC 5
Social Workers
1: 60
8 per ICC 2
Pharmacists

46. 4. Training ICC Orientation – Just in Time Training
USE TOOLS #4 and #5
ICC Orientation – Just in Time Training
Pre-event Clinical Operations Training – Public Health Clinical ICC Staff
Pre-event Clinical Skills Training 

47. 5. Clinical Standards, Protocols and Operations
Standing Orders
General
Admitting
Asthma
Heart Failure
Diabetes
Pregnancy
Palliative Care
Clinical Triage
Oxygen Delivery Alternatives
Insulin and Blood Glucose Monitoring Sheet
Pharmacy Order Form
Patient disposition log
ICC Intake Assessment Form

48. Elements of Planning: Interconnected Decisions
ALTERNATE CARE SITE
PATIENT CARE & PROTOCOLS
PATIENT “FLOW”
FACILITY LAYOUT
STAFFING
NUMBER OF PATIENTS

49. 5. Clinical Standards, Protocols and Operations
Step 1 – Develop triage guidelines.
Step 2 – Describe admissions/intake process.
Step 3 – Describe pt./bed tracking.
Step 4 – Define documentation and patient charting.
Step 5 – Describe daily evaluation.
Step 6 – Describe pharmacy formulation protocols.
Step 7 – Describe discharge criteria/procedures.
Step 8 – Develop visiting rules/regulations.
Step 9 – ID housekeeping/environmental services.

50. 5. Clinical Protocols & Patient Care Tools
USE ALL THESE TOOLS

51. 5. Patient Care Triage guidelines and admission
Admission/intake process
Standardized Orders
Admission protocols
Bed and patient tracking
Medical records/patient charts
Daily evaluation and treatment
Transfer dispositions

52. 5. Patient Care Pharmacy protocols Discharge protocols
Family care giving guidelines
Visitor guidelines
Environmental services

53. Workbook: Clinical Protocols and Patient Care
Convene a workgroup: physicians, RNs, EMS
Determine patient care “flow”
Review protocols
Santa Clara County in the APC Toolkit
New York Medical College, School of Public Health

54. 8. Facilities Step 1 - Determine criteria for facility selection.
Step 2 – List recommended facilities.
Step 3 – Diagram ICC layout.
Step 4 – ID other required facility areas needed.
Step 5: Conduct a site visit; coordinate with facility operators.

55. Facility Criteria
USE TOOL #28 and #29

56. SCC’s ICC Facility Requirements
Substantial square footage with large open areas.
Sites geographically distributed around the county.
Hotels: surge support.

57. ACS Ward Layout
USE TOOL #28 and #29

58. ACS Bay Layout
USE TOOL #28 and #29

59. Workbook – Facilities
USE TOOL #28 and #29
List facilities that may be used as an ACS/ICC in your area:

60. 6. Infection Control Step 1 – Determine necessary PPE for ICC staff.
Step 2 – Determine necessary PPE for ICC visitors.
Step 3 – Describing environmental cleaning procedure(s).
Step 4 – Develop procedures for disposal of biohazard waste.

61. 7. Fatalities - Morgue
Step 1 – ID operational area for temporary morgue.
Step 2 – ID required equipment/supplies.
Step 3 – Determine type of staffing.
Step 4 – Describe how bodies are transferred.
Step 5 – Describe personal property procedure.
(See Mass Fatality Toolkit)

62. 9. Equipment & Supplies
USE TOOL #3
Step 1 – Develop inventory list, consider local resources & scope of ACS/ICC care.
Step 2 – Determine storage and maintenance.
Step 3 – Describe process for implementing: ordering and moving supplies.

64. Equipment & Supplies Warehouse Storage
Electrical items – on shelves, plugged in, temperature controlled area
Maintenance items (i.e. Glucometer) need periodic inspection, stored in bulk containers, temperature controlled.
Pharmaceuticals, temperature controled or in refrigerator.
Stack-limited items, heavy/bulky, palletized, stored on pallet racks, 10’ wide aisles.
Bulk items, smaller, lighter, easily damaged, stored in bulk containers, stacked densely, w/o aisles.

65. 10. Security Step 1 - Describe role of Security at ICC.
USE TOOL #28 and #29
Step 1 - Describe role of Security at ICC.
Step 2 – Describe Access Control.
Step 3 – Describe Crowd Control.
Step 4 – Describe Traffic Control.
Step 5 – Describe role of Law Enforcement Interface
Step 6 – ID sources of security personnel.

66. Access Control Staff, visitors, support, media, officials.
Anticipate theft of pharmaceuticals, medical supplies.
Anticipate individuals who try to surreptitiously remove a patient or bring a patient in to the ICC.
Anticipate media attempting entry.
Badging, log-in and out.

67. Crowd Control/Traffic Control
High volumes of ill people.
Highly emotional people.
Neighborhood concerns.
Protestors, provide escorts.
Patient parking
Staff parking.
Patient loading/unloading.
Ambulance
Delivery
Media area.

68. 11.Transportation
Step 1 – Describe policy for transporting patients to the ICC.
Step 2 – Describe policy for transporting from the ICC to hospital.
Step 3 – Describe how transportation requirement will be met.
Step 4 – Describe communications for transportation operations.
Planning with OEM Logistics

69. Contacts
Olivia Nunez Santa Clara County Public Health Preparedness 976 Lenzen Avenue San Jose, CA (408) sccphd.org/APC Laurie Friedman SYA Group, Inc Broadway, Suite 4 Burlingame, CA
Rocio Luna, MPH Director, PH Preparedness and Data Management Santa Clara County Public Health Department 976 Lenzen Avenue San Jose, CA Main Line (408)