1. Planning for Surge Capacity in Health Care Services Betsey Lyman Deputy Director, Public Health Emergency Preparedness California Department of Public Health

2. California Faces Disasters on a Regular Basis Examples of disasters since 2006: Examples of disasters since 2006: 2006 Extreme Heat 2006 Extreme Heat 2007 Lake Tahoe Wildfire 2007 Lake Tahoe Wildfire 2007 Southern California Wildfires 2007 Southern California Wildfires 2008 Northern California Wildfires 2008 Northern California Wildfires 2008 Chino Hills Earthquake 2008 Chino Hills Earthquake 2008 Los Angeles Metro Link Crash 2008 Los Angeles Metro Link Crash 2008 Southern California Wildfires 2008 Southern California Wildfires 2008 Severe Cold 2008 Severe Cold

3. The Challenge Meeting the public health and medical needs of Californians during and following disasters Meeting the public health and medical needs of Californians during and following disasters Addressing statewide needs during a catastrophic event when mutual aid is limited Addressing statewide needs during a catastrophic event when mutual aid is limited

4. ……an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources and/or emergency medical services What is a Healthcare Surge?

5. The frequent emergency department overcrowding experienced by healthcare facilities (for example, Friday/Saturday night emergencies). The frequent emergency department overcrowding experienced by healthcare facilities (for example, Friday/Saturday night emergencies). A local casualty emergency that might overcrowd nearby facilities but have little to no impact on the overall healthcare delivery system. A local casualty emergency that might overcrowd nearby facilities but have little to no impact on the overall healthcare delivery system. What is NOT a Healthcare Surge?

6. Surge Capacity Basics Beds: Acute care and critical care beds Beds: Acute care and critical care beds Staffing: Licensed healthcare professionals and Staffing: Licensed healthcare professionals and support staff Medical supplies and equipment: pharmaceuticals, personal protective equipment, portable and fixed decontamination systems, isolation beds, ventilators, masks Medical supplies and equipment: pharmaceuticals, personal protective equipment, portable and fixed decontamination systems, isolation beds, ventilators, masks

7. Measuring the Gap: 2006 California Healthcare Surge Capacity Survey Standardized definitions for crisis care: Nurse-to-patient staffing ratio of 1:5 for Critical Care Beds and 1:20 for Other Medical-Surgical BedsNurse-to-patient staffing ratio of 1:5 for Critical Care Beds and 1:20 for Other Medical-Surgical Beds Assume self-sustainment within the facility for a minimum of 72 hours without re-supply of equipment, supplies or staff Assume self-sustainment within the facility for a minimum of 72 hours without re-supply of equipment, supplies or staff Assume 30% of staff will not report to workAssume 30% of staff will not report to work

8. Measuring the Gap (cont) Response : Response : 324 hospital: 80 percent of Californias 73,000 operating licensed acute care hospital beds 324 hospital: 80 percent of Californias 73,000 operating licensed acute care hospital beds Californias local health departments Californias local health departments 172 community clinics 172 community clinics Identified 19,963 beds California hospitals said they can surge Identified 19,963 beds California hospitals said they can surge Bed shortages: Bed shortages: Los Angeles areaLos Angeles area Pediatric bedsPediatric beds

9. Greater Gaps in Meeting Needs of a Catastrophic Event Using CDCs FluSurge 2.0 computer modeling program for pandemic influenza: Using CDCs FluSurge 2.0 computer modeling program for pandemic influenza: California needs 58,723 surge beds for a moderate pandemic influenza California needs 58,723 surge beds for a moderate pandemic influenza 38,760 beds or 194% above the 19,963 surge beds California hospitals said they can surge. 38,760 beds or 194% above the 19,963 surge beds California hospitals said they can surge.

10. Analysis of 2006 Survey Results California has sufficient surge capacity for a Moderate event: regional earthquake, fire, flood, or bioterrorist attack. California has sufficient surge capacity for a Moderate event: regional earthquake, fire, flood, or bioterrorist attack. Californias surge capacity is insufficient for a Catastrophic event: statewide impact, e.g., Katrina-like event or pandemic influenza. Californias surge capacity is insufficient for a Catastrophic event: statewide impact, e.g., Katrina-like event or pandemic influenza.

11. 2006 Healthcare Surge Initiative The State of California spent $172 million to improve its medical surge capacity ItemNeedBoughtCost Masks (N95 Respirators) 100 million 50.9 million $19.9 million Ventilators24,0002,400 $30.6 million Antiviral medicines -- enough to treat 25 percent of California's population 8 million courses 3.7 million courses 90% Tamiflu, 10% Relenza $54.6 million Mobile Field Hospitals 3 - 200 bed $18.3 million 21,000 extra beds with supplies for alternate care sites 42,00021,000 $33.4 million Developing new hospital guidelines and standards $5 million

12. Alternate Care Site Supplies and Equipment State Alternate Care Site Caches contain over 300 items, ranging from patient cots and linens, routine nursing supplies, suture equipment, airway breathing supplies, etc. State Alternate Care Site Caches contain over 300 items, ranging from patient cots and linens, routine nursing supplies, suture equipment, airway breathing supplies, etc. Supplies and equipment are packed in caches to support 50 patients Supplies and equipment are packed in caches to support 50 patients Each cache is stored on 20 pallets Each cache is stored on 20 pallets

13. Standards and Guidelines for Healthcare Surge during Emergencies

14. Standards of care for healthcare facilities and licensed healthcare professionals during an emergency Standards of care for healthcare facilities and licensed healthcare professionals during an emergency Liability of healthcare facilities and licensed healthcare professionals Liability of healthcare facilities and licensed healthcare professionals Reimbursement of care provided during an emergency Reimbursement of care provided during an emergency How to operate Alternate Care Sites How to operate Alternate Care Sites Surge capacity operating plans at individual hospitals Surge capacity operating plans at individual hospitals Focus of the Project Focus of the Project

15. Project Approach Developing and managing a process that includes government agencies, providers, stakeholders, and other relevant parties as participants in this project. Developing and managing a process that includes government agencies, providers, stakeholders, and other relevant parties as participants in this project. Developing written standards and guidelines for delivery of medical care services in a surge environment. Developing written standards and guidelines for delivery of medical care services in a surge environment.

16. 2008 Deliverables Foundational Knowledge document provides platform for all volumes Foundational Knowledge document provides platform for all volumes Manuals focused on target audience: Manuals focused on target audience: Hospitals Hospitals Alternate care sites Alternate care sites Payers Payers Reference Manual including legal analysis Reference Manual including legal analysis

17. Volumes under Development Licensed healthcare professionals, including Crisis Care Licensed healthcare professionals, including Crisis Care Long term care facilities Long term care facilities Clinics Clinics

18. When is a Healthcare Surge Declared? Local Surge Emergency Regional Level Surge Statewide Surge Level Surge Level GreenYellowOrangeRedBlack Enabling Authorities Regulatory/ Accrediting Agency Waiver Regulatory/ Accrediting Agency Waiver/ Local Emergency Declaration Local Emergency Declaration State of Emergency Declaration Federal Emergency Declaration Surge Monitoring Guidelines Table Green: Usual day to day status. No assistance required Yellow: Surge managed locally. No assistance required Orange: Additional healthcare assets required within jurisdiction Red:Assistance needed outside local jurisdiction or area. Black:Significant assistance needed outside local jurisdiction.

19. HOSPITAL PREPAREDNESS

20. Hospital Connection to Incident Command System Ensuring hospitals have internal Incident Command Systems Ensuring hospitals have internal Incident Command Systems Community planning: connecting hospitals to local Emergency Response Structure Community planning: connecting hospitals to local Emergency Response Structure Expanding hospital capacity to meet surge needs Expanding hospital capacity to meet surge needs

21. Reimbursement Maintaining existing revenue streams is critical to hospitals during a healthcare surge. Key concepts surrounding reimbursement during surge include: Advanced planning and collaboration with commercial health plan partners Advanced planning and collaboration with commercial health plan partners Acquiring detailed knowledge of the resources available to hospitals during surge conditions Acquiring detailed knowledge of the resources available to hospitals during surge conditions Methods to access additional resources from federal and State funded programs Methods to access additional resources from federal and State funded programs

22. Establishment of a Government-Authorized Alternate Care Site

23. A location that is not currently providing healthcare services A location that is not currently providing healthcare services Will be converted to enable the provision of healthcare services to support, at a minimum, inpatient and/or outpatient care required after a declared catastrophic emergency Will be converted to enable the provision of healthcare services to support, at a minimum, inpatient and/or outpatient care required after a declared catastrophic emergency Will help absorb the patient load after all other healthcare resources are exhausted Will help absorb the patient load after all other healthcare resources are exhausted What is a Government-Authorized Alternate Care Site? Types of Government-Authorized Alternate Care Sites Mobile Field Hospitals Mobile Field Hospitals Arenas Arenas Schools Schools Churches Churches Shuttered Hospitals Shuttered Hospitals Stadiums Stadiums

24. A government-authorized Alternate Care Site is NOT part of the expansion of an existing healthcare facility, such as extensions of general acute care hospitals extensions of general acute care hospitals clinics, or clinics, or long-term care facilities long-term care facilities What is NOT a Government- Authorized Alternate Care Site? Government-Authorized Alternate Care Sites DO NOT include: Tents set up for patient care in the parking lot of a hospital and under their control Tents set up for patient care in the parking lot of a hospital and under their control Sites set up for patient triage by Emergency Medical Services Sites set up for patient triage by Emergency Medical Services Any temporary space set up for patient care under the authority of an existing healthcare facility Any temporary space set up for patient care under the authority of an existing healthcare facility

25. 2009: Current Challenges in Surge Capacity Gap in needed surge capacity remains significant Gap in needed surge capacity remains significant 2006 Healthcare Surge Initiative addressed approximately half of the gap in needed beds 2006 Healthcare Surge Initiative addressed approximately half of the gap in needed beds California hospitals are struggling for financial survival. Loss of hospitals would increase the gap California hospitals are struggling for financial survival. Loss of hospitals would increase the gap

26. Current Challenges in Surge Capacity (cont) Unfunded: Unfunded: Maintaining surge supplies in operating order Maintaining surge supplies in operating order Refreshing expiring supplies (e.g. pharmaceuticals) Refreshing expiring supplies (e.g. pharmaceuticals) Updating medical equipment Updating medical equipment Training staff to manage, deploy and operate surge beds Training staff to manage, deploy and operate surge beds

27. Current Challenges in Surge Capacity (cont) Californias economic situation is resulting in: Californias economic situation is resulting in: Decreased expenditures for public health, with negative impact on the infrastructure to respond to public health emergencies Decreased expenditures for public health, with negative impact on the infrastructure to respond to public health emergencies Layoffs of trained Local Health Department staff trained in public health emergency preparedness Layoffs of trained Local Health Department staff trained in public health emergency preparedness

28. Current Challenges (cont) Federal funds are the financial support for public health emergency response capacity Federal funds are the financial support for public health emergency response capacity From 9-11 to current year, Californias federal grants for public health emergency preparedness decreased 25 percent. From 9-11 to current year, Californias federal grants for public health emergency preparedness decreased 25 percent.

29. Accessing the Standards and Guidelines for Healthcare Surge During Emergencies: http://bepreparedcalifornia.ca.gov/EPO/ CDPHPrograms/PublicHealthPrograms/ http://bepreparedcalifornia.ca.gov/EPO/ CDPHPrograms/PublicHealthPrograms/ EmergencyPreparednessOffice/ EPOProgramsServices/Surge/ http://bepreparedcalifornia.ca.gov/EPO/ CDPHPrograms/PublicHealthPrograms/