1. The Hospital Response Real Time Experience at AMCH Sarah Elmendorf, MD Rebecca O’Donnell MT,CIC

2. Introduction Hope for the best, plan for the worst Hope for the best, plan for the worst Evolving plan, never completed! Evolving plan, never completed! Current approach-not all the answers Current approach-not all the answers 4 initial measures (J healthcare management 2004 49 (40 227-235)) 4 initial measures (J healthcare management 2004 49 (40 227-235)) –hospital staff education –information technology –disease surveillance improvement –additional equipment and staff Regional efforts Regional efforts

3. Approach Assess a single patients entry into AMCH system Assess a single patients entry into AMCH system –Real time Identify current strengths and weaknesses Identify current strengths and weaknesses –Table top Respond to weaknesses Respond to weaknesses –Additional needs assessment/planning at department and division level Assess surge capacity Assess surge capacity

4. Key Assumptions SARS planning applied to Avian Flu Preparedness SARS planning applied to Avian Flu Preparedness Overall threat is small Overall threat is small Science 2004 304:968-969 BUT High case fatality rate High case fatality rate Who (5/05): Avian flu making ominous changes Who (5/05): Avian flu making ominous changes Potential global health impact could be catastrophic Potential global health impact could be catastrophic

6. Arrival Challenges Safe entry into the system Safe entry into the system Preparedness for the unknown Preparedness for the unknownStrategies Education of triage staff Education of triage staff Signage Signage

7. Arrival Challenges Diagnosis unknown Diagnosis unknown –Distinguish from other respiratory infections Changes in case definitions Changes in case definitionsStrategies Respiratory etiquette Respiratory etiquette Anyone who presents with a cough is immediately masked Anyone who presents with a cough is immediately masked Triage alert Triage alert Recognize risk factors Recognize risk factors –Travel, exposure to poultry, exposure to other cases

8. Arrival Challenges Sign interpretation Sign interpretationStrategies English and Spanish signs English and Spanish signs Signs with pictures- don’t reinvent, use! Signs with pictures- don’t reinvent, use! Are you confident infection is not being spread?

9. Arrival Visual Alerts Visual Alerts

10. Arrival Challenges Surge Capacity Surge CapacityStrategies Influx of patients will require regional collaboration and coordination Influx of patients will require regional collaboration and coordination

11. Triage Challenges Triage staff unsure of current events and case definitions Triage staff unsure of current events and case definitionsStrategies Communication Communication –ICP rep on ED QIT –IC rounds Alerts Alerts –Central location Education Education Test the system Test the system

12. Triage Challenges Enforcement of respiratory etiquette Enforcement of respiratory etiquette –Legal issues –Security issues Strategies Segregate patient from main waiting area Segregate patient from main waiting area Separate waiting areas/family conference room Separate waiting areas/family conference room Development of respiratory etiquette bags Development of respiratory etiquette bags Are you prepared to enforce policy?

13. Triage

14. Isolation Challenges Extended Precautions Extended Precautions Visitors and Family Visitors and FamilyStrategies Contact/Airborne signs for doorframe Contact/Airborne signs for doorframe Stickers for chart Stickers for chart Communication Communication –Notify infection control Visitor/family screening, PPE, check in logs Visitor/family screening, PPE, check in logs

15. Isolation Challenges Correct use and removal of personal protective equipment (PPE) Correct use and removal of personal protective equipment (PPE) Compliance with PPE Compliance with PPE Availability of PPE Availability of PPEStrategies Contact /Airborne sign Contact /Airborne sign PPE removal sign PPE removal sign PPE observer PPE observer PPE cart PPE cart Education sessions Education sessions

16. Isolation

17. Isolation Challenges Disinfection of environment and equipment Disinfection of environment and equipmentStrategies Dedicate where possible Dedicate where possible Empty room of unnecessary supplies Empty room of unnecessary supplies Disinfect! Disinfect! Disinfect! Disinfect! Disinfect! Disinfect! Are you prepared for extended precautions?

18. Patient Movement Challenges Contain disease Contain disease Communication CommunicationStrategies Mask patient Mask patient Identify most direct route Identify most direct route Security participation and traffic control Security participation and traffic control ICP involvement ICP involvement Use of PPE during transport Use of PPE during transport

19. Communication Challenges Multiple disciplinary involvement Multiple disciplinary involvementStrategies Prepared policies- located on Intranet site Prepared policies- located on Intranet site - Notification - Patient placement - Patient management - Identification of patient - Hand hygiene - PPE - Environment and equipment disinfection disinfection - Laboratory specimens - Linen and waste - Interdepartmental transfer - Visitors

20. Communication Challenges Internal/External communication Internal/External communication Laboratory notification Laboratory notificationStrategies County notification County notification Testing the system with other communicable diseases Testing the system with other communicable diseases Stickers for lab specimens Stickers for lab specimens Education Education Intranet site Intranet site

24. Communication Scheme Internal ED Medical/Nursing Staff Epidemiology Medical Director/ Administration Laboratory Public Relations County Health Departments External Radiology NYSDOH Regional Epidemiology NYSDOH Wadsworth Laboratory Multiple specialties Pt Care Unit Communication: a critical but time consuming element

25. Medical Evaluation

26. Challenges Medical staff fit testing/compliance Medical staff fit testing/complianceStrategies Powered air purifying respirator (PAPR) Powered air purifying respirator (PAPR) Fit testing critical medical staff Fit testing critical medical staff All sizes/types of All sizes/types of N-95 respirators available on units N-95 respirators available on units

27. Medical Evaluation Challenges Multi-specialty involvement/ education Multi-specialty involvement/ education Movement of patients Movement of patientsStrategies Emergency Preparedness Readiness Site Emergency Preparedness Readiness Site Streamline clinical management Streamline clinical management Maintain precautions Maintain precautions Intubate/extubate in negative pressure room Intubate/extubate in negative pressure room Limit movement of patient Limit movement of patient

28. Diagnosis Challenges What specimens to collect? What specimens to collect? Avian flu/other respiratory infections Avian flu/other respiratory infectionsStrategies Intranet site Intranet site –Identify specimens needed –Current case definition with symptoms/risk factors/travel Maintaining precautions Maintaining precautions

30. Treatment Challenges Options limited Options limitedStrategies Pharmacy preparedness Pharmacy preparedness Vaccination campaign Vaccination campaign Increased stock of antiviral medication Increased stock of antiviral medication Knowledge of most current recommendations Knowledge of most current recommendations

31. Potential for Surge Challenges Overwhelming resources of health care system Overwhelming resources of health care system –PPE –Equipment –Staff Strategies Early recognition Early recognition Early treatment Early treatment Early isolation Early isolation Stocked PPE Stocked PPE Negative pressure units Negative pressure units Patient diversion Patient diversion

32. Potential for Surge Challenges Overwhelming resources of health care system Overwhelming resources of health care system –PPE –Equipment –Staff Strategies Team approach Team approach On the spot tracking and references, Palm Pilots On the spot tracking and references, Palm Pilots

33. Potential for Surge Challenges Multiple hospital Collaboration Multiple hospital Collaboration Strategies Regional Resource Center Regional Resource Center HEOCC HEOCC Albany County Community Advisory Group Albany County Community Advisory Group Albany County Communicable Disease Workgroup Albany County Communicable Disease Workgroup