2 Mass Medical Care During an Influenza Pandemic: Establishing Influenza Care Centers PRESENTATION AND WORKBOOKNACCHO Advanced Practice Center (APC) Road Shows Albuquerque, New Mexico August 11-12, 2009
4 Toolkit Sections Concept of Operations Fatalities and Morgue Command and ControlCommunicationsStaffing and TrainingClinical Standards, Protocols and OperationsInfection ControlFatalities and MorgueFacilitiesEquipment and SuppliesSecurityTransportation
6 Today’s Objectives Present highlights of the toolkit. Focus on your local area requirements for mass medical care.Use the workbook to start your planning.
7 What Are Expectations or Requirements? In California:Hospitals surge to care for seriously ill or injured.Public health activates ACS/ICCs to care for moderately acute ill or injured patients, thereby taking the load off hospitals.(Originally, hospitals were expected to set up and run the ACS...).What are State-wide expectations or requirements for ACS activation?
8 What’s the Status of Current Planning ? Healthcare Surge Plan (area-wide)?Hospital surge plans?Mass dispensing site (s) operational plan?Alternate Care Site (ACS) operational plan?
9 ACS Planning Resources APC Toolkit – based on SCC’s ICC. h%20Department%20(DEP)%2FAdvanced%20Practice%20Center%20(APC)CA Dept Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume /0/volume2_ACS_FINAL.pdfCA Government-Authorized Alternate Care Site Operational Tools Manual. F781-4D8C-B A1C2C6F0C/0/Operational_ACS_Ops_Tool_FINAL.pdfSeattle-King County APC Video ia/health/publichealth/documents/hccoalition/AltCareVideo.ashx
10 Elements of Planning: Interconnected Decisions ALTERNATE CARE SITEPATIENT CARE & PROTOCOLSPATIENT “FLOW”FACILITY LAYOUTSTAFFINGNUMBER OF PATIENTS
11 Influenza Care Centers (ICC) For pandemic planning, Santa Clara County established the concept of Influenza Care Centers (ICC).ICCs are alternative care sites designed to address the needs of moderate acuity patients in a pandemic.
12 ICC Pandemic Planning Assumptions: Local hospital capacity will not meet hospitalization demand:Bed capacity limits (adult and pediatric acute care, adult critical care, pediatric & neonatal critical care).Ventilator limits (all ventilators, including disposable, mass casualty ventilators).
14 Surge and Capacity Challenges With hospital interventions to expand capacity, assume 50% of beds in any one hospital available for flu patients (other variables include: ill staff, other illnesses/trauma, waiving of license requirements)These charts show that by the third week of a pandemic, there will be a need for 461 beds for the sick that will not be available.10% of hospitalizations require ICUAverage stay is 7 days in hospital or 10 days in ICU
19 Workbook: Estimate # Patients # of local area hospital beds __________In hospital surge, 50% for flu patients= _________ beds (total includes ICU beds).
20 Workbook: Estimate # ACS/ICC Patients # beds available for flu patients _______________# patients / quarter = __________Figure % of pts/qtr for each week. (Use %’s shown).Identify peak weeks.Subtract # beds available from the #hospitalized (cumulative – add the weeks up to and including the peak week).This is the number to plan for at the ACS/ICC.
21 Toolkit Sections Concept of Operations Fatalities and Morgue Command and ControlCommunicationsStaffing and TrainingClinical Standards, Protocols and OperationsInfection ControlFatalities and MorgueFacilitiesEquipment and SuppliesSecurityTransportation
22 Concept of Operations Step 1 – Describe the ICC, Objectives Standard of CareLevel of CareStep 2 – Operational PeriodsStep 3 – ActivationStep 4 – De-activation
23 ICC ObjectivesPrimary objectives for the establishment of an ICC include, but are not limited to, the following:Decompression of acute care hospital inpatient beds (receiving site for hospital discharge patients who are not able to be cared for at home)Used instead of acute care hospital inpatient beds (inpatient care for moderate-acuity patients and palliative care)
24 Standard of CareStandard of care during a healthcare surge is the utilization of skills, diligence and reasonable exercise of judgment in furtherance of optimizing population outcomes that a reasonably prudent person or entity with comparable training, experience or capacity would have used under the circumstances. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes*.California Department of Public Health (CA DPH)
25 Pandemic Levels of Care At Home CareIsolationOral HydrationOral AntibioticsInfluenza Care CentersIntermediate CareIV & Oral HydrationOxygenNursing ServicesMD on callHospital AdmissionsCritical CareVentilatorsAncillary Services
26 Level of Care Planning Decisions Patient ReferralsAre patients transferred from hospitals?Can patients be referred by physicians?Can patients self refer?TransportationDo patients arrive by ambulance?Do patients arrive on their own?CareAcute Care Palliative CareScreened and Admitted?Outpatient Care?
27 Workbook: Level of Care Planning Decisions Estimated # patients_______Level of Care at hospital (s) _________________Level of Care at the ACS/ICC ________________
28 Operational PeriodsDefine and describe the Operational Periods in terms of a likely pandemic cycle and daily operation.It is anticipated that an ICC will be operational from eight to fourteen weeks for the first wave of a pandemic influenza event and then for an additional eight to twelve weeks during the second wave.Operational periods = 12 hours.Staffing
29 ACS ActivationFollows area’s event/emergency activation procedures per NIMs.Authority to activate/operational policy:The Health Officer will notify the local officials of the intent to activate and then coordinate implementation through the Medical-Health Branch of the Operational Area Emergency Operations Center. Positions in the ICC are filled according to National Incident Management System (NIMS). Once ICCs have been activated, only patients routed to ICCs or those triaged on-site for admission will be accepted. Patients that are admitted to an acute care hospital at the time the ICC is activated will remain in the acute care facility and will not be transferred to an ICC.
30 Workbook: ActivationDescribe how emergency operations are activated per NIMS.Who has authority to activate the ACS?What patients are admitted upon activation?
31 Deactivation Authority to de-activate. NIMS position to oversee deactivation.Exit strategy in catastrophic failure:Facility fireCivil unrest, gun fireGovernment, societal failure
32 Workbook: Deactivation Who has authority to deactivate the ACS?Which NIMS position oversees deactivation?Describe catastrophic failures that might occur:
33 2. Command/Control ICC organization Hospital Incident Command (HICS) USE TOOL #2ICC organizationHospital Incident Command (HICS)Planning with:Hospital representativesEmergency management representativesFire and Law enforcementInventory managers
34 2. Command/ControlUSE TOOL #2Step 1 – Describe relationship of ICC to Public HealthStep 2 – Describe relationship between ICC to the EOC – Medical Health BranchStep 3 – Prepare organizational charts
36 County EOC - Operations Section Medical/Health Branch Director ACS Site Incident Commander*Safety OfficerOperations Section ChiefMedical Care Branch DirectorClinical Support Branch DirectorSite Security Branch DirectorLogistics Section ChiefServices Branch DirectorSupport Branch DirectorPlanning Section ChiefResource Unit LeaderSituation Unit LeaderDocumentation Unit LeaderDemobilization Unit LeaderFinance/Admin Section ChiefTime Unit LeaderCompensation Claims Unit LeaderFacility Liaison
37 Workbook – ICC Organization Chart USE TOOL #2 and TOOL #5The ACS/ICC is a field operation of __________________.The ACS/ICC Incident Commander reports to ____________.Logistics and support is provided by: __________________________
38 3. Communications Step 1 – Determine ICC needs. USE TOOL #3 TOOL #18Step 1 – Determine ICC needs.Step 2 – Describe methods.Step 3 – Consider communications:Within the ICCBetween the ICC and other ICCsBetween the ICC and hospitals/healthcare providersBetween the ICC and the EOC
39 3. Communications Wireless Laptop Computer USE TOOL #3 TOOL #18Wireless Laptop Computer(5) Portable 800 MHz radios (EMS Frequencies)Access to existing landline fax machinesAccess to existing landline phonesAccess to internet-accessible computersAccess to a television with cable or satellite serviceAccess to a radioHandheld Patient Tracking DevicesWireless router
40 4. Staffing and Training Step 1 – Determine staff ratios. USE TOOLS #4 and #5Step 1 – Determine staff ratios.Step 2 – Describe functional roles. (Tool 4 – Functional Roles Matrix)Step 3 – Determine training requirements for categories of positions.Step 4 – Identify types of support staff needed.
41 4. Staffing and TrainingUSE TOOLS #4 and #5Local public health agency employees will not be sufficient for staffing the ICCs. The broader health care community, city governments, and community volunteers must provide human resources to ensure adequate staffing of the ICCs.
42 4. Staffing and TrainingUSE TOOLS #4 and #5The recommended staffing patterns are based on the following scenario for Santa Clara:Total number of patients per ICC = 45012-hour shifts for all staffPatient population includes 50% patients on IV fluids (n=225) and 60% on Oxygen via nasal cannula (n=270)Each ICC is divided into sections (treatment units) of up to 40 patients each.
44 Workbook: Staffing Number of patients (beds) in the ICC = (#) USE TOOLS #4 and #5Number of patients (beds) in the ICC = (#)Using staffing ratio chart, determine staffing ratios to be used.Review and revise Tool #5 Job Action SheetsIdentify community support for staffing.
45 Workbook: Staffing USE TOOLS #4 and #5 ACS Staffing Ratios Position Staff-Pt RatioICC (450) Santa Clara (Toolkit Example SCC needs twelve bed ICCs )ICC (100) (22% of SCC ICC)(Any town, USA Example)ICC (___) = ___ % of SCC ICC (450)Staff Ratio as % of SCC’s Staff-Patient RatioMedical Doctors1: 50-608-9 per ICC1-2Registered Nurses1: 15-2023-30 per ICC5-7Respiratory Therapists1: 20-3015-23 per ICC3-5Care Givers (Health Technicians)1: 590 per ICC20Clerical1: 2023 per ICC5Social Workers1: 608 per ICC2Pharmacists
46 4. Training ICC Orientation – Just in Time Training USE TOOLS #4 and #5ICC Orientation – Just in Time TrainingPre-event Clinical Operations Training – Public Health Clinical ICC StaffPre-event Clinical Skills Training
47 5. Clinical Standards, Protocols and Operations Standing OrdersGeneralAdmittingAsthmaHeart FailureDiabetesPregnancyPalliative CareClinical TriageOxygen Delivery AlternativesInsulin and Blood Glucose Monitoring SheetPharmacy Order FormPatient disposition logICC Intake Assessment Form
48 Elements of Planning: Interconnected Decisions ALTERNATE CARE SITEPATIENT CARE & PROTOCOLSPATIENT “FLOW”FACILITY LAYOUTSTAFFINGNUMBER OF PATIENTS
50 5. Clinical Protocols & Patient Care Tools USE ALL THESE TOOLS
51 5. Patient Care Triage guidelines and admission Admission/intake processStandardized OrdersAdmission protocolsBed and patient trackingMedical records/patient chartsDaily evaluation and treatmentTransfer dispositions
52 5. Patient Care Pharmacy protocols Discharge protocols Family care giving guidelinesVisitor guidelinesEnvironmental services
53 Workbook: Clinical Protocols and Patient Care Convene a workgroup: physicians, RNs, EMSDetermine patient care “flow”Review protocolsSanta Clara County in the APC ToolkitNew York Medical College, School of Public Health
54 8. Facilities Step 1 - Determine criteria for facility selection. Step 2 – List recommended facilities.Step 3 – Diagram ICC layout.Step 4 – ID other required facility areas needed.Step 5: Conduct a site visit; coordinate with facility operators.
59 Workbook – FacilitiesUSE TOOL #28 and #29List facilities that may be used as an ACS/ICC in your area:
60 6. Infection Control Step 1 – Determine necessary PPE for ICC staff. Step 2 – Determine necessary PPE for ICC visitors.Step 3 – Describing environmental cleaning procedure(s).Step 4 – Develop procedures for disposal of biohazard waste.
61 7. Fatalities - MorgueStep 1 – ID operational area for temporary morgue.Step 2 – ID required equipment/supplies.Step 3 – Determine type of staffing.Step 4 – Describe how bodies are transferred.Step 5 – Describe personal property procedure.(See Mass Fatality Toolkit)
62 9. Equipment & SuppliesUSE TOOL #3Step 1 – Develop inventory list, consider local resources & scope of ACS/ICC care.Step 2 – Determine storage and maintenance.Step 3 – Describe process for implementing: ordering and moving supplies.
64 Equipment & Supplies Warehouse Storage Electrical items – on shelves, plugged in, temperature controlled areaMaintenance items (i.e. Glucometer) need periodic inspection, stored in bulk containers, temperature controlled.Pharmaceuticals, temperature controled or in refrigerator.Stack-limited items, heavy/bulky, palletized, stored on pallet racks, 10’ wide aisles.Bulk items, smaller, lighter, easily damaged, stored in bulk containers, stacked densely, w/o aisles.
65 10. Security Step 1 - Describe role of Security at ICC. USE TOOL #28 and #29Step 1 - Describe role of Security at ICC.Step 2 – Describe Access Control.Step 3 – Describe Crowd Control.Step 4 – Describe Traffic Control.Step 5 – Describe role of Law Enforcement InterfaceStep 6 – ID sources of security personnel.
66 Access Control Staff, visitors, support, media, officials. Anticipate theft of pharmaceuticals, medical supplies.Anticipate individuals who try to surreptitiously remove a patient or bring a patient in to the ICC.Anticipate media attempting entry.Badging, log-in and out.
67 Crowd Control/Traffic Control High volumes of ill people.Highly emotional people.Neighborhood concerns.Protestors, provide escorts.Patient parkingStaff parking.Patient loading/unloading.AmbulanceDeliveryMedia area.
68 11.TransportationStep 1 – Describe policy for transporting patients to the ICC.Step 2 – Describe policy for transporting from the ICC to hospital.Step 3 – Describe how transportation requirement will be met.Step 4 – Describe communications for transportation operations.Planning with OEM Logistics
69 ContactsOlivia Nunez Santa Clara County Public Health Preparedness 976 Lenzen Avenue San Jose, CA (408) sccphd.org/APC Laurie Friedman SYA Group, Inc Broadway, Suite 4 Burlingame, CARocio Luna, MPH Director, PH Preparedness and Data Management Santa Clara County Public Health Department 976 Lenzen Avenue San Jose, CA Main Line (408)