1. No Vacancy: Healthcare Surge Capacity in Disasters John L. Hick, MD MDH/HCMC July 22, 2004

2. 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 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’ Surge Capability – ‘the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions’ Barbera and Macintyre Barbera and Macintyre

3. Different types of ‘surge’ Unexpected vs. expected Unexpected vs. expected Timeline and potential for secondary cases (anthrax vs. plague) Timeline and potential for secondary cases (anthrax vs. plague) Static vs. dynamic Static vs. dynamic Triage / field treatment Triage / field treatment Healthcare facility-based Healthcare facility-based Community-based Community-based

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

5. HCF AHCF CHCF B Healthcare Facility 1 st Tier 2 nd Tier Healthcare “Coalition” (Compact) Jurisdiction I (PH/EM/Public Safety) Non-HCF Providers Medical Support 3 rd Tier Jurisdiction Incident Management (County) 4 th Tier Jurisdiction II (PH/EM/Public Safety) Coordination of Intrastate Regions (MDH) 5 th Tier Federal Response 6 th Tier State / Interstate Coordination (MDH) State AState B Federal Response (Regional & National) Tiers of Response – Patient Care

6. Minnesota Local Public Health Regions HRSA Grant

7. Minnesota Hospital Resources Minnesota Hospital Resources 140 acute care hospitals 140 acute care hospitals State total 16,414 licensed beds State total 16,414 licensed beds Less than 50% of these operating Less than 50% of these operating Loss of 36 hospitals, 3000 beds in past 20 yrs Loss of 36 hospitals, 3000 beds in past 20 yrs Nearly half of MN hospitals are either ‘critical access’ or considering such designation Nearly half of MN hospitals are either ‘critical access’ or considering such designation Staff shortages, particularly nursing staff Staff shortages, particularly nursing staff

8. Metropolitan Hospital Compact Since April 9, 2002 Since April 9, 2002 27 hospitals, approximately 4800 operating beds 27 hospitals, approximately 4800 operating beds 7 counties 7 counties Agreement provides for: Agreement provides for: Staff and supply sharing Staff and supply sharing Staffing off-site facilities for first 48h Staffing off-site facilities for first 48h Communications, JPIC Communications, JPIC Regional Hospital Resource Center (HCMC) Regional Hospital Resource Center (HCMC)

9. Regional Coordination Regional Hospital Resource Center (RHRC) Regional Hospital Resource Center (RHRC) Acts as ‘broker’ for patient transfers Acts as ‘broker’ for patient transfers Coordinates hospital response and requests within region Coordinates hospital response and requests within region Represents hospital needs and issues to RCC Represents hospital needs and issues to RCC Regional Coordination Center (RCC or MAC) Regional Coordination Center (RCC or MAC) Multi-agency coordination center for policy and strategic guidance Multi-agency coordination center for policy and strategic guidance NO jurisdictional authority NO jurisdictional authority Functions and scope determined by incident Functions and scope determined by incident

10. Hospital Response Hospital Response At least 50% arrive self-referred At least 50% arrive self-referred On average, 67% of patients in any given disaster are cared for at the hospital nearest the event (range 41-97%) On average, 67% of patients in any given disaster are cared for at the hospital nearest the event (range 41-97%) Redistribution from the hospital closest to the incident scene to other facilities may be as (or more) important than transport from the scene Redistribution from the hospital closest to the incident scene to other facilities may be as (or more) important than transport from the scene

11. Facility-based Surge Usually can free up 15% of beds at a given facility Usually can free up 15% of beds at a given facility Get ‘em up and get ‘em out (ED, clinics) Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home) Discharges and transfers (eg: nursing home) Board patients in halls Board patients in halls Cancel elective procedures Cancel elective procedures Convert procedure/PACU areas to patient care Convert procedure/PACU areas to patient care Accommodate vents on floor (or BVM or austere O2 flow powered ventilators) Accommodate vents on floor (or BVM or austere O2 flow powered ventilators) Supply and staffing issues (72h ahead) Supply and staffing issues (72h ahead)

12. Per 1000 patients injured Per 1000 patients injured 250 dead at scene 250 dead at scene 750 seek medical care 750 seek medical care 188 admitted 188 admitted 47 to ICU 47 to ICU ‘Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11 ‘Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11

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

14. Potential Alternative Care Sites Aircraft hangers Aircraft hangers Military facilities Military facilities Churches Churches National Guard armories National Guard armories Community/recreation centers Community/recreation centers Surgical centers / medical clinics Surgical centers / medical clinics Convalescent care facilities Convalescent care facilities Sports facilities / stadiums Fairgrounds Trailers Government buildings Tents Hotels/motels Warehouses Meeting halls

15. Factors to consider Ability to lock down/Security Ability to lock down/Security HVAC HVAC Lab/specimen handling Lab/specimen handling Lighting Lighting Laundry Laundry Loading Dock Loading Dock Equipment storage Equipment storage Oxygen delivery capability Oxygen delivery capability Waste disposal Waste disposal Parking Parking Communications capability Communications capability Patient decon Door size Pharmacy areas Electrical power with backup Proximity to hospital Family areas Toilets/showers/waste Food supply / prep area Water supply Wired for IT/Internet access

16. Off-site hospital Triage / admission criteria Triage / admission criteria Level of care – basic nursing, drip meds, IVs, NG feeds Level of care – basic nursing, drip meds, IVs, NG feeds Medications Medications Documentation / order management Documentation / order management Laboratory Laboratory Food / water / sanitary Food / water / sanitary Linen and medical waste handling Linen and medical waste handling Oxygen? Oxygen?

17. Personnel Augmentation Personnel Augmentation Hospital personnel Hospital personnel Clinic personnel Clinic personnel Medical Reserve Corps Medical Reserve Corps Non-clinical practice professionals Non-clinical practice professionals Retired professionals (eg: HC Medical Society) Retired professionals (eg: HC Medical Society) Trainees in health professions Trainees in health professions Ski patrol, civil air patrol, other service organizations Ski patrol, civil air patrol, other service organizations Lay public (CERT teams, etc) Lay public (CERT teams, etc) Federal / interstate personnel Federal / interstate personnel

18. Sample Site

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

20. Resources Off-site matrix: www.denverhealth.org/bioterror/tools Off-site matrix: www.denverhealth.org/bioterror/tools www.denverhealth.org/bioterror/tools MaHIM: www.gwu.edu/~icdrm MaHIM: www.gwu.edu/~icdrmwww.gwu.edu/~icdrm Model hospital planning: www.er1.org Model hospital planning: www.er1.orgwww.er1.org Off-site facilities and community planning: www2.sbccom.army.mil/hld/bwirp/ Off-site facilities and community planning: www2.sbccom.army.mil/hld/bwirp/ Annals of Emergency Medicine www.mosby.com/aem ‘articles in press’ (left side) Annals of Emergency Medicine www.mosby.com/aem ‘articles in press’ (left side) www.mosby.com/aem