CAPT Holly Ann Williams Strengthening Emergency Response: Development of Standard Operating Procedures for Use in Federal Medical Stations CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist, CDC CDR Robin Bartlett Pharmacist, Indian Health Service LT Josef Otto Occupational Therapist, Department of Defense 2011 U.S. Public Health Service Scientific and Training Symposium New Orleans, LA 23 June 2011 Center for Global Health International Emergency and Refugee Health Branch

Outline Definition of a Standard Operating Procedure (SOP) Purpose Description and elements of a SOP Template and example of written format Federal Medical Stations Description of services Environment during an emergency response and importance of SOPs during deployments Development of SOPs by PHS Rapid Deployment Force (RDF) 3 : Types of SOPs

Definition: Standard Operating Procedure (SOP) Set of written instructions that document a routine or repetitive activity followed by an organization Key concepts: Prescribed procedures To be followed routinely Deviations should be noted Written for specific situations Should be easily understood by those required to use it Should be written by persons knowledgeable with the activity and organizational structure Source: EPA QA/G-6 April 2007, “Guidelines for Preparing Standard Operating Procedures (SOPs); http:// www.epa.gov/quality/qs-docs/g6-final.pdf FAO, “Guidelines for quality management in soil and plant laboratories, Chapter 2, Standard Operating Procedures, http://www.fao.org/docrep/w7295e/w7295e)4.htm.

Purpose of a SOP Promotes quality: Decreases variation and promotes quality through consistent implementation of activities for a given situation, regardless of personnel changes Provides officers with the information for how to function in their particular deployment role Describes how the various sections work together to complete necessary activities Illustrates expectations for performance - can be used in training new officers Offers the ‘ideal’ framework against which actual response activities can be compared: Can be used to frame “lessons learned”

Description of a SOP A “living” document: Should be reviewed routinely and re-enforced by command/section/branch leadership Concise, step-by-step and easy-to-read style: Keep it simple and short but have sufficient detail so that someone with limited experience could successfully understand it and perform the activity Flow charts or diagrams should illustrate processes when applicable Tactical in nature: How to perform in humanitarian response situations

Elements of a SOP Numbering system with a unique title: Version number with date of approval, date of last revision Implementation date Purpose of the SOP, which should match the title: “SOP – Patient Flow” Purpose: “The purpose of the SOP is to describe the process in which patients move through the Federal Medical Station from initial contact through discharge.” Scope: identify those individuals that will use the SOP or be affected by the process: Scope: “This SOP is applicable to RDF staff, volunteers, patients and caregivers.”

Elements: II Responsibilities - who does what by section/branch: You may need to add statement that additional staff would be pulled as necessary during a surge or exacerbated emergency situation Procedure – what will be done, described in present tense References – other material to support this activity: outside sources, other SOPs, checklists Definitions

SOP Template Standard Operating Procedure – 1. Purpose The purpose of this Standard Operating Procedure (SOP) is to describe the process in which…… 2. Scope This SOP is applicable to RDF staff, volunteers, patients, and caregivers. 3. Responsibilities Operations Section: Preventative Medicine Branch, Ancillary Services Branch, Patient Transport/Labor Pool:. Logistics Section Procedures:

SOP Template: II References http://www.apic.org/Content/Navigation Menu/EmergencyPreparedness/SurgeCapacity/Shelters_Disasters.pdf 6. Definitions RDF – Rapid Deployment Force - The RDF consists of five pre-identified teams, each comprising 105 or more multidisciplinary staff. The teams serve on a rotating call basis, with the on-call team capable of deploying within 12 hours of notification. RDF teams have a built-in command structure and can provide mass care at shelters (including FMSs), and staff Points of Distribution and Casualty Collection Points. The RDF can also conduct community outreach and assessments, among other functions.  

Why are SOPs Necessary in a Humanitarian Response?

FMS Prior to Patient Arrivals Credit: Williams, RDF 3, LSU Field House, Hurricane Gustav, 2008

FMS After Patients Arrive! Credit: Williams, RDF 3, LSU Field House, Hurricane Gustav, 2008

Credit: Williams, RDF 3, LSU Field House, Hurricane Gustav, 2008

Federal Medical Stations Designed as medical asset to offer scalable surge capacity for all-hazards casualty care events: Provides basic services for displaced populations Intended for low-acuity and special needs patients BUT reality means acuity level often much higher than anticipated Higher acuity patients create multiple challenges: Staffing level often inadequate for number and acuity of patients Patients tend to come in surges or waves: Need systems for triage , registration and provision of care by acuity level (red, yellow, green) Officers may be in their first deployment situations Pace is fast and stressful May be co-deployed with a Disaster Medical Assistance Team (DMAT) and/or local/state partners

Development of SOPs by RDF 3 Standardized, clear and concise guidance for staff was recognized as need: Prompted development of SOPs Original SOPs were developed through the Preventive Medicine Branches of all five RDFs but never approved by OFRD (2006): Animal health emergency support, APHT/RDF Collaboration, community health facility assessment, community outreach, community water assessment, FMS site selection, infectious diseases and hand washing, medical waste, solid waste, surveillance in the community, surveillance in the FMS, vectors, waste water, and water. Later, selected SOPs revised again in 2007 and 2009

Development of SOPs by RDF 3: II Current SOPs that have been sent to OFRD: Management of death in a FMS Infection control Patient flow and patient flow expanded (situation of disease outbreak) Red , yellow/green clinical areas Registration Triage Additional SOPs in development with RDF 3: Children in the FMS Patient referral to outside facilities Rapid needs assessments of existing health care facilities Special dietary needs Surge capacity in the FMS Violence in the FMS

Standard Operating Procedure – Patient Flow 1. Purpose Rapid Deployment Force #3 SOP # Revision # Implementation Date TBD Page # 1 of Last Reviewed/Update Date SOP Owner Operations Section Approval Standard Operating Procedure – Patient Flow 1. Purpose The purpose of this Standard Operating Procedure (SOP) is to describe the process in which patients move through the Federal Medical Station (FMS) from initial contact through discharge. 2. Scope This SOP is applicable to RDF staff, volunteers, patients, and caregivers. 3. Responsibilities Ancillary Services Branch, Medical Records Group: Complete the Patient Admission log on all new arrivals to the FMS. Register patients in the Electronic Medical Record (EMR). If EMR system is unavailable, plan a back-up “paper system” as deemed appropriate. Give all patients an armband for identification purposes. Preventative Medicine Branch: Assist with completing Patient Admission log and Surveillance Assessment/Triage Form on all new arrivals, to identify any potential infectious diseases or conditions requiring isolation. Medical Services Branch: Triage all new patients Determine bed availability and assign patients to beds Evaluate and treat patients Assist with establishing discharge plan in collaboration with staff from the Services Access Team (SAT), if available.

Standard Operating Procedure – Patient Flow 4. Procedure Rapid Deployment Force #3 SOP # Revision # Implementation Date TBD Page # 1 of Last Reviewed/Update Date SOP Owner Operations Section Approval Standard Operating Procedure – Patient Flow 4. Procedure The concept of patient flow will use the RAD model – Registration, Assessment, Discharge. The flow of patients within the FMS will move from Registration, to Assessment, and finally to Discharge. Each of the areas will have multiple components and assignments.   Registration - Enrollment Enrollment of the patients at the FMS will take place immediately after their arrival and be located at an identified patient entrance. RDF staff will complete the Patient Admission Log in written format to ensure accountability of all patients and provide a backup in the event the EMR is unavailable. RDF staff will enter all patients in the EMR. RDF staff will give each patient an armband for identification purposes and direct them to the Triage area.

Patient Flow-RAD Registration Assessment Discharge Patient processed into FMS Patient Evaluation and Treatment Return to Community or Transfer of Medical Care Registration Assessment Discharge

Patient Flow-RAD Registration Assessment Discharge Enrollment Triage Transport Patient Flow-RAD Assessment Bed Assignment Evaluation Treatment Discharge Discharge Plan Reestablish

Thank you to the original five Preventive Medicine Branches of the RDFs and the entire RDF 3 staff who have worked on various versions of the existing SOPs. Center for Global Health International Emergency and Refugee Health Branch