1. Medical Surge Capacity Planning Strategies Robert Gougelet MD

2. Overview Review Medical Surge Guidelines Review Modular Emergency Medical System (MEMS) Exercise Operation PREP: Med-Surge functional exercise Medical Surge Capacity Plan Template Planning Strategies for tough spots: –Space, Staff, Supplies Questions

3. Before we get started… There is no such thing as a stupid question The ultimate goal of this planning process is to prevent as much injury, illness, and death as possible during a public health emergency Keep this in mind when it gets hard and you want to quit

4. Definitions Medical Surge Capacity “The quantifiable amount of community or regional resources and services available for providing medical care in emergencies that overwhelm the normal medical infrastructure (through numbers or types of patients or loss of infrastructure)”

5. Definitions The Modular Emergency Medical System (MEMS) A conceptual framework for managing a surge in patients requiring triage, prophylaxis, or inpatient care Components include: –Neighborhood Emergency Help Center (NEHC) –Acute Care Center (ACC) –Medical Command & Control –Casualty Transportation System –Community Outreach –Mass Prophylaxis (PODs) –Public Information

6. Home Private MDs & Clinics Triage/Treatment START Neighborhood Emergency Help Centers (NEHC) Outpatient Triage Patient Registration Patient Information Transportation, Logistics Pharmaceuticals, Administration Community Outreach Treatment/Support Isolation at Home Door to Door Citizen Mobilization Acute Care Centers (ACC) Inpatient Acute Triage/Treatment Care & Comfort Area Hospitals Acute Triage/Treatment Medical Command Centers Fatality Management Casualty Transportation System Non-Infectious Patients Communication & Coordination Incident Patients & Worried Well

7. Definitions Neighborhood Emergency Help Center (NEHC) Intended to serve outpatient needs in a medical surge event Functions can include: –Distribution of self-help information and instruction for home care –Triage for large numbers of people seeking care –Distribution of mass prophylaxis During an infectious disease event, ill or infected individuals should not be in contact with individuals seeking information or coming to a POD. The NEHC must be separate from a POD in this case.

8. Definitions Acute Care Center (ACC) Provides medical care in a community-based setting Provides limited care to patients that generally would require hospitalization Designed to provide the most good for the greatest number of people when there are limited resources Designed to care for patients until the regional healthcare system can take care of the extended load The ACC may provide mass isolation of individuals who cannot be isolated in their own homes

9. Definitions Buildings of Opportunity Large facilities, not normally used for health care services, but which have the basic utilities needed to support medical functions Ideally have internal systems to handle medical oxygen and vacuum capability – but this is unlikely Common buildings of opportunity include schools, gymnasiums, and community centers

10. Definitions Medical Command and Control Medical Command and Control is assumed by a single hospital within the affected area Provides medical command, oversight, administrative assistance, technical supervision, and consultation services in support of health and medical response operations

11. Medical Surge Tiered Response Medical Surge Capacity & Capability (MSCC) Management System The 6 Tiers are: 1)Individual healthcare assets 2)Healthcare coalitions (i.e. VAHHS) 3)Sub-state regional (Public Safety Districts or LEPCs) 4)State 5)Interstate 6)Federal Tier 3 is defined as interagency coordination at the regional level to facilitate patient care and staff surge capacity needs

12. Activation of Tiered Response Medical surge facilities may be opened under the following scenarios: 1)If the Commissioner of Health declares a local, regional, or statewide Public Health Incident 2)In response to a recommendation from VDH, through the EOC, when the Governor has issued a regional or statewide emergency declaration 3)A Federal disaster declaration VDH and the command staff at the Emergency Operations Center/MCC have the authority and responsibility to open med-surge facilities as part of ESF- 8 actions

13. Regional Med-Surge/Mass Care Centers 8 centers planned across the State 2 centers planned per Public Safety District Sites identified in Barre and St. Albans Planning will involve VDH, the LEPCs, and other local participants Each center will have the capacity to care for: –200 mass care individuals –50 med-surge patients

14. Facility Identification Identify buildings of opportunity in your area Consider developing memoranda of understanding (MOUs) to ensure that buildings will be available during an event Consider other uses for the same facility that may affects its available Ensure your plan includes procedures for activation, notification, and opening the facilities

15. Facility Staffing The type of event, number of victims, and the care required will determine the number and type of individuals requires to staff any med- surge facility Healthcare provides may be in extremely short supply The local hospital(s) will not have the capacity to be the primary provider of staff to the facilities

16. Facility Staffing Consider local sources of medical / healthcare volunteers: –Local medical providers: off-duty or non-emergency volunteers –Developing or enhancing local Medical Reserve Corps units (MRCs) –Expanded groups of providers: vets, dentists, medical/nursing students Consider additional / State sources of medical volunteers: –Metropolitan Medical Response System (MMRS) Strike Team –State ESAR-VHP system (Emergency System for the Advance Registration of Volunteer Health Professionals)

17. Facility Staffing Non-medical, community volunteers should be used to do a variety of tasks: –Registration –Housekeeping –Food service –Transportation –Family services Consider sources of non-medical volunteers: –Local volunteer organizations: Community Emergency Response Teams (CERT), civic and faith-based organizations –Pre-established volunteer lists –Spontaneous volunteers

18. Facility Supplies Each facility will require critical equipment and supplies to provide ACC care for 50+ patients for a minimum of 72 hours Regions may request supplies from the State The State is considering different approaches to supplying these regional facilities

19. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf The Incident Command System (ICS)

20. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf ICS Sections

21. ICS Overview Is a standardized management tool for meeting the demands of all sizes of emergencies Represents "best practices" and has become the standard for emergency management across the country May be used for planned events, natural disasters, and acts of terrorism Is a key feature of the National Incident Management System (NIMS) Anyone who may have a leadership role in a public health emergency should receive ICS training Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

22. ICS Essential Features There are 14 essential ICS features: Common Terminology: Using common terminology helps to define organizational functions, incident facilities, resource descriptions, and position titles. Modular Organization: The Incident Command organizational structure develops in a top-down, modular fashion that is based on the size and complexity of the incident, as well as the specifics of the hazard environment created by the incident. Management by Objectives: Includes establishing overarching objectives; developing and issuing assignments, plans, procedures, and protocols; establishing specific, measurable objectives for various incident management functional activities; and directing efforts to attain the established objectives. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

23. ICS Essential Features Reliance on an Incident Action Plan: Incident Action Plans (IAPs) provide a coherent means of communicating the overall incident objectives in the contexts of both operational and support activities. Chain of Command and Unity of Command: Chain of command refers to the orderly line of authority within the ranks of the incident management organization. Unity of command means that every individual has a designated supervisor to whom he or she reports at the scene of the incident. These principles clarify reporting relationships and eliminate the confusion caused by multiple, conflicting directives. Incident managers at all levels must be able to control the actions of all personnel under their supervision. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

24. ICS Essential Features Unified Command: In incidents involving multiple jurisdictions, a single jurisdiction with multi-agency involvement, or multiple jurisdictions with multi-agency involvement, Unified Command allows agencies with different legal, geographic, and functional authorities and responsibilities to work together effectively without affecting individual agency authority, responsibility, or accountability. Manageable Span of Control: Span of control is key to effective and efficient incident management. Within ICS, the span of control of any individual with incident management supervisory responsibility should range from three to seven subordinates. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

25. ICS Essential Features Resource Management: Resource management includes processes for categorizing, ordering, dispatching, tracking, and recovering resources. It also includes processes for reimbursement for resources, as appropriate. Resources are defined as personnel, teams, equipment, supplies, and facilities available or potentially available for assignment or allocation in support of incident management and emergency response activities. Information and Intelligence Management: The incident management organization must establish a process for gathering, sharing, and managing incident-related information and intelligence. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

26. ICS Essential Features Transfer of Command: The command function must be clearly established from the beginning of an incident. When command is transferred, the process must include a briefing that captures all essential information for continuing safe and effective operations. Integrated Communications: Incident communications are facilitated through the development and use of a common communications plan and interoperable communications processes and architectures. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

27. ICS Essential Features Accountability: Effective accountability at all jurisdictional levels and within individual functional areas during incident operations is essential. To that end, the following principles must be adhered to: –Check-In: All responders, regardless of agency affiliation, must report in to receive an assignment in accordance with the procedures established by the Incident Commander. –Incident Action Plan: Response operations must be directed and coordinated as outlined in the IAP. –Unity of Command: Each individual involved in incident operations will be assigned to only one supervisor. –Span of Control: Supervisors must be able to adequately supervise and control their subordinates, as well as communicate with and manage all resources under their supervision. –Resource Tracking: Supervisors must record and report resource status changes as they occur. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

28. ICS Essential Features Pre-designated Incident Locations and Facilities: Various types of operational locations and support facilities are established in the vicinity of an incident to accomplish a variety of purposes. Typical pre-designated facilities include Incident Command Posts, Bases, Camps, Staging Areas, Mass Casualty Triage Areas, and others as required. Deployment: Personnel and equipment should respond only when requested or when dispatched by an appropriate authority. Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

29. Putting it all together…

30. Medical Surge Functional Exercise: Operation PREP Upper Valley All Health Hazard Region (Hanover/Lebanon NH) Wednesday, November 15 th, 2006 Functional exercise to practice integration of multiple partners during a medical surge event Cooperation of multiple organizations is key to a successful response Organizations that don’t work together will have to during a disaster Practice (drills and exercises) will ensure this collaboration and cooperation are effective This is new to everyone! Exercise was a learning experience for all participants

31. Operation PREP Players Town of Hanover, NH City of Lebanon, NH Dartmouth-Hitchcock Medical Center (DHMC) Dartmouth College Northern New England Metropolitan Medical Response System (NNE MMRS) New England Center for Emergency Preparedness (NECEP)

32. Activities and Observations Hanover emergency planners set up EOC in new location – what to bring? Practice with ICS – not all familiar with chain of command Job Action Sheets and diagram assisted ICS set-up Communication: cell phones, landlines, internet – did not test radios Community Objectives: Practice setting up Emergency Operations Center and implementing Incident Command Structure. Practice communicating with hospital and State.

33. Activities and Observations Multiple organizations: NNE MMRS NH Strike Team, HFD Besides Hanover FD, none of these people had ever worked together before Determine ICS – Job Action Sheets and diagram helpful Physical set up of Cabela’s cots – Supplied by Hanover Receiving and unloading of medical supplies from DHMC Secure facility Community Objectives: Practice setting up an Acute Care Center

36. Activities and Observations Local High School and Dartmouth students volunteered as “patients” No acting – each received a patient card with a description of symptoms Strike team admitted patients No patient care given Written orders to track activities, use of staff and supplies Community Objectives: Practice admitting 50 patients to ACC

38. Activities and Observations Patients given tag with bar code at triage (ED, NEHC) Scanned at every point of contact – discharge facility, transfer, receiving Handheld scanners (HCS) are multipurpose tool HCS linked to WebEOC, monitors anything and everything Athena tracks care given, resources used Community Objectives: Practice tracking 50 patients in ACC using patient tracking and electronic medical records software

39. Operation PREP Outcomes Good practice of collaboration between multiple agencies Built confidence and comfort with concept of med-surge by walking through steps of setting up an ACC Raised awareness of planning activities in the community –High school and college volunteers –Local and national press coverage Successful deployment of NH strike team Tested information technology

40. So how do we get there?

41. Medical Surge Plan Template This template is a planning tool to aid in the consistency of plans across the state It is intended as a starting point to develop plans, relationships, and procedures specific to your region Be realistic about the available resources, capacities, and capabilities of your region The objective is to use available resources to provide the best care possible

42. Medical Surge Plan Template Use the template to organize your information Ensure that all critical areas are addressed Continuously ask: –What will we need to know? –What will we need to do? Make sure the answers to those questions are in your plan

43. Medical Surge Plan Template: Outline Introduction Preparation Response Appendices

44. Medical Surge Plan Template: Introduction Planning Team Members Regional Population Estimates Definitions, including: –Medical Surge Capacity –ACC –NEHC Assumptions

45. Medical Surge Plan Template: Preparation Facilities: –Identify your buildings of opportunity and backup sites –Ensure a plan to access & use these sites Staffing: –Identify potential staffing needs and available resources –Consider staffing for med-surge facilities (ACCs, PODs, NEHCs) –Consider staffing for other necessary services (i.e. transportation, hotlines, etc.) Supplies: –Identify local supply caches and sources –Identify cache locations and protocols for access and replenishment –Include regional supply inventory as an appendix

46. Medical Surge Plan Template: Preparation Standards of Care: –The Standard of Care may be altered depending on the situation –Information and/or guidance may come from the State Memoranda of Understanding (MOUs): –Identify what resources (space, supplies, etc.) are needed –Consider signing MOUs with local businesses, suppliers, and building owners –Consider asking these groups about other MOUs they have signed to avoid over-committing resources Risk Communication: –Include a risk communication appendix –Consider how to alert your region about opening community- based medical facilities

47. Medical Surge Plan Template: Preparation Finances: –Ensure that you keep records during an event –Develop a plan and documents for this in advance Pandemic Influenza: –Consider the additional requirements of a protracted event –Estimates range up to 30% ill –Duration up to 8-12 weeks in multiple waves Functional Needs Populations: –Identify the functional needs groups in your region –Consider the best ways to reach these individuals –Consider who your best partners may be (service orgs, religious leaders) –Consider accommodations for functional needs individuals in medical surge facilities

48. Medical Surge Plan Template: Response Notification –Consider how notification works in your region – among responders, volunteers, and the public Command and Control Communication Resources –Can you obtain the resources you planned on? ACC and NEHC Concept of Operations

49. Medical Surge Plan Template: Appendices Appendix A: Regional Resource Inventory Appendix B: Copies of Regional MOUs Appendix C: State Medical Surge Guidelines Appendix D: Supply list recommendations Etc.

50. Troubleshooting: Facilities Identify Buildings of Opportunity (and backups) Conduct site inspection for: –Appropriateness Use the AHRQ assessment RMSMCC’s are being assessed with the AHRQ & Red Cross Surveys –Safety Ensure that your facilities are inspected by Fire and Police representatives Draft & Sign MOUs with facility owners: –Ensure that facilities will be available when needed –Clarify any issues related to accessing the site, and responsibility for the facility during incident

51. Troubleshooting: Facilities Common Buildings of Opportunity: Aircraft hangers Religious sites Community/Recreation Centers Convention Facilities Fairgrounds Government Buildings Hotels/Motels Meeting Halls Same Day Surgery Centers or Clinics (alternative medical facilities) Sports Facilities/Stadiums

52. Troubleshooting: Staff Sample staffing model for 50-bed ACC unit for each 12-hour shift

53. Troubleshooting: Staff The type of event, number of victims, and the care required will determine the number and type of individuals required to staff the facilities

54. Troubleshooting: Staff A RMSMCC should be staffed with local providers as available –Be creative: school nurses, specialists (cancelled elective procedures), etc. –Also consider non-traditional providers: vets, medical students, ophthalmologists, etc. –Consider that the hospitals may also plan on claiming these providers! Individuals should be contacted and recruited before an event occurs Encourage affiliation with the State Emergency System for the Advanced Registration of Volunteer Health Professionals (ESAR- VHP) The Northern New England Metropolitan Medical Response System (NNE MMRS) VT Medical Strike Team is available for deployment during a localized event

55. Troubleshooting: Supplies Plan on obtaining enough critical supplies to last at least 72 hours Coordinate medical supplies with local health care facilities –Hospitals may be able to provide some during an event –Consider setting up system of rotation for items with a shelf life –Consider involving other health care facilities in storage and rotation (i.e. nursing homes, clinics)

56. Troubleshooting: Supplies Consider alternative sources of non-medical supplies –Get administrative supplies, desks, chairs from schools or local businesses –Draft MOUs for any of these agreements Before making purchases, ensure that you know what is already available in the region

57. Resources Information on ICS and NIMS –FEMA Training Institute: http://www.training.fema.gov/http://www.training.fema.gov/ –Other online training resources: http://www.ualbanycphp.org/learning/default.cfm http://www.ualbanycphp.org/learning/default.cfm The Agency for Healthcare Research and Quality (AHRQ) tool for ranking buildings of opportunity http://www.AHRQ.gov/research/altsites/altmatrix1_final.htm http://www.AHRQ.gov/research/altsites/altmatrix1_final.htm Additional description of the MEMS system http://www.nnemmrs.org/surge http://www.nnemmrs.org/surge

58. Resources The New England Center for Emergency Preparedness, Dartmouth Medical School, http://dms.dartmouth.edu/necep/ http://dms.dartmouth.edu/necep/ The Vermont Department of Health, http://healthvermont.gov/ http://healthvermont.gov/ Vermont Emergency Management, http://www.dps.state.vt.us/vem/ http://www.dps.state.vt.us/vem/

59. NECEP Mission The New England Center for Emergency Preparedness (NECEP) is a collaborative organization involved in the regionalization and coordination of planning and response for Northern New England in the case of a disaster or mass casualty event. The mission of NECEP is to apply leading-edge research and expertise from the Dartmouth-Hitchcock Medical Center (DHMC), Dartmouth Medical School, the Center for the Evaluative Clinical Sciences, and other Dartmouth resources to preparedness for large-scale emergencies across the Northern New England (NNE) region.

60. NECEP Scope Currently, NECEP is coordinating emergency planning and response with Maine, New Hampshire, and Vermont through the Metropolitan Medical Response System (MMRS) as well as through a variety of State projects.

61. Director/PI Dr. Robert Gougelet, M.D. Rgougelet@dartmouth.edu Main Office: (603) 653-1189 Fax: (603) 653-1479