1. Standards and Guidelines for Healthcare Surge during Emergencies Volume II: Government-Authorized Alternate Care Sites

2. 2 Learning Objectives Define a government-authorized Alternate Care Site and understand when it will be established during a healthcare surge Describe the roles and responsibilities of local government and the Alternate Care Site Planning Team State the considerations for facility selection List the supplies, pharmaceuticals, and equipment needed for a catastrophic event Discuss the operations of an Alternate Care Site

3. 3 Learning Objectives Describe the administrative support functions of an Alternate Care Site Describe reimbursement procedures for an Alternate Care Site Describe the activation of an Alternate Care Site Describe tasks associated with the closure of an Alternate Care Site Identify key tools for a healthcare surge.

4. Overview

5. 5 Organization of the Alternate Care Site Volume  Hard Copy is Split into two sections: Standards and Guidelines Operational Tools  Available on the CD ACS PowerPoint Training Instructor’s Manual with hints and tips on training

6. 6 A government-authorized Alternate Care Site is a location that is not currently providing healthcare services and will be converted to enable the provision of healthcare services to support, at a minimum, inpatient and/or outpatient care required after a declared catastrophic emergency includes facilities not currently licensed to provide healthcare services that, under the authority of local government, are designated as an Alternate Care Site to help absorb the patient load after all other healthcare resources are exhausted What is a Government-Authorized Alternate Care Site? Types of Government-Authorized Alternate Care Sites  Mobile Field Hospitals  Arenas  Schools  Churches  Shuttered Hospitals  Stadiums ACS Volume, Pages 12-14

7. 7 A government-authorized Alternate Care Site is NOT part of the expansion of an existing healthcare facility, such as  extensions of general acute care hospitals  clinics, or  long-term care facilities What is NOT a Government-Authorized Alternate Care Site? Government-Authorized Alternate Care Sites DO NOT include:  Tents set up for patient care in the parking lot of a hospital and under their control  Sites set up for patient triage by Emergency Medical Services  Any temporary space set up for patient care under the authority of an existing healthcare facility

8. 8  Patient care services will be established to absorb the patient load until the local healthcare system can manage the demands of patients during a healthcare surge.  Services will not include all services found in hospitals and will vary based on resource availability and event-specific patient needs and will take into account three considerations: Healthcare Surge Capacity of a Government-Authorized Alternate Care Site Patient TypeLevel of CareFacility Type  Inpatient/Outpatient  Critical Patients  Supportive Patients  Level of care will be driven by resource availability  At a minimum, inpatient/outpatient services will be provided  At a minimum, facility must have ability to provide inpatient/outpatient services

9. Establishment of a Government-Authorized Alternate Care Site

10. 10  A government-authorized Alternate Care Site will be established only when it is anticipated that all other healthcare resources are exhausted. When will a Government-Authorized Alternate Care Site be Established? Event ACS Volume, Page 24

11. 11  The Local Health Department has the responsibility to plan and coordinate the establishment a government-authorized Alternate Care Site. Authority to Establish Government-Authorized Alternate Care Sites  The operations of a government-authorized Alternate Care Site is the responsibility of the local government and is dependent upon the participation of government entities such as:  County Office of Emergency Services  Local Emergency Medical Services Agencies  Local Sherriff’s Offices  The setup and operations the government-authorized Alternate Care Site may also require significant participation from private entities. ACS Volume, Page 14

12. 12  Local Health Departments will need to formalize an Alternate Care Site Planning Team to plan and coordinate the establishment a government-authorized Alternate Care Site.  The Alternate Care Site Planning Team should include individuals with expertise in the following areas: The Alternate Care Site Planning Team  Disaster Response Coordination  Security  Emergency Management Coordination  Patient Transport  Organization of Clinical Care  Patient Information Management  Clinical Staffing  Procurement of Supplies  Facility Setup  Procurement of Pharmaceuticals  Facility Management and Operations  Procurement of Equipment  Engineering ACS Volume, Pages 16-17

13. Facility Selection

14. 14  Appropriate individuals will need to participate in the facility assessment, as the Alternate Care Site location is critical for successful operations.  The following are considerations for the designated Alternate Care Site Planning Team members as they assess potential Alternate Care Site locations:  Site Selection  Roadway Access and Security  Building Size Considerations  Building Security  Clinical Considerations  Physical Configuration Facility Selection ACS Volume, Pages 30-38

15. 15  Site Selection – Recommended structures include, but are not limited to shuttered hospitals, mobile field hospitals, airports, arenas, stadiums, fairgrounds, parks, schools, and churches  Roadway Access and Security – An Alternate Care Site should be accessible to at least two roadways to allow for continual access in the event that one roadway becomes blocked or inaccessible  Building Size Considerations - The building should be large enough to effectively care for patients; the exact allocation of space will be largely determined by the facility design Facility Selection

16. 16  Building Security – An Alternate Care Site should have limited number of entry ways that are readily controllable for security purposes  Clinical Considerations – It is important to consider the clinical care requirements necessary for treating patients when selecting a facility for an Alternate Care Site.  Physical Configuration – The physical configuration of an Alternate Care Site must be flexible to provide effective patient care. Patient care will be driven by the type of catastrophic event Facility Selection

17. Facility Operations

18. 18  The Alternate Care Site Planning Team should consider the needs for all of the following types of staff:  site setup  clinical  support  operations/incident command  Staffing plans must include enough staff for the first three to seven days of operation.  Acquisition of staff can be accessed through SEMS/NIMS and other staffing sources such as the American Red Cross and the California Medical Volunteers Staffing ACS Volume, Pages 42-74

19. 19 Staffing continued  Minimum levels of staff - Functions rather than actual classifications  List of Potential Staffing Solutions – key role for community planning  Maintaining Staff Workforce Resiliency Policies Protection of healthcare workers Behavioral Health Issues Family Preparedness – work site family care

20. 20  Effective planning requires participation from key healthcare personnel who are familiar with:  Pharmaceutical requirements for patient treatment  Methodology for the selection and acquisition process  Plans should include pharmaceuticals for at least the first 72 hours and two types of pharmaceuticals:  General pharmaceuticals  Event-specific pharmaceuticals  Acquisition of pharmaceuticals can be accessed through:  Operational Areas  Vendor-managed contracts Pharmaceuticals ACS Volume, Pages 82-91

21. 21  Effective planning requires an all-hazards approach and participation from key healthcare personnel who are familiar with:  Healthcare supply and equipment needs  Procurement strategies  Personal protective equipment must also be provided for all employees if necessary to provide protection during a healthcare surge.  Acquisition of supplies and equipment can be accessed through:  Vendor-managed contracts  CDPH Alternate Care Site Caches  Operational Areas Supplies and Equipment ACS Volume, Pages 91-105

22. 22  When an Alternate Care Site is activated, the staff will need to provide patient care in a manner that will save as many lives as possible.  Authority for patient healthcare management in an emergency is vested in the licensed or certified healthcare professional at the scene of the emergency who is most medically qualified specific to the provision of rendering emergency medical care.  If no licensed or certified healthcare professional is available, the authority of patient healthcare management is vested in the most appropriate medically qualified public safety agency representative who has responded to the scene of the emergency. Patient Management ACS Volume, Page 107

23. 23  An Alternate Care Site should be open to the public ONLY if, at a minimum, one armed guard is present at the time of opening.  Security processes should be established to:  Ensure the security of existing supplies, pharmaceutical and equipment inventory and caches by using personnel  Control access into and within the Alternate Care Site  Identify and track patients, staff and visitors  Work with local authorities prior to a healthcare surge to address heightened security needs and private security entities Security Services ACS Volume, Pages 108-116

24. 24  As soon as local government has authorized the establishment of an Alternate Care Site, an environmental crew should be the first staff at the site.  Environmental service staff should be considered to perform the following:  Clean the facility to bring it to sanitary standards for patient admission  Maintain sanitary water, air and other environment throughout the course of operations  Launder bedding and other cloth goods  Dispose of hazardous materials  Dispose of medical and other waste Environmental Services ACS Volume, Pages 117-118

25. Administration

26. 26  The following concepts should serve as guiding principles when developing processes for paper-based patient tracking:  Collect minimum necessary data  Assign patients a unique identifier  Patient tracking is a priority  Paper-based tracking is an essential contingency Patient Tracking ACS Volume, Pages 125-130

27. 27  Patient registration should include the minimum data elements for billing as reimbursement for operations will be based on time and materials.  Justification for time and material charges should be collected at the time of patient registration by documenting the numbers and types of patients treated. Patient Registration ACS Volume, Pages 131-134

28. 28  A paper-based medical records system will need to be established as a backup contingency and to ensure interoperability for several reasons:  An electronic medical record system would probably not be interoperable with the systems at the hospitals from which the patients originate (and possibly to which they return).  Electronic systems require hardware, software, technicians, and clinical personnel who are trained in that particular system. The equipment will most likely not be available on short notice, and staff coming from many other settings will not be familiar with the selected system.  An electronic system does not appear warranted because the Alternate Care Site will be in operation for only a few weeks. Medical Record Documentation ACS Volume, Pages 135-138

29. Activation and Closure

30. 30  Tasks for the activation of an Alternate Care Site entails:  Coordination with team members to ensure that the Alternate Care Site can be fully operational within 72 hours of the determination to activate  Activation of set-up process  Ensuring that at the time of opening, there is at a minimum: one armed guard, one physician and one nurse regardless of the size of the facility.  Contacting Alternate Care Site Director and operations chief  Contacting administrative staff Activation ACS Volume, Pages 149-152

31. 31  Tasks for the activation of an Alternate Care Site entails:  Assembling all applicable contracts for services and staff  Contacting and mobilizing staff for security, environmental, administrative, clinical and pharmaceutical services  Contacting vendors for supplies, pharmaceuticals and equipment to ensure smooth delivery  Facility assessment to ensure the structural integrity of the facility based on the type of emergency Activation (continued)

32. 32  The Local Health Department and Alternate Care Site operations personnel will use professional judgment to determine when to shut down an Alternate Care Site and oversee shut-down activities.  Shutdown of an Alternate Care Site will require removal of equipment and termination of ongoing contracts or arrangements. Closure of an Alternate Care Site ACS Volume, Page 153

33. Reimbursement

34. 34  Reimbursement for operations will be through local, State and Federal resources.  Office of Emergency Services will assist local jurisdictions with reimbursement from both State and federal emergency funds.  State funds are also available under the California Disaster Assistance Act and the Federal Emergency Management Agency funds. Reimbursement ACS Volume, Pages 147-148

35. Liability and Standby Orders

36. 36  Under the Emergency Services Act, liability protections are afforded to Alternate Care Site staff:  Disaster Service Workers  Licensed Physicians, Pharmacists, Nurses and Dentist acting as volunteers  Additional liability protections are afforded to volunteers under the following provisions of law:  Volunteer Protection Act of 1997  Government Code Section 8657  Standby Orders/Executive Orders may offer additional protections Immunities from Liability for Staff ACS Volume, Pages 74-80

37. 37  Government-authorized Alternate Care Sites are NOT a covered entity as defined by HIPAA and would not be covered under HIPAA.  California State privacy law pertaining to the privacy of information is expected to remain effective during healthcare surge.  Alternate Care Sites should take reasonable steps to ensure the privacy of identity and health information HIPAA and California State Privacy Law ACS Volume, Page 139

38. 38  During a healthcare surge, individuals providing healthcare services in an Alternate Care Site may be unable to fully adhere to statutes, regulations and professional standards of practice relating to patient rights and professional ethics.  Under the Emergency Services Act, the Governor may suspend those regulatory requirements perceived to be an obstacle to an effective emergency response effort through an executive standby order of the Governor. Standby Orders ACS Volume, Page 77-80

39. 39 Scope of Practice  Objectives: Flexibility in scope of practice of healthcare professionals to expand the capacity of the healthcare delivery system in a surge Liability protection for healthcare professionals and facilities that act outside their normal scope of practice to mitigate the impact of the emergency Reimbursement for healthcare services provided ACS Volume, Pages 74-80

40. 40 Government Code 8659  Government Code Section 8659. Any physician or surgeon (whether licensed in this state or any other state), hospital, pharmacist, nurse, or dentist who renders services during any state of war emergency, a state of emergency, or a local emergency at the express or implied request of any responsible state or local official or agency shall have no liability for any injury sustained by any person by reason of such services, regardless of how or under what circumstances or by what cause such injuries are sustained; provided, however, that the immunity herein granted shall not apply in the event of a willful act or omission.

41. 41 Solution for Scope of Practice  Executive Order issued by Governor which balances professional judgment and the appropriate authority for flexing scopes of practice  State health officer identifies which healthcare professionals will need to expand their scope of practice to mitigate the needs of the emergency  Local health officers and/or chief medical officers at a hospital direct healthcare providers under their authority to mitigate the medical needs caused by the emergency  Creating a flow of authority from the Governor, to the local operation person, to the actual healthcare provider will link the action to the protections of the Emergency Services Act

42. 42 Scope of Practice  Scope of Practice Standby Order It is hereby ordered that in the area proclaimed to be in a State of Emergency and/or that specific area(s) designated by the State Public Health Officer outside of the proclaimed area(s) but which is (are) essential to the relief and aid of the medical and health needs of the people within the proclaimed area, those rules that regulate the practice of licensed health care providers, including but not limited to ___________, ___________, shall be waived or amended as directed by the State Public Health Officer in order to increase the availability of acute medical care. Pursuant to the State Public Health Officer's actions, the local health officer, or chief medical officer at a hospital, shall direct health care providers under their authority to mitigate the medical needs caused by the emergency.

43. 43 Overview of Key Tools – Operational Tools Section of Binder  ACS Site Assessment Tool (page 3)  Sample Memorandum of Understanding (with Site Owners) (page 104)  Alternate Care Site Sample Estimated Staffing Levels (page 61)  List of Potential Staffing Resources (page 100)  ACS Patient Tracking From (page 47)  ACS Patient Registration Log (page 45)  ACS Short Form Medical Record (page 73)  Key Pharmaceuticals for Healthcare Surge (page 29)  Key Supplies and Equipment for Healthcare Surge (page 78)