Mass Medical Care During an Influenza Pandemic: Establishing Influenza Care Centers PRESENTATION AND WORKBOOK NACCHO Advanced Practice Center (APC) Road Shows Albuquerque, New Mexico August 11-12, 2009

APC Toolkit

Toolkit Sections Concept of Operations Fatalities and Morgue Command and Control Communications Staffing and Training Clinical Standards, Protocols and Operations Infection Control Fatalities and Morgue Facilities Equipment and Supplies Security Transportation

Toolkit Tools

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.

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?

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?

ACS Planning Resources APC Toolkit – based on SCC’s ICC. http://www.sccgov.org/portal/site/phd/agencychp?path=%2Fv7%2FPublic%20Healt h%20Department%20(DEP)%2FAdvanced%20Practice%20Center%20(APC) CA Dept Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume 2 http://bepreparedcalifornia.ca.gov/NR/rdonlyres/640A3732-2667-4F61-B044- 413478888816/0/volume2_ACS_FINAL.pdf CA Government-Authorized Alternate Care Site Operational Tools Manual. http://bepreparedcalifornia.ca.gov/NR/rdonlyres/C2AD6528- F781-4D8C-B900-828A1C2C6F0C/0/Operational_ACS_Ops_Tool_FINAL.pdf Seattle-King County APC Video http://www.kingcounty.gov/healthservices/health/preparedness/%7e/med ia/health/publichealth/documents/hccoalition/AltCareVideo.ashx

Elements of Planning: Interconnected Decisions ALTERNATE CARE SITE PATIENT CARE & PROTOCOLS PATIENT “FLOW” FACILITY LAYOUT STAFFING NUMBER OF PATIENTS

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.

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).

ICC Pandemic Planning Assumptions: Illness, hospitalizations, fatalities 25-35% popn clinically ill 13-22% require hospitalization 2.5-5.0% fatalities 12 months w/illness, hospitalizations, fatalities evenly distributed each quarter.

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 ICU Average stay is 7 days in hospital or 10 days in ICU

Estimate # Patients, Sample – Albuquerque, New Mexico Estimated (Albuquerque) population 600,000 600,000 x .25 = 150,000 = # clinically ill 150,000 (# clinically ill) x .22 = 33,000 = # require hospitalization 33,000 (# require hospitalization) / 4 = 8,250 pts / quarter = (12-week pandemic “wave”)

Estimate # Beds for Flu Patients Sample – Albuquerque, New Mexico # of local area (Albuquerque) hospital beds University of New Mexico Hospital - 431 Heart Hospital of New Mexico - 55 Presbyterian Hospital - 453 The Children's Center at Presbyterian Hospital - 81 Lovelace Women's Hospital - 185 Kaseman Presbyterian Hospital – 252 Specialty Hospital of Albuquerque - 82 Kindred Hospital-Albuquerque – 61 Total = 1,519 beds In hospital surge, 50% for flu patients = 760 beds (total includes ICU beds).

Estimate # of ACS Patients, Sample – Albuquerque, New Mexico

Workbook – Estimate # Patients Estimated population: ________ _____ x .25 = ______ = # clinically ill _______ (# clinically ill) x .22 = ________ = # require hospitalization _______ (# require hospitalization) / 4 = ______ pts / quarter = (12-week pandemic “wave”)

Workbook: Estimate # Patients # of local area hospital beds __________ In hospital surge, 50% for flu patients = _________ beds (total includes ICU beds).

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.

Toolkit Sections Concept of Operations Fatalities and Morgue Command and Control Communications Staffing and Training Clinical Standards, Protocols and Operations Infection Control Fatalities and Morgue Facilities Equipment and Supplies Security Transportation

Concept of Operations Step 1 – Describe the ICC, Objectives Standard of Care Level of Care Step 2 – Operational Periods Step 3 – Activation Step 4 – De-activation

ICC Objectives Primary 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)

Standard of Care Standard 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)

Pandemic Levels of Care At Home Care Isolation Oral Hydration Oral Antibiotics Influenza Care Centers Intermediate Care IV & Oral Hydration Oxygen Nursing Services MD on call Hospital Admissions Critical Care Ventilators Ancillary Services

Level of Care Planning Decisions Patient Referrals Are patients transferred from hospitals? Can patients be referred by physicians? Can patients self refer? Transportation Do patients arrive by ambulance? Do patients arrive on their own? Care Acute Care Palliative Care Screened and Admitted? Outpatient Care?

Workbook: Level of Care Planning Decisions Estimated # patients_______ Level of Care at hospital (s) _________________ Level of Care at the ACS/ICC ________________

Operational Periods Define 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

ACS Activation Follows 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.

Workbook: Activation Describe how emergency operations are activated per NIMS. Who has authority to activate the ACS? What patients are admitted upon activation?

Deactivation Authority to de-activate. NIMS position to oversee deactivation. Exit strategy in catastrophic failure: Facility fire Civil unrest, gun fire Government, societal failure

Workbook: Deactivation Who has authority to deactivate the ACS? Which NIMS position oversees deactivation? Describe catastrophic failures that might occur:

2. Command/Control ICC organization Hospital Incident Command (HICS) USE TOOL #2 ICC organization Hospital Incident Command (HICS) Planning with: Hospital representatives Emergency management representatives Fire and Law enforcement Inventory managers

2. Command/Control USE TOOL #2 Step 1 – Describe relationship of ICC to Public Health Step 2 – Describe relationship between ICC to the EOC – Medical Health Branch Step 3 – Prepare organizational charts

ICC Organizational Chart General Staff ICC Division Manager Safety Officer Operations Section Chief Finance/Admin Section Chief (See below) Medical Care Branch Director Infrastructure Branch Director Security Branch Director Logistics Section Chief Planning Section Chief

County EOC - Operations Section Medical/Health Branch Director ACS Site Incident Commander* Safety Officer Operations Section Chief Medical Care Branch Director Clinical Support Branch Director Site Security Branch Director Logistics Section Chief Services Branch Director Support Branch Director Planning Section Chief Resource Unit Leader Situation Unit Leader Documentation Unit Leader Demobilization Unit Leader Finance/Admin Section Chief Time Unit Leader Compensation Claims Unit Leader Facility Liaison

Workbook – ICC Organization Chart USE TOOL #2 and TOOL #5 The ACS/ICC is a field operation of __________________. The ACS/ICC Incident Commander reports to ____________. Logistics and support is provided by: __________________________

3. Communications Step 1 – Determine ICC needs. USE TOOL #3 TOOL #18 Step 1 – Determine ICC needs. Step 2 – Describe methods. Step 3 – Consider communications: Within the ICC Between the ICC and other ICCs Between the ICC and hospitals/healthcare providers Between the ICC and the EOC

3. Communications Wireless Laptop Computer USE TOOL #3 TOOL #18 Wireless Laptop Computer (5) Portable 800 MHz radios (EMS Frequencies) Access to existing landline fax machines Access to existing landline phones Access to internet-accessible computers Access to a television with cable or satellite service Access to a radio Handheld Patient Tracking Devices Wireless router

4. Staffing and Training Step 1 – Determine staff ratios. USE TOOLS #4 and #5 Step 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.

4. Staffing and Training USE TOOLS #4 and #5 Local 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.

4. Staffing and Training USE TOOLS #4 and #5 The recommended staffing patterns are based on the following scenario for Santa Clara: Total number of patients per ICC = 450 12-hour shifts for all staff Patient 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.

4. Staffing the ICC USE TOOLS #4 and #5

Workbook: Staffing Number of patients (beds) in the ICC = (#) USE TOOLS #4 and #5 Number of patients (beds) in the ICC = (#) Using staffing ratio chart, determine staffing ratios to be used. Review and revise Tool #5 Job Action Sheets Identify community support for staffing.

Workbook: Staffing USE TOOLS #4 and #5 ACS Staffing Ratios Position Staff-Pt Ratio ICC (450) Santa Clara (Toolkit Example SCC needs twelve 450 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 Ratio Medical Doctors 1: 50-60 8-9 per ICC 1-2 Registered Nurses 1: 15-20 23-30 per ICC 5-7 Respiratory Therapists 1: 20-30 15-23 per ICC 3-5 Care Givers (Health Technicians) 1: 5 90 per ICC 20 Clerical 1: 20 23 per ICC 5 Social Workers 1: 60 8 per ICC 2 Pharmacists

4. Training ICC Orientation – Just in Time Training USE TOOLS #4 and #5 ICC Orientation – Just in Time Training Pre-event Clinical Operations Training – Public Health Clinical ICC Staff Pre-event Clinical Skills Training 

5. Clinical Standards, Protocols and Operations Standing Orders General Admitting Asthma Heart Failure Diabetes Pregnancy Palliative Care Clinical Triage Oxygen Delivery Alternatives Insulin and Blood Glucose Monitoring Sheet Pharmacy Order Form Patient disposition log ICC Intake Assessment Form

Elements of Planning: Interconnected Decisions ALTERNATE CARE SITE PATIENT CARE & PROTOCOLS PATIENT “FLOW” FACILITY LAYOUT STAFFING NUMBER OF PATIENTS

5. Clinical Standards, Protocols and Operations Step 1 – Develop triage guidelines. Step 2 – Describe admissions/intake process. Step 3 – Describe pt./bed tracking. Step 4 – Define documentation and patient charting. Step 5 – Describe daily evaluation. Step 6 – Describe pharmacy formulation protocols. Step 7 – Describe discharge criteria/procedures. Step 8 – Develop visiting rules/regulations. Step 9 – ID housekeeping/environmental services.

5. Clinical Protocols & Patient Care Tools USE ALL THESE TOOLS

5. Patient Care Triage guidelines and admission Admission/intake process Standardized Orders Admission protocols Bed and patient tracking Medical records/patient charts Daily evaluation and treatment Transfer dispositions

5. Patient Care Pharmacy protocols Discharge protocols Family care giving guidelines Visitor guidelines Environmental services

Workbook: Clinical Protocols and Patient Care Convene a workgroup: physicians, RNs, EMS Determine patient care “flow” Review protocols Santa Clara County in the APC Toolkit New York Medical College, School of Public Health

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.

Facility Criteria USE TOOL #28 and #29

SCC’s ICC Facility Requirements Substantial square footage with large open areas. Sites geographically distributed around the county. Hotels: surge support.

ACS Ward Layout USE TOOL #28 and #29

ACS Bay Layout USE TOOL #28 and #29

Workbook – Facilities USE TOOL #28 and #29 List facilities that may be used as an ACS/ICC in your area:

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.

7. Fatalities - Morgue Step 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)

9. Equipment & Supplies USE TOOL #3 Step 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.

Equipment & Supplies Warehouse Storage Electrical items – on shelves, plugged in, temperature controlled area Maintenance 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.

10. Security Step 1 - Describe role of Security at ICC. USE TOOL #28 and #29 Step 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 Interface Step 6 – ID sources of security personnel.

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.

Crowd Control/Traffic Control High volumes of ill people. Highly emotional people. Neighborhood concerns. Protestors, provide escorts. Patient parking Staff parking. Patient loading/unloading. Ambulance Delivery Media area.

11.Transportation Step 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

Contacts Olivia Nunez Santa Clara County Public Health Preparedness 976 Lenzen Avenue San Jose, CA 95126 (408) 792-5266 sccphd.org/APC Laurie Friedman SYA Group, Inc. 1126 Broadway, Suite 4 Burlingame, CA 94010 650-373-7747 Laurie@syagroup.com Rocio Luna, MPH Director, PH Preparedness and Data Management Santa Clara County Public Health Department 976 Lenzen Avenue San Jose, CA 95126 Main Line (408) 792-5040