1. Stephen P. Pickard MD Career Epidemiology Field Officer Assigned to North Dakota Department of Health Science and Public Health Practice Office Coordinating Office for Terrorism Preparedness and Emergency Response State-Facilitated Pandemic Influenza Planning for Health Care

2. OMB Disclaimer The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention

3. Acknowledgement Brenda Vossler, RN North Dakota Department of Health Derek Hanson St. Alexius Medical Center, Bismarck, ND Tim Wiedrich, MS North Dakota Department of Health

4. Methods Plans were derived using consensus of hospitals, not research methods Limited implementation detail  Lack of supporting data Conclusions are based on a set of assumptions  How the epidemic will unfold  How the health care system will respond

5. Assumptions Hospital bottom line:  “We can provide care most efficiently for the most patients with our own people in our own facility, even if we have to line the halls with stretchers.” HCW, not space, will be the limiting factor 1918 lesson: nursing care matters! ND pre-event resource acquisition  Stockpile medical supplies, not vents State cannot extend tort protection to private HCF

6. Planning Content Standards of care during a disaster Minimal care facilities State Medical Director Vaccine prioritization among hospital personnel Surge management (e.g., staffing, elective admits, transfer) Sheltering in place (e.g., utility loss, supply loss) Outpatient management (complicated by anti-virals) Medical supply cache use protocol Clinic management

7. Alternative Standards of Care Staged Reduction in Quality of Care

8. Standard of Care What is the liability of facilities offering less than usual care? What is the impact of various care reduction options and the preferred order of introduction? How can we measure relative hospital overload and how much overload can a hospital take? How do we time the opening of alternative inpatient care sites to maximize hospital utilization? How do we communicate altered standards of care to the public?

9. Standard of Care (SOC) Proposal: Hospitals petition NDDoH for change of SOC  Staged reduction: normal, I, II, III, and “minimum care”  Each stage associated with recommended actions  Transfer preferable to reduction in SOC  Overload formula based on weighted critical and non-critical care patient load and critical and non-critical nurse staffing level Usage  Control care? No Recognize change in capacity? Yes  Mandatory? No Provision of guidelines? Yes

10. Minimum Care Facilities Alternative Inpatient Care

11. Minimum Care Facilities Alternate inpatient, contagion facility (influenza only)  MCF preparation initiated by Stage III SOC declaration  Very low level of care – utter last resort State authorized, community operated, volunteer staffed Hydration, nutrition, hygiene for seriously ill who have:  No home care available, or  Dehydration, not able to take oral fluids

12. MCF: Concept of Operation Hospital preferentially takes non-influenza, treatable complications, pediatrics, mentally ill Open acute care floor (e.g., 120 patients) with assisted care in nearby rooms No limit on illness severity accepted Co-located with palliative care One licensed HCW per 12 hour shift

13. MCF: Concept of Operation State medical director  Authorizes MCF under state management guidelines and tort protection  Releases supplies and PPE from cache Hospital medical director assigns patients MCF medical director identifies patients most likely to benefit from transfer up to hospital Local ethical oversight

14. MCF: Concept of Operations Rehydration fluids via nasogastric tube  Can be “homemade”  Save IVF for hospitals Minimum invasion – NGT, IV, foley if needed  Volunteers uncomfortable even with that Few medications administered  If needed, use patient’s own meds down NGT No oxygen, No advanced care, No rescue care

15. Medical Director Limited Health Care System Management

16. Medical Director Hospitals want central policy coordination CEOs have agreed, in principle, to cede limited authority to a Medical Director  Located in DOC, Ops Section of NDDoH  Activated during governor-declared disaster  MOU to spell out specific authority  CEOs want clinicians in role (10 identified)

17. Medical Director Role Health care facility assistance Inter-hospital coordination (e.g., transfer, electives) State medical cache allocation Priority vaccine allocation Allocation of anti-virals Standard of care stage determination MCF authorization

18. Resources and Contact MCF concept paper and other policy documents available at request Stephen Pickard Career Epidemiology Field Officer, CDC Assigned to North Dakota spickard@nd.gov 701.328.2365