1. Hospital preparedness for pandemic

2. Objectives  Pandemic definition  Historical, Current & possible future pandemics  The impacts of pandemics on communities & health care systems  Planning Assumptions and Considerations in pandemics preparedness & planning  Hospital preparedness & planning elements in pandemic situations

3. Pandemic definition  A pandemic is an epidemic of infectious disease that has spread through human populations across a large region; for instance multiple continents, or even worldwide.epidemicinfectious diseasecontinents

4. Why Do We Care in pandemics? Historically pandemics have killed million s and destroyed entire societies:  The Black Plague in Europe in the Middle Ages killed as much as 50% of the entire population, and wiped out entire communities.  The 1918 Influenza Pandemic killed more than 20 million people worldwide in less than a year, some now estimate that it was 100 million.

5. The "Hong Kong Flu", 1968–69. An H3N2 caused about 34,000 deaths in the United States. from Hong Kong in early 1968 and spread to the United States later that year. This pandemic of 1968 and 1969 killed approximately one million people worldwideHong Kong Flu Cholera Seventh pandemicSeventh pandemic 1962–66. Began in Indonesia, called El Tor after the strain, and reached Bangladesh in 1963, India in 1964, and the USSR in 1966IndonesiaEl Tor Influenza

6. Current pandemics  2009 H1N1 pandemics. 2009H1N1  AIDS, is currently a pandemic, with infection rates as high as 25% in southern and eastern Africa. AIDS  AIDS could kill 31 million people in India and 18 million in China by 2025, according to projections by U.N. population researchers. AIDS death toll in Africa may reach 90–100 million by 2025.IndiaChinaAfrica

7. Concern about possible future pandemics  Viral hemorrhagic fevers  Antibiotic resistance  SARS  Influenza  H5N1 (Avian Flu)

8. What Have We Learned from Past Pandemics? (1)  Pandemics can vary in severity.  Hospitals and clinics will become completely overloaded, and most people will have to be treated at home.  Services may be interrupted when many people are sick—including police, water, electricity, food supplies, banks, telephones, etc.

9. What Have We Learned from Past Pandemics? (2)  Outside help will probably not come because many people will be sick everywhere allover the world.  Some families may need community help if everyone in the family is sick.

10. What Will Life Be Like in a Severe Pandemic?

11.  Lost work days (absenteeism) will result in decreased production, reduced international and national transports, and missed deliveries to local areas.  The supply chain will be very vulnerable.  Shortages of essential goods may occur—including food, water, fuel, medicines, and many more.  Available goods may be subject to personal consumption, looting, and hoarding. A. Shortages of Essential Goods

13. B. Disruption in Routine Services  Schools, government offices, the post office and some workplaces may need to clos e during the pandemic may be closed.  Electricity, telephone service, the Internet, and commercial radio and TV broadcasts could also be interrupted if the electric power grid falters or fails.  Local automated teller machines and banks may be shut down

14. C. Changes in Public Transportation and Other Municipal and Private Services  Buses, taxis, and other transportation services may be stopped or limited.  Gasoline supplies may be limited or unavailable.  Trash removal, road repair and other services may be limited.  Utility service and repairs may be delayed.

16. D. Restrictions of Personal Movement  Isolation and quarantine may be necessary.  Restrictions on public gatherings, such as funerals, parties, and other events—may be necessary.  Travel may be restricted.

17. Planning Assumptions and Considerations in pandemics It is assumed that during an pandemic:  Health care systems may be overwhelmed and laboratories will be unable to keep pace with testing demands.  Health care, emergency medical and laboratory staff may be ill and will subsequently reduce the available workforce.

18. Planning Assumptions and Considerations in pandemics It is assumed that during an pandemic:  There may be shortages of equipment and resources available to keep pace with increased demand for patient care and testing (also might be shortages of items such as gloves, ventilators, and laboratory testing supplies.  mutual aid resources might be overwhelmed due to the pandemic situation.

19. Planning Assumptions and Considerations in pandemics It is assumed that during an pandemic:  Routine laboratory testing be suspended in order to redirect staff and resources to pandemic specimen testing.  Citizens will seek medical care once signs and symptoms are experienced. It is also assumed that the media will impact the decisions of citizens to seek medical care versus staying at home.

20. Planning Assumptions and Considerations in pandemics It is assumed that during an pandemic:  All levels of government need to a strong public information program that will provide a level of confidence to the citizens.  The local surge plans will be inadequate during a pandemic situation due to depending on other facilities or receiving assistance from a common vendor.

21. Goals The primary goals of the Pandemic Preparedness and Response Plan is to enable countries & health care systems to be prepared :  To recognize and manage a pandemic.  To decrease cases, hospitalizations and deaths (To limit morbidity and mortality ).  To decrease the spread of disease. Planning may help to reduce transmission of the pandemic  To limit its complications during a pandemic

22. Objectives  Keep maintenance of treatment capacity throughout the state.  Keep safety of responders, their families, and the public.  To decrease social disruption and economic loss.  And totally provide optimal medical care and maintain essential community services.

23.  The purpose is to provide basic patient care and laboratory services to a greater volume during a pandemic incident.

25. Hospitals in pandemics  All hospitals should be equipped and prepared for : 1) a limited number of patients infected with a pandemic diseases 2)Or a large number of patients in the event of escalating transmission of pandemic.

26. General Principles Even in a disaster situation hospitals have to..  Ensure continuity of essential services  Manage an extra-load of patients  Organize the response  Protect the facility and its services (staff &patients) from harm  Provide specific services for the pre- hospital phase

27. Hospital Planning Elements  Determining criteria for distinguishing pandemics  Predetermined thresholds for activating pandemic response plans  Procedures to facilitate laboratory testing on site.  Mechanisms for conducting surveillance in emergency departments  Mechanisms for monitoring employee absenteeism  Mechanisms for tracking emergency department visits and hospital admission/discharges for suspected/confirmed pandemic patients  Determine types of data reportable to state and local health departments

28. 10 main steps  1. Surveillance and Detection  2. Laboratory Testing  3. Antiviral and Vaccine Purchase and Distribution  4. Restriction of Movement or Activities to Control Disease Spread  5. Emergency and Risk Communication  6. Fatality Management  7. Training and Exercise Schedule and Plan  8. Public Health and Medical Surge  9. Infection Control and Personal Protective Equipment (PPE)

29. Hospital Risk Communications 1  Use guidance from state or local health departments for external communications.  Identify key topics for ongoing communications.  Determine how public inquiries would be handled.  Determine how to keep hospital personnel and patients informed.

30. Hospital Risk Communications 2  Communicate effectively with community leaders and the media to maintain public awareness, avoid social disruption, and provide information on evolving pandemic response activities.  Inform health care providers and the public about disease and the course of the pandemic, the ability to treat mild illness at home, the availability of vaccine, and priority groups for earlier vaccination

31. Hospital Education and Training 1  Identify educational resources for hospital personnel.  Develop educational policies and procedures for the care of pandemic patients.  Create a distribution plan for educational materials.

32. Hospital Education and Training 2  Develop plans for training clinical personnel, intake and triage staff to detect patients.  Develop a strategy for “just-in-time” training of non- clinical staff.  Develop educational materials for patients and family members.

33. Case management Hospital Triage and Admission Procedures  Employ a Triage Coordinator to manage patient flow.  Establish separate triage and waiting areas for persons with symptoms of disease.  Establish phone triage (Telephone hotline) Pre-hospital triage will be needed to relieve pressure on hospital operations

34. Case management Hospital Triage and Admission Procedures  Identify “ trigger” points for triage (Triage criteria)  Develop procedures for clinical evaluation.  Develop admission procedures (admission criteria) with streamlining techniques.  Establish Method to specifically track admission and discharges of patients

35. Hospital Facility Access  Define essential and nonessential visitors.  Identify “triggers” for temporary closing hospital to new admissions and transfers  Involve hospital security services to enforce access controls.  Establish policies for restricting visitors.  Hospital Security

36. Human resources 1 Planning for personnel I.Remains biggest challenge we face in pandemics II.Legal protections are key to recruiting personnel III.Large number of non-clinical personnel also needed  12% of work force will be absent during the peak weeks ( UK Planning Assumptions 2009)

37. Human resources 2 Planning for personnel  Develop pandemic staffing contingency plans. Potential sources of clinical surge personnel: Internal Hospital Strategies volunteers Medical Reserve Corps that are not included in hospital staff Retired, inactive health professionals Students (medical, nursing, pharmacy) Staff list updated regularly

38. Human resources 3 Planning for personnel  Identify mental health, psychological support programs and faith-based resources for counseling personnel.  Develop a strategy to support healthcare workers’ needs for rest and recuperation.  Create a strategy for housing and feeding personnel.

39. Human resources 4 Planning for personnel  Develop a strategy for supporting personnel family needs.  Establish policies for managing healthcare workers with disease symptoms.  Create a plan to protect personnel at high risk for complications from exposure.  Encourage staff to stay at home when ill

40. Human resources 5 Planning for personnel Pay attention:  Professional qualifications must be checked and verified ahead of time  Volunteers cannot be assigned to take care of patients until their specific knowledge and skills are understood  It takes time to do this – volunteers who have not been pre-registered and pre-credentialed may be delayed in receiving an assignment

42. Infection prevention and control 1  Develop a pandemic diseases vaccination plan.  Develop a strategy for rapidly vaccinating or providing prophylaxis to personnel.  Ensure documenting vaccination for personnel.

43. Infection prevention and control 2  Develop a strategy for prioritizing vaccinations to critical personnel.  Design units for case patient care  Short distance to designated wards  Transport to the wards distant from patient main stream

44. Logistics Management 1  Estimation of quantities of essential patient care  needed Materials and equipment (masks, gowns, gloves etc.)  Provide estimates of the quantities of vaccine & drugs needed for hospital staff and patients  Instructional materials for affected patients and their relatives  Brochures and posters

45. Logistics Management 2  Estimates are shared with the provincial health authorities and regional hospitals  Stockpiling agreements  Contingency plan for an increased need for post mortem care  Involvement of local morticians

46. Hospital Surge Capacity 1  Alternate care spaces will need to be identified to expand hospital capacity  Estimate minimum number of needed personnel and determine categories for surge capacity of personnel  Recruit retired health care personnel.  Use trainees.  Use patients’ family members.  health care personnel from other settings (e.g., medical offices and same day surgery centers).

47. Hospital Surge Capacity 2  Surge Capacity & Hospital Admissions:  Establish admissions criteria for when bed capacity is limited.  May need to cancel elective admissions during triage phase  Identify “triggers” for canceling elective procedures.  Develop policies/procedures for expediting patient discharge (Early discharge of patients)  Use non-acute beds for acute patients

48. Hospital Surge Capacity 3  Develop transfer agreements.  Establish policies/procedures for shifting patients between nursing units.  Expand bed capacity during times of crisis.  Identify areas of facility that can be dedicated to extra patients.  Stockpile consumable resources.  Identify “triggers” for ordering extra supplies.

49. Hospital Surge Capacity 4  Develop a strategy for ensuring uninterrupted provision of medications.  Determine main agencies have identified key components of surge capacity and response to the demand  Applying Telemedicine  Consider telemedicine capability and privileges so physicians not required to attend hospital

50. Fatality Management Hospital Mortuary Issues  Ensure fatality management plans include a partnership with the local coroner’s office in the event the hospital morgue capacity is exceeded.  Assess current refrigeration capacity for deceased persons.  Develop a mass fatality plan.  Identify temporary morgue sites.  Determine scope and volume of supplies needed for deceased persons.

51. Hospital Preparedness & Response

52.  Preparedness:  State and community level planning  Build and distribution plan  Work with WHO and other international orgs  Build and exercise plans at all levels of gov.  Plan for medical and veterinary surge capacity Disaster Management Cycle Preparedness

53. Preparedness on a hospital level  A local preparedness plan was developed Based on:  WHO documents, national and provincial Pandemic Plan  In collaboration with other hospitals Disaster Management Cycle Preparedness

54. 1- Training:  The targeted audiences include decision makers and other key elected and appointed officials, first responders, local health department personnel, and health care system personnel.  Some of the more important topics to be covered: plans and procedures familiarization, media relations, and pandemic characteristics and history

55. Disaster Management Cycle Preparedness 2- Exercises:  Tabletop exercises must be conducted for various audiences, including those who will implement the state’s response plans, response partners and other stakeholders.  roles and main operational concepts have been established and tested via tabletop exercises, functional and/or full-scale exercises may be needed to test the emergency response organizational structure in “real time”

56. Disaster Management Cycle Preparedness 3- Planning for Risk communication :  Timely, accurate, consistent and useful information must be regularly provided to the public, health care providers, local officials and the news media.

57. Disaster Management Cycle Preparedness 4- Resource stockpiling :  Vaccines  Drugs & ….  national and state stockpiles of medications will be necessary to support response activities.

58. Planning – What does it Require? Surge capacity for beds, personnel, morgue Personnel protective equipment Ventilators, gloves & ….. Major isolation plan Staff education Develop internal rationing plan Facilities Supplies Infection control Vaccine/ Drugs Coordinate with State/County

59. Disaster Management Cycle Response 1- Coordination and management: The main thrust is to keep state partners in the response effort informed through briefings, conference calls, and other updating and shared decision making mechanisms.

60. 60 Disaster Management Cycle Response 2- First and foremost: “Scene” safety!!!  Research has shown that a significant percentage of health care workers, and, by extension, other priority personnel who will come in contact with the public, such as law enforcement, will not come to work in a pandemic out of fear of self contamination or contamination of their families. Plans will need to be made to provide protection to these personnel, or very little else will go according to plan.

61. Disaster Management Cycle Response 3- Needs assessment: Meeting health care needs Basic societal needs  Law enforcement  Food deliveries  Fuel deliveries  Utilities  Monetary system  Power plants  Continuity of government

62. Disaster Management Cycle Response 4- collaborate with the World Health Organization (WHO) and other nations in all related pandemic efforts Work with counties/cities in the designation of quarantine and isolation sites, and provide enforcement where necessary.

63. Disaster Management Cycle Response 5- Control of the Pandemic (Activate Surveillance and laboratory testing):  Activate prevention and control activities  Define the magnitude and severity of pandemic  Epidemiologic surveillance  Provide front-line pathology labs  Provide definitive reference labs and epidemiologic surveillance/information  monitor circulating strains

64. Disaster Management Cycle Response 6- Vaccine delivery:  Once vaccine becomes available, major activities will consist of distributing vaccine to public and/or private sector vaccinators, appropriate storage, handling and vaccination, dose tracking, safety monitoring, and also using

65. Disaster Management Cycle Response 7- Medication distribution:  Coordinate distribution of pharmaceuticals, vaccines and other critical medical supplies and equipment to states of key medical supplies and personnel  This is primarily a logistical operation.

66. Disaster Management Cycle Response 8- Risk communications: A sufficient quantity of spokespersons should receive media training, instruction in crisis and risk communications and guidance on public health measures and messages prior to the onset of a pandemic. Technology, including Internet Websites, faxes, electronic mass mailing systems, satellite uplinks and telephone hotlines will play key roles in keeping the public and the health care community informed.

67. Disaster Management Cycle Response 9- Review and modify Plans and procedures: Plans and procedures must be adjusted to reflect any emergency legislation or administrative rule changes. In addition, response partners must review and modify plans and procedures to reflect changing conditions and needs.

68. طرح مقابله بیمارستانی با بحران وقوع پاندمی ها : 1 ـ طرح هاي بحران کشوري، منطقه‌اي و بیمارستانی را مورد بررسي قرار داده و اقدامات مرتبط با بیمارستان خود را مورد توجه قرار دهيد. 2 ـ جهت ادامه کار بیمارستان با وجود کاهش تعداد و توان شاغلين برنامه ريزي نماييد. 3 ـ توانايي تأمين کنندگان تجهيزات و ملزومات جهت ادامه کار در زمان بحران را مورد بررسي قرار دهيد. 4 ـ سياستگذاري ويژه استراحت پزشکي مبتلايان به بيماري انجام پذيرد 5 ـ ميزان تماس هر يک از کارمندان با بيماران احتمالي و مراجعين مورد ارزيابي قرار گيرد.

69. 6 ـ آيا امکان انجام وظايف کارکنان در منزل وجود دارد ؟ ( اين امر ممکن است نياز به تأمين تجهيزات مخابراتي ويژه‌اي داشته باشد. ) 7 ـ مشاغل حياتي در بیمارستان را شناسايي نماييد و براي اين مشاغل سه يا چهار فرد جانشين را معرفي نموده يا آموزش دهيد چنانکه بتوانند آن شغل را بدون اختلال در عملکرد ادامه دهند. همچنين راههايي براي ادامه حيات بیمارستان بدون وجود اين مشاغل پيش بيني کنيد. 8- تجهيزات و ملزومات کافي ( از قبيل دستمال کاغذي و صابون و لوازم شوينده و غيره و تجهيزات پزشکي لازم ) را انبار نموده و به تاريخ مصرف لوازم نيز توجه نماييد. در مصرف تجهيزات ابتدا لوازم قديمي تر مورد استفاده قرار گيرد. طرح مقابله بیمارستانی با بحران در خصوص وقوع پاندمی ها :

70. 9 ـ اطمينان حاصل نماييد که طرح بحران ( Disaster Plan) کليه شاغلين و مراجعين و جمعيت عمومي منطقه را تحت حمايت قرار مي‌دهد. 10- سياستهايي جهت افرايش فاصله ميان شاغلين و مراجعين و سايرين اتخاذ نماييد. تماسهاي چهره به چهره را کاهش داده و سياستهاي اشتغال از راه دور را توسعه دهيد. 11 ـ تيم مرکزي جهت اطلاع رساني به کارمندان و مشتريان تشکيل دهيد تا اطلاعات صحيح به موقع در اختيار همگان قرار گيرد. طرح مقابله بیمارستانی با بحران در خصوص وقوع پاندمی ها :

71. 12 ـ با کليه شاغلين ( استخدامي ، قراردادي ، پيمانکاري و غيره ) مسائلي از قبيل ، مسافرت ، حمل و نقل ،‌استراحت پزشکي ، مراقبت از افراد خانواده و ساير مسائل مربوط به نيروي انساني را مورد حلاجي قرار دهيد. 13- لوازم کنترل عفونت ( لوازم محافظتي مانند ماسک و دستکش و لوازم بهداشتي مانند صابون و دستمال کاغذي ) به مقدار کافي در محل کار تعبيه نماييد. 14 ـ اطلاعات و آموزشهاي لازم را بطور مداوم و به صورت قابل فهم به کليه پرسنل و جمعيت تحت پوشش خود ارائه دهيد. طرح مقابله بیمارستانی با بحران در خصوص وقوع پاندمی ها :

72. 15 ـ هماهنگي لازم با سازمانهاي خدماتي بهداشتي و درماني و سازمانهاي بيمه گر در زمينه چگونگي ارائه خدمات حين بحران را انجام دهيد. 16 ـ به شاغلين سازمان جهت مديريت ساير عوامل استرس زا حين بحران ( مانند مراقبت از بستگان ، کمبود لوازم ، فوت نزديکان و موارد مشابه ) کمک نماييد. 17 ـ جهت حمايت از شاغلين در برابر ابتلا به بيماري و کاهش ريسک انتقال بيماري در محيط کار برنامه ريزي نماييد.

73. Example  In planning for a possible influenza pandemic, the WHO published a document on pandemic preparedness guidance in 1999, revised in 2005 and in February 2009, defining phases and appropriate actions for each phase in an aide memoir entitled WHO pandemic phase descriptions and main actions by phase. The 2009 revision, including definitions of a pandemic and the phases leading to its declaration, were finalized in February 2009.

74. Example. Key components of the hospital preparedness checklist for pandemic influenza Incident pharmaceuticals command system:  Communication  Continuity of essential health services and patient care  Surge capacity  Human resources  Logistics and management of supplies, including pharmaceuticals

75.  Essential support services  Infection prevention and control  Case management  Surveillance: early warning and monitoring  Laboratory services Example. Key components of the hospital preparedness checklist for pandemic influenza

76. Don’t Remember: a pandemic will NOT stop other diseases or disasters

77. Tank you!