1. Emergency Management Strategies for Identifying and Integrating Community Resources to Expand Medical Surge Capacity: Alternate Care Facilities Washington, DC February 5, 2008 Stephen V. Cantrill, MD Department of Emergency Medicine Denver Health Medical Center The National Emergency Management Summit

2. Cantrill 2 Surge Capacity Ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system  Intrinsic:  Facility based  Community based: Alternate Care Facilities  Extrinsic: State / Federal

3. Cantrill 3 Community Based Surge Capacity  Requires close planning and cooperation amongst diverse groups who have traditionally not played together  Hospitals  Offices of Emergency Management  Regional planners  State Department of Health  MMRS may be a good organizing force

4. Cantrill 4 Where Have We Been?

5. Cantrill 5 Hospital Reserve Disaster Inventory  Developed in 1950’s-1960’s  Designed to deal with trauma/nuclear victims  Developed by US Dept of HEW  Hospital-based storage  Included rotated pharmacy stock items

6. Cantrill 6 Packaged Disaster Hospitals  Developed in 1950’s-1960’s  Designed to deal with trauma/nuclear victims  Developed by US Civil Defense Agency & Dept of HEW  2500 deployed  Modularized for 50, 100, 200 bed units  45,000 pounds; 7500 cubic feet

7. Cantrill 7 Packaged Disaster Hospitals  Last one assembled in 1962  Adapted from Mobile Army Surgical Hospital (MASH)  Community or hospital-based storage

8. Cantrill 8 Packaged Disaster Hospital: Multiple Units  Pharmacy  Hospital supplies / equipment  Surgical supplies / equipment  IV solutions / supplies  Dental supplies  X-ray  Records/office supplies  Water supplies  Electrical supplies/equipment  Maintenance / housekeeping supplies  Limited oxygen support

9. Cantrill 9 Packaged Disaster Hospital

10. Cantrill 10 Packaged Disaster Hospitals  Congress refused to supply funds needed to maintain them in 1972  Declared surplus in 1973  Dismantled over the 1970’s-1980’s  Many sold for $1

11. Cantrill 11 The Re-Emergence of a Concept: The Alternate Care Facility  Planning Issues:  Augmentation vs Alternate Facility?  Physical space  Inclusion of actual structure  Tents, trailers, etc  Cost? Storage? Ownership?  Structure of opportunity  Private vs Public sites  Who grants permission to use?  Need for decon after use to restore to original function?

12. Cantrill 12 Alternate Care Facility Planning Issues  It is not a miniature hospital  “Ownership”, command and control?  HICS is a good starting structure  Who decides to open the ACF?  Scope & level of care to be delivered?  Offloaded hospital patients  Primary victim care  Nursing home replacement  Ambulatory chronic care / shelter

13. Cantrill 13 ACF Planning Issues  Staffing  Medical Staff  Ancillary Staff  Operational support  Meals  Sanitary needs  Infrastructure  Supplies  Pharmaceuticals  Documentation of care  Security

14. Cantrill 14 ACF Planning Issues  Communications  Hospitals  EMS  Emergency Management: State/Local  Relations with EMS  Rules/policies for operation  Exit strategy  Exercising the plan

15. Cantrill 15 Level I Cache: Hospital Augmentation  Bare-bones approach  Physical increase of 50 beds  Would rely heavily on hospital supplies  Stored in a single trailer  About $20,000  Within the realm of institutional ownership  Readily mobile - but needs vehicle

16. Cantrill 16 Level I Cache: Hospital Augmentation  Trailer  Cots  Linens  IV poles  Glove, gowns, masks  BP cuffs  Stethoscopes (Developed under AHRQ Task Order: Rocky Mountain Regional Care Model for Bioterrorist Events)

17. Cantrill 17 Used During Katrina Evacuee Relief

18. Cantrill 18 Level II Cache: Regional Alternate Care Facility (ACF)  Significantly more robust in terms of supplies  Designed by one of our partners, Colorado Department of Public Health and Environment

19. Cantrill 19 Level II Cache: Regional Alternate Care Facility  Designed for initial support of 500 patients  Per HRSA recommendations of 500 patient surge per 1,000,000 population  Modular packaging for units of 50-100 pts  Regionally located and stored  Trailer-based for mobility  Has been implemented  Approximate price less than $100,000 per copy

20. Cantrill 20 Level II: Level I Plus:  Ambu bags  Bed pans / Urinals  Medical ID bracelets  Chairs  Cribs  Emesis basins  Forms for documentation  IV sets  Oxygen masks  Ice packs  Pillows  Privacy screens  Soap  Tables  Duct tape  Adhesive tape  Thermometer strips  Tongue depressors  (Still No Drugs)

21. Cantrill 21 Level III Cache: Comprehensive Alternate Care Facility  Adapted from work done by US Army Soldier and Biological Chemical Command  50 Patient modules  Most robust model  Closest to supporting non-disaster level of care, but still limited  More extensive equipment support

22. Cantrill 22 Work at the Federal Level  DHHS: Public Health System Contingency Station  Specified and demonstrated  250 beds in 50 bed units  Quarantine or lower level of care  For use in existing structures  Multiple copies to be strategically placed  Owned and operated by the federal government

23. Cantrill 23 Basic Concept: HHS Public Health Service Contingency Stations (Federal Medical Stations)

24. Cantrill 24

25. Cantrill 25 Station Layout Hall A

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27. Cantrill 27

28. Cantrill 28 Possible Alternative Care Facilities Hotel Recreation Center Church Stadium School

29. Cantrill 29 ACF Site Selection  What is the best existing infrastructure/site in the region for delivering care? (Developed under AHRQ Task Order: Rocky Mountain Regional Care Model for Bioterrorist Events)

30. Cantrill 30

31. Cantrill 31 ACF Site Selection Tool  ACF infrastructure factors listed on one axis of a matrix.  Potential ACF sites listed on the other axis of the matrix.  Relative weight scale for each factor using a 5-point scale comparing factor to that of a hospital.  Developed as an Excel spreadsheet.

32. Cantrill 32 Potential ACF Sites (pre-selected) Aircraft hangers Churches Community/recreation centers Convalescent care facilities Fairgrounds Government buildings Hotels/motels Meeting Halls Military facilities National Guard armories Same day surgical centers/clinics Schools Sports Facilities/stadiums Trailers/tents (military/other) Shuttered Hospitals Detention Facilities

33. Cantrill 33 Factors to Weigh in Selection of an Alternate Care Facility Site  Infrastructure  Total Space and Layout  Utilities  Communication  Other Services

34. Cantrill 34 Factors to Weigh in Selection of an Alternate Care Facility Site  Infrastructure  Door sizes  Floor  Loading Dock  Parking for staff/visitors  Roof  Toilet facilities/showers (#)  Ventilation  Walls

35. Cantrill 35 Factors to Weigh in Selection of an Alternate Care Facility Site  Total Space and Layout  Auxiliary Spaces (Rx, counselors, chapel)  Equipment/Supply storage area  Family Areas  Food supply/prep area  Lab/specimen handling area  Mortuary holding area  Patient decon areas  Pharmacy areas  Staff areas

36. Cantrill 36 Factors to Weigh in Selection of an Alternate Care Facility Site  Utilities  Air conditioning  Electrical power (backup)  Heating  Lighting  Refrigeration  Water

37. Cantrill 37 Factors to Weigh in Selection of an Alternate Care Facility Site  Communication  Communication (# phones, local/long distance, intercom)  Two-way radio capability  Wired for IT and Internet Access

38. Cantrill 38 Factors to Weigh in Selection of an Alternate Care Facility Site  Other Services  Ability to lock down facility  Accessibility/proximity to public transportation  Biohazard & other waste disposal  Laundry  Ownership/other uses during disaster  Oxygen delivery capability  Proximity to main hospital  Security personnel

39. Cantrill 39 Weighted Scale 5 = Equal to or same as a hospital. 4 = Similar to that of a hospital, but has SOME limitations (i.e. quantity/condition). 3 = Similar to that of a hospital, but has some MAJOR limitations (i.e. quantity/condition). 2 = Not similar to that of a hospital, would take modifications to provide. 1 = Not similar to that of a hospital, would take MAJOR modifications to provide. 0 = Does not exist in this facility or is not applicable to this event.

40. Cantrill 40

41. Cantrill 41 Customizing the Site Selection Matrix Additional relevant factors or facility sites can be added to the tool based on your area or the type of event.

42. Cantrill 42 Issues to Consider Is each factor of equal weight? What if another use is already stated for the building in a disaster situation? (i.e. a church may have a valuable community role) Are missing, critical elements able to be brought in easily to site?

43. Cantrill 43 WHO needs this tool? Incident commanders Regional planners Planning teams including: fire, law, Red Cross, security, emergency managers, hospital personnel Public works / hospital engineering should be involved to know what modifications are needed.

44. Cantrill 44 WHEN should you use this tool? Before an actual event. Choose best site for different scenarios so have a site in mind for each “type”. Available from: www.ahrq.gov/research/altsites.htm

45. Cantrill 45 Who has used this tool?  Greece, in preparation for the Olympics  California  Florida  Other states/locations  Available from: www.ahrq.gov/research/altsites.htm

46. Cantrill 46 The Supplemental Oxygen Dilemma  Supplemental oxygen need highly likely in a bioterrorism incident  Has been carefully researched by the Armed Forces  Most options are quite expensive with high cost/patient  Many have very high power requirements  Most require training/maintenance  All present logistical challenges  Remains an unresolved issue for civilian ACFs

47. Cantrill 47 And Then The “Other” Problems:  Ventilators:  Currently in US: 105,000  In daily use: 100,000  Projected pandemic need: 742,500  Respiratory Therapists

48. Cantrill 48 Ventilators – Surge Supply  Additional full units - $32,000 each  Smaller units for $6,000 each  Many “Disposable” Units - $65 each

49. Cantrill 49 Respiratory Therapists: Just-In-Time Training MD RT Trainee Pt Trainee Pt Trainee Pt Trainee Pt RT Trainee Pt Trainee Pt Trainee Pt Trainee Pt AHRQ: Project XTREME: www.ahrq.gov/prep/projxtreme/

50. Cantrill 50 ACF Ideal Staffing: 33 Per 12 Hour Shift  Physician[1]  Physician extenders (PA/NP)[1]  RNs or RNs/LPNs [6]  Health technicians [4]  Unit secretaries[2]  Respiratory Therapists [1]  Case Manager[1]  Social Worker[1]  Housekeepers[2]  Lab [1]  Medical Asst/Phlebotomy [1]  Food Service[2]  Chaplain/Pastoral[1]  Day care/Pet care  Volunteers[4]  Engineering/Maintenance [.25]  Biomed[.25]  Security[2]  Patient transporters[2] MEMS ACC guidelines

51. Cantrill 51 Emergency System for Advanced Registration of Volunteer Health Professionals: ESAR-VHP  State-based registration, verification and credentialing of medical volunteers  Should allow easier sharing of volunteers across states  Still missing:  Liability coverage  Command and control

52. Cantrill 52 Medical Reserve Corps  Local medical volunteers  No corps unit uniform structure  330 units of 55,000 volunteers  Deployments do not qualify for FEMA reimbursement  Liability concerns are still an issue  ESAR-VHP may help with credentialing

53. Cantrill 53 Development of Gubernatorial Draft Executive Orders  Developed by the Colorado Governor’s Expert Emergency Epidemic Response Committee (GEEERC)  Multi-disciplinary  20 different specialties/fields (from attorney general to veterinarians)  To address pandemics or BT incidents  Work started in 2000

54. Cantrill 54 Development of Gubernatorial Draft Executive Orders  Declaration of Bioterrorism/Pandemic Disaster  Suspension of Federal Emergency Medical Treatment and Active Labor Act (EMTALA)  Allowing seizure of specific drugs from private sources  Suspension of certain Board of Pharmacy regulations regarding dispensing of medication

55. Cantrill 55 Development of Gubernatorial Draft Executive Orders  Suspension of certain physician and nurse licensure statutes  Allows out-of-state or inactive license holders to provide care under proper supervision  Allowing physician assistants and EMTs to provide care under the supervision of any licensed physician  Allowing isolation and quarantine  Suspension of certain death and burial statutes

56. Cantrill 56 Katrina: ACF Lessons Learned  Importance of regional planning  Importance of security: uniforms are good  Advantages of manpower proximity  Segregating special needs populations  Organized facility layout  Importance of ICS

57. Cantrill 57 Katrina: ACF Lessons Learned  The need for “House Rules”  Importance of public health issues  Safe food  Clean water  Latrine resources  Sanitation supplies

58. Cantrill 58 Available from AHRQ: www.ahrq.gov/research/mce/mceguide.pdf www.ahrq.gov/research/mce/mceguide.pdf Contents:  Ethical considerations  Legal aspects  Prehospital care  Hospital/Acute care  Alternative care sites  Palliative care  Pan-flu case study

59. Cantrill 59 Disaster Alternate Care Facilities Agency for Healthcare Research and Quality Contract No. HHSA290200600020 Task Order No. 4  Review and Revise the Alternative Care Site Selection Tool

60. Cantrill 60 Task Order  Review AARs and Lessons Observed from:  Response to Hurricanes Katrina and Rita  - Sites such as Superdome, Convention Center  Use of Federal Medical Stations  NDMS DMATs  Use of other mobile assets  State experiences in site selection

61. Cantrill 61 Task Order  Review, reconsider, revise site selection tool  Develop draft staffing and resource requirements for a full range of ACFs  Develop draft ACF conops

62. Cantrill 62 Summary  We are rediscovering some old concepts  Supplemental oxygen and respiratory support remain problems  Surge staffing facilitation requires advance planning at multiple levels and may still fail  Developing medical surge capacity requires close planning and cooperation amongst diverse groups who have traditionally not played together