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Surge Capacity: Preparing for the worst- case scenario John L. Hick, MD Hamilton, Ontario May 29, 2006.

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Presentation on theme: "Surge Capacity: Preparing for the worst- case scenario John L. Hick, MD Hamilton, Ontario May 29, 2006."— Presentation transcript:

1 Surge Capacity: Preparing for the worst- case scenario John L. Hick, MD Hamilton, Ontario May 29, 2006

2 What defines a disaster? Demand for critical resources outstrips availability thus putting patients or staff in danger Goal is to plan ahead to ensure: More effective use of available resources Mobilization of additional resources Outcome: ‘special incident’ doesn’t become a ‘disaster’ May depend on time / day / facility





7 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


9 Surge Capacity Partners EMS (and other patient transportation resources) Emergency Management Public Health Public Safety/Law enforcement Healthcare Systems Hospitals and hospital associations Red Cross Behavioral health Jurisdictional legal authorities Professional associations inc pharmacy, medical, nursing, mental health

10 Concepts and Principles Standardization Incident Management System Multi-Agency Coordination System Public Information Systems Interoperability (eg: personnel and resource typing) Scalability Flexibility Tiers of capacity (spillover to next level)

11 Surge Capacity Coordination

12 HCF AHCF CHCF B Healthcare Facility 1 st Tier 2 nd Tier Healthcare “Coalition” Jurisdiction I (PH/EM/Public Safety) Non-HCF Providers Medical Support 3 rd Tier Jurisdiction Incident Management 4 th Tier Jurisdiction II (PH/EM/Public Safety) Regional Coordination 5 th Tier National Response 6 th Tier Provincial Coordination Province AProvince B Provincial and National Response Tiers of Response – Patient Care

13 Capabilities and Resources National Response Regional / Mutual Response Systems Provincial Response Increasing magnitude and severity Local Response Tiered Response Strategy MinimalLowMediumHighCatastrophic


15 Facility / Community Planning Emergency Management Plan HVA Command, control, communications Community partners Regional partners Training Drills Review / modify Functional Planning MCI Security Event Fire Chemical exposure Radiologic Event Infectious Disease Evacuation

16 Local Attractions...

17 Emergencies Present Themselves In 2 Ways… Oklahoma City Bombing September 11, 2001 Hurricane Katrina Midwest Floods Pandemic InfluenzaNorthridge Earthquake The Amount of Time We’re Given To Pre-Organize People and Pre-Stage Equipment Can Drastically Change Our Response Effectiveness Anticipated and/or With Warning Anticipated and/or With Warning Unanticipated and/or Without Warning Unanticipated and/or Without Warning

18 ‘C’ first and foremost Command Control Communication Coordination

19 Command / Control Who is in charge? Who has authority to declare a special incident, evacuate, etc? Where is the EOC/Command Post? How does the EOC/CP interact with: Community resources Other hospitals/public health Tiered, scalable, flexible plans Use of Hospital Incident Command System

20 Getting Organized… INCIDENT BRIEFING Date/time of start of incident Type of incident Services involved Current incident status Current resource status Current strategy/objectives Communications systems being used Special problems/issues Nature Size Location Time of Day Day of the Week Initially Mobilization Checklist Mobilization Checklist What ? Where ? When ? Who’s Involved ? Where Is It Going ? What ? Where ? When ? Who’s Involved ? Where Is It Going ? Emergency Operations Center Incident Action Planning

21 Communication Within ED / hospital Phone (redundant?), local cellular Paging Portable radios Alpha pagers, SMS, email, VOIP Runners Outside facility – phone, cell, HEAR, amateur radio, internet – VOIP, email, net-based

22 Coordination Within facility (for ICU, CT, etc.) Outside facility: Transfers (including ambulances, helos) Resource requests Outside agencies Regional Hospital Resource Center (RHRC) Coordinates hospital response and requests within region

23 ‘S’ - Logistics Space Staff Stuff

24 Space Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home) Discharge holding area Board patients in halls Cancel elective procedures Convert procedure/PACU areas to patient care Accommodate vents on floor (or BVM or austere O2 flow powered ventilators) Alternative ambulatory care areas (lobbies, clinics, etc.)

25 Staff Different events = different staff needs Eg: HAZMAT vs. trauma vs. monkeypox Scope of event = scope of staff call-in Mechanism to reach staff Support staff – eg: central supply, food, psychosocial Labor pool unit leader Assign staff to specific areas when possible Nursing staff often limiting factor

26 Staffing


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

29 Stuff Patient care supplies – look at by type of event Pharmacy – analgesia, sedation, dT, abx PPE – masks, barrier gowns Supply and staffing issues (72h ahead) Logistics and planning sections

30 Surge Capability

31 Pharmaceuticals

32 Personal Protective Equipment

33 HCMC Security HCMC Security

34 ‘T’ - Operations Triage Treatment Transport

35 Triage Primary – immediate, often scene-based (eg: EMS) Secondary – at hospital or for in-hospital resources, re-assessment Location Supplies Personnel Tertiary – after admission / initial care

36 Treatment Where provided? (eg: will certain patients be cohorted in certain areas?) What treatment will be provided? (resource limitations?) What are the limiting factors? Staff Supplies Space

37 Transportation Ground assets (including buses and out-of- area EMS) Rotor-wing “Loading zones” for both ground and air units Receiving facilities Coordination of patients, records Prioritization for evacuation and method

38 Transportation Capacity/Capability

39 IN-HOUSE Distressed Staff INPATIENT Distressed Inpatients Family Members of Inpatients INCOMING Behavioral Health Surge MediaVolunteersOnlookers PsychologicalCasualties EMS-ProcessedMedicalSelf-Transported Medical Casualties Bystanders or FamilyMembers,Friends,Co-workers of Incoming Casualties Family Members Searching for Missing Loved Ones Injured,Exposed,DistressedDisaster/EmergencyWorkers


41 Community- Based Surge Clinics Homecare Nursing homes Procedure centers Family-based care Off-site hospitals (Acute Care Center) Off-site clinics (Neighborhood Emergency Help Centers) (assessment and clinic level care) Local / Regional referral / NDMS

42 Influenza calls to MDH December 2003

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

44 Hospital Metro Resources Routinely staffed beds 4857 Avg. daily census 4143 Surge Capacity Census vs. staffed variance 714 Unstaffed but available beds 1068 15% of total beds staffed = 728 PACU/procedure rooms 536 Convertible rooms single to double 473 Total average overall surge capacity 2500-3519 Adjusted standard of care surge capacity 500- 1000

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

46 Regional Hospital Resource Center Hospital A Hospital B Hospital C Clinic coord Healthsystem Multi-Agency Coordination Center EM EMS PH Public Health Agencies EMS Agencies Jurisdiction Emergency Management A A B CA B C C B

47 Hospital Resources Metro Population 2,600,000 10% population affected by ‘pandemic’ = 260,000 patients 20% of affected patients too sick to care for selves = 52,000 20% of those patients lack family members that can care for them or are too sick for homecare (require IV fluids, etc.) = 10,400 Requires off-site care facilities and triage of resources

48 Off-site hospital Incident recognized, regional coordination established, need for off-site care recognized Primary and secondary sites pre-selected and screened Public health authority is authorizing/controlling entity Compact provides for first 48h: Teams of providers (RN, MD, HCA/NA/EMT) <200 beds – 1 team >200 beds – 2 teams Each 6-8 person team has up to 50 patients May be required when hospital infrastructure damaged, especially in smaller community

49 Sample Site


51 Food Restrooms Staff rehab areas Secure HVAC system specs Paging /messaging /radio Power Phone, T1 lines, etc. City owned!



54 Adjusting Standards of Care The last resort ‘What do you do when you can’t surge any more’ Gracefully, systematically change your standard of care to one appropriate for the resources available Staffing and staff roles / responsibilities Policy changes (eg: documentation) Resource triage decisions

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

56 What are the goals? Understanding by the community of the limits of resources and the plans when they are exhausted Evidence-based strategy for triage of resources (based upon chance of survival, not subjective factors) Regional, not facility-based criteria Provide support and framework for physician decisions Provide governmental support for response efforts including liability protection


58 Restrictions on Mechanical Ventilation Do not offer or withdraw ventilator support for: Tier 1 – multi-organ failure Tier 2 – severe underlying disease conditions Tier 3 – other criteria (event driven) possible: Sequential Organ Failure Assessment Score Age related? Other markers for poor outcomes?

59 What can I do? Know your role in your institutional plan Work with your emergency preparedness committee Look at your C, S, T - have you optimized your preparedness? Ask questions, run scenarios… KISS Job action sheets / task cards Extension of daily tasks / responsibilities Education where these differ from your plan Start small, grow big


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