1. Surge Capacity Management Plan Presentation to Ontarios Registered Respiratory Therapists Critical Care Secretariat November 30, 2009

2. Agenda 1.Overview of Surge Capacity Management Plan 2.Ventilator Procurement and Distribution 3.Moderate Surge Response-Ventilator Process 4.Provincial Ventilator Stockpile 5.Next Steps: Ventilator Strategy 2

3. 3 Expanded capacity Defined expandable capacity requirement 15% HSAA Predetermined Plans Management Health Human Resources Physical Space Equipment and Technology Surge Processes Increased access to information Utilization of available information to maximize resources Critical Care Information System CritiCall Improved System Design & Organization Improve the coordination of providers involved in delivering Critical Care Services through a scalable framework January 19 Ministry announced Surge Capacity Management Program Surge Capacity Management Program What are we achieving?

4. Surge Capacity Management Framework Major Surge An unusually high increase in demand that overwhelms the health care resources of individual hospital and regions for an extended period of time. An organized response at the provincial or national level is required Moderate Surge A larger increase in demand for critical services that impacts on a LHIN/ Region. An organized response at the LHIN/ Regional Network level is required. Minor Surge An Acute increase in demand for Critical Care services- up to15% beyond the normal capacity (as defined by the CCIS Inventory), and is localized to an individual hospital

5. Surge Capacity Management Elements Management Health Human Resources Alternative Physical Space Equipment and Technology Surge Processes Foundation of the plan Standardized practice for planning Ensure a consistent application of the framework during surge response 5

6. 6 Ontarios Plan of Action- HSAA Key Response Principles Central AuthorityReadiness to act for all categories of surgeResponse built on partnershipsTiered escalation responseOperational capabilities will be scalable, flexible and adaptable

7. Minor Surge Plan Hospital Teams Established plans for the 5 elements of the surge capacity management Ensure the surge response plan follows the outlined principles Ensure the operations are scalable and flexible to 15% above the normal critical care capacity Share information with the LHIN and partnering LHIN hospitals to develop inventory of resources Utilize CritiCall to facilitate the transfer to another organization in the LHIN or across the province 7

8. 8 Moderate Surge Defined as an increase in demand for critical care services that goes beyond individual hospitals and impacts on a Local Health Integration Network (LHIN) A system-level approach applicable in all surges. Aimed at sustaining critical care services in a time where demand exists the capacity or capability of the hospital and regional resources are required –Hospital capacity 115% or patient safety compromised

9. Moderate Surge Response Framework 9

10. Index Hospital Moderate Surge Escalation Index hospital activates minor surge plans Expand Capacity to 115% Index hospital activates minor surge plans Expand Capacity to 115% Critical Care Gatekeeper informs Senior Management of minor event surge event Critical Care Gatekeeper informs Senior Management of minor event surge event Hospital CEO /Delegate notifies CritiCall and triggers the LHIN Moderate Surge Response Plan Hospital CEO /Delegate notifies CritiCall and triggers the LHIN Moderate Surge Response Plan Index hospital critical care capacity is exhausted or patient safety is compromised Index hospital critical care capacity is exhausted or patient safety is compromised Hospital CEO or delegate identifies: The current situation The actions taken in the organization to mitigate the escalation ( minor surge response) The actions required during the moderate surge response, Specifically the services and resources necessary to sustain patient's) access to critical care in the organization and /or across the LHIN Hospital CEO or delegate identifies: The current situation The actions taken in the organization to mitigate the escalation ( minor surge response) The actions required during the moderate surge response, Specifically the services and resources necessary to sustain patient's) access to critical care in the organization and /or across the LHIN

11. Moderate Surge Response Framework 11

12. Partner Hospital Response 1. Hospital informed by CritiCall of activation of LHIN moderate surge management plans and requests partner hospital involvement 2. Partner hospital performs an environmental scan 4. Partner hospital CEO/ Delegate joins teleconference (set time and number provided by CritiCall) Note: CEO should have information from environmental scan* prior to calling CritiCall *Details on required information will be provided

13. Ventilator Inventory Ventilator Survey- August 2009 For the 131 hospitals with ventilator capacity the following information has been identified: Total number of invasive ventilators – 1832 1537 in use and 282 in storage excludes HFO, operating room and portable ventilators Total number of invasive ventilators including HFO, operating room and portable ventilators 3215 Total HFO reported across the province - 74 13

14. Ventilator Procurement & Distribution The goal of the ventilator stockpile is to enhance critical care ventilator capacity across the province and provide hospitals with the ability to respond to unexpected increases in critical care patient volumes. 216 ventilators were procured by the province to assist with Provincial Surge Capacity Management Plan Ventilators were allocated to each LHIN across the province based on current ventilator capacity analysis of specific variables from CCIS relating to capacity, location and services provided

15. Ventilator Procurement & Distribution The Ministry has procured the following three ventilator models to accommodate the needs of all patient populations: –PB840 (Tyco Healthcare) –Avea (Viasys Health Care) –Evita XL (Drager Medical) Each ventilator provides the capability to ventilate neonates, pediatrics and adults and provides basic and advanced modes such as Airway Pressure Release Ventilation (APRV). Specific details regarding ventilator capabilities will be provided directly by the vendor. All ventilators are equipped with a N100 expiratory filter system for infection control purposes.

16. Ventilator Procurement & Distribution Ventilators will be stored in host hospital in each LHIN to ensure that hospitals requiring additional ventilators receive them in a timely manner Host hospitals will have an asset agreements with MOH outlining accountabilities Ventilators will be made accessible to Ontario hospitals when all available resources within the LHIN have been considered Any hospital in the province will have access to the provincial stockpile according to the process identified in Moderate Surge Planning Receiving hospitals will receive an asset agreement prior to access to the stockpile outline accountabilities

17. Host Hospitals for Provincial Ventilator Stockpile LHINHOST HOSPITAL Central WestWilliam Osler Health Centre Toronto CentralUniversity Health Network Sunnybrook Health Sciences Centre St. Michaels Hospital North Simcoe MuskokaThe Royal Victoria Hospital of Barrie North WestThunder Bay Regional Health Sciences Centre North EastSudbury Regional Hospital – Laurentian Site CentralNorth York General Hospital ChamplainThe Ottawa Hospital Central EastLakeridge Health Corporation Erie St.ClairHotel-Dieu Grace Hospital Waterloo WellingtonGrand River Hospital South EastKingston General Hospital HNHBHamilton Health Sciences Corporation – General Site Mississauga HaltonMilton District Hospital South WestLondon Health Sciences Centre

18. Moderate Surge Response Ventilator Process Index hospital is approaching their maximum ventilator capacity and has considered all organizational vent capacity Index hospital is approaching their maximum ventilator capacity and has considered all organizational vent capacity Index hospital notifies CritiCall CritiCall facilitates teleconference between CC LHIN Lead & Index hospital CritiCall facilitates teleconference between CC LHIN Lead & Index hospital Predetermined LHIN equipment sharing plan actioned/ CC LHIN Lead identifies potential resources within the LHIN Predetermined LHIN equipment sharing plan actioned/ CC LHIN Lead identifies potential resources within the LHIN When all local equipment measures are exhausted the CC LHIN Lead will notify CCS for ventilator equipment options When all local equipment measures are exhausted the CC LHIN Lead will notify CCS for ventilator equipment options

19. Each hospital will take measures to ensure there is an adequate four week supply of equipment and resources to sustain their critical care units as functional Each hospital will ensure current supply of ventilators are maintained and the ventilator inventory is current Each hospital will verify the functionality of all ventilators in storage and identify which ventilators from storage can be utilized during a time of increasing demand. In addition to ventilators in operation the ventilators in storage would be checked and verified for functionality Moderate Surge Response Ventilator Process

20. In addition to ventilators in operation the ventilators in storage would be checked and verified for functionality Organizations would share equipment at a LHIN level prior to expanding to other LHINs or the province –Equipment sharing agreement –Tracking tools 20

21. Provincial Ventilator Stockpile Each ventilator will come equipped with supporting equipment such as a heated humidifier, temperature probe and humidifier cable, as well as disposable equipment such as circuits and humidifier pots. The following tests are required prior to the ventilator being put into circulation for clinical use and results be must be documented by the hospital: –Standard Biomedical Check (done by vendor or hospital Biomedical Engineering Department if accredited to perform) –Electrical Safety Testing by hospital Biomedical Engineering Department –Acceptance/Functionality Testing by Respiratory Therapy Department Service manuals will be provided for all ventilators and humidifiers as well as information on equipment reprocessing.

22. Provincial Ventilator Stockpile-Maintenance The host hospital is responsible to ensure ventilators and accompanying equipment is maintained according to the vendors maintenance schedule. Ventilators are currently under warranty to the manufacturer and includes access to preventative maintenance servicing Hospitals must notify the Critical Care Secretariat before doing any sort of preventative maintenance beyond what the manufacturer provides. Hospitals must notify the Critical Care Secretariat of any malfunctions or damage to the ventilators that occurs at any time. Proposed repairs will be assessed by the Critical Care Secretariat and coordinated with the vendor.

23. Provincial Ventilator Stockpile-Training Each vendor will provide access to ventilator clinical training services, educational resources and on-line technical support for Respiratory Therapy staff and/or Biomedical Engineering staff at no additional charge 24 hours per day. Hospitals are required to follow their internal policy guidelines and directives regarding ventilation. Access to clinical advice, protocols and support networks in circumstances such as ventilating unfamiliar patient populations or use of new ventilation modes should be addressed at the professional level.

24. Next Steps MOHLTC will distribute instructions for host hospitals to identify a contact person that will be available 24hours a day, 7 days a week that can be contacted to release a ventilator(s) from the provincial stockpile to identify the training requirements for models unfamiliar to the organization from the stockpile Priority will be given to host hospitals Webinar will follow for all receiving hospital Respiratory therapy teams, Critical Care Units and Hospitals Administrators 24

25. Thank you! Success always comes when preparation meets opportunity! 25

26. Contact Information Critical Care Secretariat Julie Trpkovski –Phone: 416-340-4800 ext 2767 –BB: 416-399-1173 –Julie.Trpkovski@ontario.caJulie.Trpkovski@ontario.ca Laura Pus –Phone: 416-340-4800 ext 2766 –Laura.pus@uhn.on.caLaura.pus@uhn.on.ca 26 Emergency Management Branch Adam Miller –Phone: 416-212-7062 –Adam.miller@ontario.caAdam.miller@ontario.ca Donna Dupont –Phone : 416-212-4465 –Donna.dupont@ontario.caDonna.dupont@ontario.ca