For Independent Medical Practices

In Central Ohio

Columbus Medical Association

Sponsored by:

Central Ohio Trauma System

Ohio Department of Health

CME & DisclosuresOhio State Medical Association

1.5 AMA PRA Category 1 Credits ™As a provider accredited by the Accreditation Council for Continuing Medical Education, the Ohio State Medical Association, who is certifying this activity for CME credit, requires planning members and faculty to disclose if they have any financial relationships with commercial interests that would be considered in conflict with this presentation. The content of this presentation does not relate to any product of a commercial interest. Neither the speakers nor any planning committee member has any financial relationships with commercial interests to disclose.

MGMA / ACMPE2.0 Continuing Education Units

It’s Coming“One of the most important public health issues our Nation and the world faces is the threat of a global disease outbreak called a pandemic.

No one in the world today is fully prepared for a pandemic – but we are better prepared today than we were yesterday - and we will be better prepared tomorrow than we are today.”

Mike Leavitt, Health & Human Services Secretary

Experience ShowsNumber of Episodes of Illness, Healthcare Utilization, and Death Associated with Moderate and Sever Pandemic Influenza Scenarios*

Source: 2006 HHS Pandemic Influenza Plan

Impact in Central Ohio2000 Census for Franklin County 1,068,978*

30% infection rate 320,693

50% seeking outpatient medical care160,347

Potential death rate

Moderate impact (0.23%) 2,459

Severe impact (2.1%) 22,449

*2000 Ohio County Profiles: Franklin County

From Outbreak to PandemicOutbreakSudden onset of a virus that

spreads rapidlyLocalized to a community or

regionHigh mortality rateThose infected are

asymptomatic during initial onset (show no evidence of the disease)

PandemicAn outbreak that spreads

worldwideNear-simultaneous

outbreaks in communities across the US

Enormous demand on healthcare system

Delays & shortage of vaccinesDisruption of community and

national infrastructures

MGMA Connexion, January 2009, Pg 13

Focus for Medical PracticesPandemic Response Plan Includes:

Clinical Care Plan

Business Continuity Plan

Personal and Family Response Plan

For Medical Offices

Necessary ComponentsCreate an internal flu monitoring systemDiagnosing Influenza-Like-Illness (ILI)Responding to suspected casesInfection controlAntiviral medications and vaccinesOther considerations

Flu Monitoring SystemUse various methods for diagnosing influenza cases

Rapid testingCulturing by an appropriate labWatch for signs and symptoms of

seasonal influenza

Track possible casesConsider monitoring all seasonal flu cases for experienceNecessary information to track for the CDC form

Demographics, Onset & duration, Related past medical history, Treatment regimen, Travel, Contacts potentially exposed, etc.

Flu Monitoring System (continued)Signs & Symptoms of Seasonal Flu

Acute infection of respiratory tract Fever (101oF – 102oF), usually with an

abrupt onset GI symptoms (nausea, vomiting,

diarrhea) Generally subside in 3-7 days Watch for complications

Febrile convulsions Viral pneumonia Bacterial pneumonia Otitis media

Diagnosing ILI (Influenza-Like-Illness)

History of Recent Exposure

Potential Occupational

Exposure

and

either/both

Current Signs of IllnessI

II III

CLINICAL CRITERIA

EPIDEMIOLOGIC CRITERIA

Diagnosing ILI I. Clinical Criteria

Temperature > 101oF – 102oF

Cough, sore throat, or dyspnea (labored breathing)

Requires hospitalization, or has a strong epidemiologic link

AND

Diagnosing ILIII. History of Recent Exposure

Recent travel to an affected area

Close contact with a person with suspected or confirmed novel influenza

Close contact with a person who died or was hospitalized due to a severe respiratory illness

Diagnosing ILIIII. Employment in an Occupation at Risk

Healthcare worker in direct contact with suspected or confirmed novel influenza case

Worker in a Lab that contains live novel influenza viruses

Worker in a poultry farm, live poultry market, or poultry processing operation with a known or suspected avian flu infection

Diagnosing ILICollecting Lab Specimen

Collect ALL of the following:Nasopharyngeal swabNasal swabThroat swabTracheal aspirate (if

intubated)

Storing specimen:Place into viral

transport mediaRefrigerate at 4oC

Responding to Suspected CasesIf “YES” to either Recent or Occupational exposure:

Initiate standard and droplet precautionsTreat as clinically indicatedNotify Communicable Disease Response System

CDRS (614) 719-8888 ext 1 (24 hours)

Initiate general work-up as clinically indicatedCollect and submit specimen for Novel Influenza virus

testing to the practice’s preferred laboratoryBegin empiric antiviral treatmentHelp identify all contacts, including healthcare workers

Infection Control“The period when an infected person is contagious depends on the age of the person. Adults may be contagious from one day before becoming sick and for three to seven days after symptoms develop. Some children may be contagious for longer than a week”

Source: “Influenza Fact Sheet”, Ohio Dept of Health, 2005

Pre-Symptom Onset of Symptoms

0 1 2 3 4 5 6 7 8 9 10

Potential Contagious Duration for an Adult

Potential Contagious Duration for a Child

Infection Control (Continued)Goal: Care for the sick and do not expose the healthy

Practices need an alternate plan

for patient flow during a Pandemic:Reschedule non-urgent office visitsTriage appointments by phone before

visit and redirect ILI casesRequire appropriate infection control measures for all

patients, family, transport, vendors, personnel, etc: Hand Hygiene/Cough Etiquette & Appropriate use of PPE Separation of ILI-patients from others

Infection Control (Continued)Personal Protective Equipment (PPE)

OSHA has outlined the following PPE to be used:Contact Precautions

Gloves and Gowns - New gloves and gown for each patient Use disposal equipment if possible (Thermometers, BP Cuffs) Disinfect other equipment between each patient (stethoscope)

Droplet Precautions Goggles when within 3 feet of the patient

Airborne Precautions Face Masks for patients and visitors N95 Respirators for personnel

(requires fit testing)

Antiviral Medications and Vaccinations

Antiviral medications for a novel influenza strain require 6 months to prepare

HHS will distribute vaccines from the national stockpile, coordinated by local health authorities

Healthcare workers are among the first to receive the vaccine, followed by high-risk individuals

Other Considerations1. Dual Medical Responsibility

2. Additional space needs

3. Increased hours of operation

4. Staff communications outside the office

5. Security considerations

6. Patient transport

7. Handling patient deaths in the office

8. Monitoring stress indicators of personnel

For Medical Offices

Necessary ComponentsBudgeting and stockpiling of medical suppliesPurchasing and storage of medical suppliesAntivirals and VaccinesEducation and training of personnelBudgeting for temporary reduction in cash flowAnticipate significant loss of available personnelPotential changes to sick-leave policyTemporary closure of the practice

Budgeting and Stockpiling Access to Supplies

Stockpile necessary medical supplies

Determine need & purchase over time

Employ FIFO ruleConsider warehousing

and security needs

Disposable SuppliesHand hygiene suppliesFace masks and

respiratorsFace shields, gowns,

glovesBlood pressure cuffsThermometersFacial tissue paper

Purchasing and Storage of Disposable Medical SuppliesCMA will maintain an emergency stockpile of limited

supplies for 20 days for the region N95 Respirators, Gloves, Gowns, & Face Masks

Practices should accumulate a 10 day stockpile Above items plus hand cleaners, BP cuffs, thermometers, tissue Store in a safe and secure space to protect from:

Unintended Use Accidental Damage or Theft Consider impact from natural environment (temperature, light,

moisture, etc) Rotate supplies to reduce waste from expiring

Antivirals & VaccinesHHS recommends against offices stockpiling antivirals

Individual purchases require prescription Expensive with Rx (Per dose: Tamiflu® $7-$8/ Relenza® $90-$105)*

3-5 times more expensive without Rx, authorized purchasers only Shelf Life (Tamiflu® – 36 mo / Relenza® – 60 mo)

National Stockpile Activities Ohio is ahead of its accumulation target:

25% of population by 2010, enough to cover Tier 1 individuals In 2010, set new stockpile target

Distribution will be conducted by HHS and carried out by Ohio DOH

*Current pricing as of December 2008

Education and Training“to ensure that all personnel understand the implications of, and control measures

for pandemic flu” –CDC, 2006

Identify a person with appropriate authority to coordinate training

Identify medical training programs (web-based & local)

Educate on infection control measures to prevent spread

Conduct an annual disaster drill which includes response to pandemic flu

Budgeting for Temporary Reduction in Cash FlowAnticipate a disruption in the billing & revenue cycle

Establish a Rainy Day FundDiscuss specific options with your accountantHow much the practice spends on average each dayHow many days the disruption will last (6-8 wks)How much disruption to expect (25%-35%)

Anticipate Significant Lossof Available PersonnelIn the worst scenarios, as much as 25% of the

population could be impactedPractices should prepare for a temporary reduction in

their workforce Cross-train personnel to perform critical tasks Focus on episodic care, avoiding unnecessary clinical steps Change workflow to accommodate critical needs Cancel unrelated or non-critical patient appointments Eliminate unnecessary business office tasks

Sick-Leave PolicyConsider modifications to address:

Onset of ILI symptoms in the workplaceCare for family membersAccess to, or leave for counseling services

Healthcare facilities must prepare to:Protect healthy personnel from exposureEvaluate and manage symptomatic and ill

personnel

Temporary Office ClosurePractice size mattersWho will decide to close the officeWhat triggers will be included

Space limitations Overwhelming reduction in staff Lack of necessary medical supplies

What resources may be reassigned Healthy personnel, medical supplies, available office space

Who will reassign available resources Potential support from a local Incident Command Center

For Medical Offices

Necessary ComponentsPractice personnel should consider how to address:

School and daycare center closingsMedical care for chronically illEssential services may be disrupted

Banks, restaurants, post offices, telephone companies, etc

Preparing a written family response planFamily food storageRainy day fund for each family member

Questions and Answers

For Medical Offices

Reporting Form for ILI Cases

http://www.ncid.cdc.gov/flu/H5Forms/H5CSF_Revised27Feb04.pdf

Supplies U/MOrder Qty* Cost/Unit Total Cost

Antimicrobial Soap 12/case 4 $40.80 $163.20Anti-bacterial lotion (waterless) 12/case 4 $181.32 $725.28Disposable Face Masks 50/box 160 $12.95 $2,072.00

Disposable (N95 Compliant) Respirators 30/box 60 $10.93 $655.80

Face Shields, Disposable 24/box 75 $35.49 $2,661.75

Gowns 50/case 29 $34.99 $1,007.71

Gloves 1000/case 13 $68.90 $909.48

Disposable BP Cuffs 5/box 320 $36.19 $11,580.80

Disposable thermometers 100/box 16 $15.75 $252.00

Facial Tissues 30/case 4 $21.65 $86.60

Subtotal Costs $20,114.62Taxes and shipping not included

*Staffing assumes 2 physicians, 4 clinical assistants and 3 administrative staff. Patient volume assumes 40 ILI patients per day, 5 days per week, 8 weeks

Education and Training Programs for Pandemic Influenza

CDC http://www.cdc.gov/flu/professionals/training/

HHS http://www.hhs.gov/pandemicflu/plan/sup4.htm

Ohio Dept of Health https://oh.train.org/DesktopShell.aspx?tabid=1

Necessary Cash On-Hand Required to Stay Open Per FTE Physician

25% Impact   Projection 1 Projection 2 Projection 3

Day's Cash On-Hand 45 60 90

Anticipated Impact 25% 25% 25%

Avg Daily Operating Cost* $1,625 $1,625 $1,625

Required Cash On-Hand $18,276 $24,368 $36,552

35% Impact   Projection 4 Projection 5 Projection 6

Day's Cash On-Hand 45 60 90

Anticipated Impact 35% 35% 35%

Avg Daily Operating Cost* $1,625 $1,625 $1,625

Required Cash On-Hand $25,586 $34,115 $51,173

           *Median Total Operating Cost from 2007 MGMA Cost Survey; Table 1.4c Operating Cost per FTE Physician All Multispecialty; TC/NPP excluded; Adjusted to 1/250 of total median figure (50 weeks x 5 days per week).