1. Medical Surge Capacity Planning Strategies Robert Gougelet, MD

2. Overview Review NH Medical Surge Guidelines for All Health Hazards Regions (AHHRs) Review the Modular Emergency Medical System (MEMS) Exercise Operation PREP overview Medical Surge Capacity Plan Template Planning Strategies for tough spots:  Space, Staff, Supplies Questions

3. Before we get started… There is no such thing as a stupid question The ultimate goal of this planning process is to prevent as much injury, illness, and death as possible during a public health emergency Keep this in mind when it gets hard and you want to quit

4. Definitions Medical Surge Capacity “The quantifiable amount of community or regional resources and services available for providing medical care in emergencies that overwhelm the normal medical infrastructure (through numbers or types of patients or loss of infrastructure).” Source: NH Medical Surge Capacity Guidelines

5. Definitions The Modular Emergency Medical System (MEMS) A conceptual framework for managing a surge in patients requiring triage, prophylaxis, or inpatient care Components include:  Neighborhood Emergency Help Center (NEHC)  Acute Care Center (ACC)  Medical Command & Control  Casualty Transportation System  Community Outreach  Mass Prophylaxis (PODs)  Public Information Source: NH Medical Surge Capacity Guidelines

6. Home Private MDs & Clinics Triage/Treatment START Neighborhood Emergency Help Centers (NEHC) Outpatient Triage Patient Registration Patient Information Transportation, Logistics Pharmaceuticals, Administration Community Outreach Treatment/Support Isolation at Home Door to Door Citizen Mobilization Acute Care Centers (ACC) Inpatient Acute Triage/Treatment Care & Comfort Area Hospitals Acute Triage/Treatment Medical Command Centers Fatality Management Casualty Transportation System Non-Infectious Patients Communication & Coordination Incident Patients & Worried Well

7. Definitions Neighborhood Emergency Help Center (NEHC) Intended to serve outpatient needs in a medical surge event Functions can include:  Distribution of self-help information and instruction for home care  Triage for large numbers of people seeking care  Distribution of mass prophylaxis During an infectious disease event, ill or infected individuals should not be in contact with individuals seeking information or coming to a POD. The NEHC must be separate from a POD in this case

8. Definitions Acute Care Center (ACC) Provides medical care in a community-based setting Provides limited care to patients that generally would require hospitalization Designed to provide the most good for the greatest number of people when there are limited resources Designed to care for patients until the regional healthcare system can take care of the extended load The ACC may also provide mass isolation of individuals who cannot be isolated in their own homes

9. Definitions Buildings of Opportunity Large facilities, not normally used for health care services, but which have the basic utilities needed to support medical functions Ideally have internal systems to handle medical oxygen and vacuum capability – but this is unlikely Common buildings of opportunity include schools, gymnasiums, and community centers

10. Definitions Medical Command and Control Medical Command and Control is assumed by a single hospital within the affected area Provides medical command, oversight, administrative assistance, technical supervision, and consultation services in support of health and medical response operations

11. Medical Surge Tiered Response New Hampshire has adopted the federal Medical Surge Capacity & Capability (MSCC) Management System The 6 Tiers are: 1) Individual healthcare assets 2) Healthcare coalitions (i.e. New Hampshire Hospital Association) 3) Sub-state regional (AHHRs) 4) State 5) Interstate 6) Federal Tier 3 is defined as interagency coordination at the regional level to facilitate patient care and staff surge capacity needs Source: NH Medical Surge Capacity Guidelines

12. Activation of Tiered Response An ACC or NEHC may be opened under 2 scenarios:  A Public Health Incident is declared (RSA 508:17-a)  The Governor has issued a State of Emergency (RSA 4:45) The local Emergency Operations Center (EOC) or Regional multi-agency command entity (MAC) has the authority and responsibility to open an ACC / NEHC

13. AHHR Facility Selection Identify buildings of opportunity in your region Consider developing memoranda of understanding (MOUs) to ensure that buildings of opportunity will be available during an event Consider other uses for the same facility that may affect its availability (i.e. Red Cross shelter) Aim to identify 2 separate locations capable of hosting an ACC and an NEHC, allowing for simultaneous operation Ensure your plan includes procedures for activation, notification, and opening the facilities

14. AHHR Facility Staffing The type of event, number of victims, and the care required will determine the number and type of individuals required to staff the ACC / NEHC / PODs Healthcare providers may be in extremely short supply The local hospital(s) will not have the capacity to be the primary provider of staff to the facilities

15. AHHR Facility Staffing Consider local sources of medical / healthcare volunteers:  Local medical providers: off-duty or non-emergency volunteers  Developing or enhancing local Medical Reserve Corps (MRC) units  Expanded groups of providers: vets, dentists, medical/nursing students Consider additional / State sources of medical volunteers:  Metropolitan Medical Response System (MMRS) Strike Teams  NH ESAR-VHP system: Emergency System for the Advance Registration of Volunteer Health Professionals

16. AHHR Facility Staffing Non-medical, community volunteers should be used to do a variety of tasks:  Registration  Housekeeping  Food service  Transportation  Family services Consider sources of non-medical volunteers:  Local volunteer organizations: Community Emergency Response Teams (CERT), civic and faith-based organizations  Pre-established volunteer lists  Spontaneous volunteers

17. AHHR Supplies Regions are expected to maintain critical equipment and supplies to provide ACC care for 50+ patients (or 1 per 1,000 population) for 72 hours A limited cache of supplies may be available from one of the trailers purchased by the State Regions may request supplies from the State Critical and comprehensive medical equipment lists have been provided to AHHRs  Including: cots, blankets, IV supplies, and PPE

18. The Incident Command System (ICS) Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

19. ICS Sections Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

20. ICS Overview Is a standardized management tool for meeting the demands of all sizes of emergencies Represents "best practices" and has become the standard for emergency management across the country May be used for planned events, natural disasters, and acts of terrorism Is a key feature of the National Incident Management System (NIMS) Anyone who may have a leadership role in a public health emergency should receive ICS training Source: http://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdfhttp://www.training.fema.gov/EMIWeb/IS/ICSResource/assets/reviewMaterials.pdf

21. Putting it all together…

22. Medical Surge Functional Exercise: Operation PREP Upper Valley AHHR Wednesday, November 15 th, 2006 Functional exercise to practice integration of multiple partners during a medical surge event Cooperation of multiple organizations is key to a successful response Organizations that don’t work together will have to during a disaster Practice (drills and exercises) will ensure this collaboration and cooperation are effective This is new to everyone! Exercise was a learning experience for all participants

23. Town of Hanover City of Lebanon Dartmouth-Hitchcock Medical Center (DHMC) Dartmouth College Northern New England Metropolitan Medical Response System (NNE MMRS) New England Center for Emergency Preparedness (NECEP) Operation PREP Players

24. Activities and Observations Hanover emergency planners set up EOC in new location – what to bring? Practice with ICS – not all familiar with chain of command Job Action Sheets and diagram assisted ICS set-up Communication: cell phones, landlines, internet – did not test radios Community Objectives: Practice setting up Emergency Operations Center and implementing Incident Command Structure. Practice communicating with hospital and State.

25. Activities and Observations Multiple organizations: NNE MMRS NH Strike Team, Hanover Fire Besides Hanover Fire, none of these people had ever worked together before Determine ICS – Job Action Sheets and diagram helpful Physical set up of cots – supplied by Hanover Receiving and unloading of medical supplies from DHMC Secure facility Community Objectives: Practice setting up an Acute Care Center

28. Activities and Observations Local High School and Dartmouth students volunteered as “patients” No acting – each received a patient card with a description of symptoms Strike team admitted patients No patient care given Written orders to track activities, use of staff and supplies Community Objectives: Practice admitting 50 patients to ACC

30. Activities and Observations Patients given tag with bar code at triage (ED, NEHC) Scanned at every point of contact – discharge facility, transfer, receiving Handheld scanners (HC Standard) are multipurpose tool HC Standard linked to WebEOC, monitors anything and everything Community Objectives: Practice tracking 50 patients in ACC using patient tracking and electronic medical records software

31. Operation PREP Outcomes Good practice of collaboration between multiple agencies Built confidence and comfort with concept of med-surge by walking through steps of setting up an ACC Raised awareness of planning activities in the community  High school and college volunteers  Local and national press coverage Successful deployment of strike team Tested information technology

32. So how do we get there?

33. Medical Surge Plan Template This template is a planning tool to aid in the consistency of plans across the state It is intended as a starting point to develop plans, relationships, and procedures specific to your region Be realistic about the available resources, capacities, and capabilities of your region The objective is to use available resources to provide the best care possible

34. Medical Surge Plan Template Use the template to organize your information Ensure that all critical areas are addressed Continuously ask:  What will we need to know?  What will we need to do? Make sure the answers to those questions are in your plan

35. Medical Surge Plan Template: Outline Introduction Preparation Response Appendices

36. Medical Surge Plan Template: Introduction Regional Coordinating Council (RCC) Members Regional Population Estimates Definitions, including:  Medical Surge Capacity  ACC  NEHC Assumptions

37. Medical Surge Plan Template: Preparation Facilities:  Identify your buildings of opportunity and backup sites  Ensure a plan to access & use these sites Staffing:  Identify potential staffing needs and available resources  Consider staffing for med-surge facilities (ACCs, PODs, NEHCs)  Consider staffing for other necessary services (i.e. transportation, hotlines, etc.) Supplies:  Identify local supply caches and sources  Identify cache locations and protocols for access and replenishment  Include regional supply inventory as an appendix

38. Medical Surge Plan Template: Preparation Standards of Care:  The Standard of Care may be altered depending on the situation  Information and/or guidance may come from the State Memoranda of Understanding (MOUs):  Identify what resources (space, supplies, etc.) are needed in your region  Consider signing MOUs with local businesses, suppliers, and building owners  Consider asking these groups about other MOUs they have signed to avoid over-committing resources Risk Communication:  Include a risk communication appendix  Consider how to alert your region about opening community- based medical facilities

39. Medical Surge Plan Template: Preparation Finances:  Ensure that during an event you keep records  Develop a plan and documents for this in advance Pandemic Influenza:  Consider the additional requirements of a protracted event  Estimates range up to 30% ill  Duration up to 8-12 weeks in multiple waves Functional Needs Populations:  Identify the functional needs groups in your region  Consider the best ways to reach these individuals  Consider who your best partners may be (service orgs, religious leaders)  Consider accommodations for functional needs individuals in medical surge facilities

40. Medical Surge Plan Template: Response Notification  Consider how notification works in your region – among responders, volunteers, and the public Command and Control  Consider setting up a MAC for information flow Communication Resources  Can you obtain the resources you planned on? ACC and NEHC Concept of Operations

41. Medical Surge Plan Template: Appendices Appendix A: Regional Resource Inventory Appendix B: Copies of Regional MOUs Appendix C: State Medical Surge Guidelines for the AHHRs Appendix D: ACC supply list recommendations

42. Troubleshooting – Facilities Identify Buildings of Opportunity (and backups) Conduct site inspection for:  Appropriateness Use the AHRQ assessment  Safety Ensure that your facilities are inspected by Fire and Police representatives Draft & Sign MOUs with facility owners:  Ensure that facilities will be available when needed  Clarify any issues related to accessing the site, and responsibility for the facility during incident

43. Troubleshooting – Facilities Common Buildings of Opportunity: Aircraft hangers Religious sites Community/Recreation Centers Convention Facilities Fairgrounds Government Buildings Hotels/Motels Meeting Halls Same Day Surgery Centers or Clinics (alternative medical facilities) Sports Facilities/Stadiums

44. Troubleshooting - Staff Sample staffing model for 50-bed ACC unit for each 12-hour shift From the NH Medical Surge Guideline, October 2006

45. Troubleshooting - Staff The type of event, number of victims, and the care required will determine the number and type of individuals required to staff the facilities

46. Troubleshooting – Staff An ACC should be staffed with local providers as available  Be creative: school nurses, specialists (cancelled elective procedures), etc.  Also consider non-traditional providers: vets, medical students, ophthalmologists, etc.  Consider that the hospital may also plan on claiming these providers! Individuals should be contacted and recruited before an event occurs Encourage affiliation with the State Emergency System for the Advanced Registration of Volunteer Health Professionals (ESAR- VHP) The Northern New England Metropolitan Medical Response System (NNE MMRS) NH Medical Strike Team is available for deployment during a localized event

47. Troubleshooting – Supplies Plan on obtaining enough critical supplies to last 72 hours Some AHHR funds can be spent on supplies  Prioritize durable items with long shelf-life  Use the critical supplies list provided by DHHS Coordinate medical supplies with local health care facilities  Hospitals may be able to provide some during an event  Consider setting up system of rotation for items with a shelf life  Consider involving other health care facilities in storage and rotation (i.e. nursing homes, clinics)

48. Troubleshooting - Supplies Consider alternative sources of non-medical supplies  Get administrative supplies, desks, chairs from schools or local businesses  Draft MOUs for any of these agreements Before making purchases, ensure that you know what is already available in the region State Logistics Trailers available in localized event

49. Resources New Hampshire Department of Health and Human Services, Division of Public Health Services, http://www.dhhs.state.nh.us/DHHS/DPHS/default.htm http://www.dhhs.state.nh.us/DHHS/DPHS/default.htm New Hampshire Department of Safety. Homeland Security and Emergency Management, http://www.nh.gov/safety/divisions/bem/index.html http://www.nh.gov/safety/divisions/bem/index.html The New England Center for Emergency Preparedness, Dartmouth Medical School, http://dms.dartmouth.edu/necep/ http://dms.dartmouth.edu/necep/

50. Resources The State of New Hampshire Influenza Public Health Preparedness & Response Plan, NH Department of Health and Human Services, March 2, 2006. http://www.dhhs.state.nh.us/DHHS/CDCS/LIBRARY/Policy- Guideline/dphs-influenza-plan.htm http://www.dhhs.state.nh.us/DHHS/CDCS/LIBRARY/Policy- Guideline/dphs-influenza-plan.htm The State of New Hampshire Medical Surge Guideline, NH Department of Health and Human Services, October 24, 2006. http://www.co.rockingham.nh.us/nhac/reports/nhdhhsmedsurgeguid eline.pdf http://www.co.rockingham.nh.us/nhac/reports/nhdhhsmedsurgeguid eline.pdf The State of New Hampshire Public Health Emergency Preparedness and Response Plan, NH Department of Health and Human Services, March 8, 2006. http://www.dhhs.state.nh.us/DHHS/CDCS/LIBRARY/Policy- Guideline/dphs-health-emergency-plan.htm http://www.dhhs.state.nh.us/DHHS/CDCS/LIBRARY/Policy- Guideline/dphs-health-emergency-plan.htm

51. Resources Information on ICS and NIMS  FEMA Training Institute: http://www.training.fema.gov/http://www.training.fema.gov/  Other online training resources: http://www.ualbanycphp.org/learning/default.cfm http://www.ualbanycphp.org/learning/default.cfm The Agency for Healthcare Research and Quality (AHRQ) tool for ranking buildings of opportunity http://www.AHRQ.gov/research/altsites/altmatrix1_final.htm http://www.AHRQ.gov/research/altsites/altmatrix1_final.htm Additional description of the MEMS system http://www.nnemmrs.org/surge http://www.nnemmrs.org/surge