No Vacancy: No Vacancy: Healthcare Surge Healthcare Surge Capacity in Capacity in DisastersDisasters

John L. Hick, MDJohn L. Hick, MDMDH/HCMCMDH/HCMCJuly 22, 2004July 22, 2004

Capacity vs. CapabilityCapacity vs. Capability

Surge Capacity – ‘the ability to manage Surge Capacity – ‘the ability to manage increased patient care volume that increased patient care volume that otherwise would severely challenge or otherwise would severely challenge or exceed the existing medical infrastructure’exceed the existing medical infrastructure’

Surge Capability – ‘the ability to manage Surge Capability – ‘the ability to manage patients requiring unusual or very patients requiring unusual or very specialized medical evaluation and specialized medical evaluation and intervention, often for uncommon medical intervention, often for uncommon medical conditions’conditions’

Barbera and MacintyreBarbera and Macintyre

Different types of ‘surge’Different types of ‘surge’

Unexpected vs. expectedUnexpected vs. expected Timeline and potential for secondary Timeline and potential for secondary

cases (anthrax vs. plague)cases (anthrax vs. plague) Static vs. dynamicStatic vs. dynamic Triage / field treatment Triage / field treatment Healthcare facility-basedHealthcare facility-based Community-basedCommunity-based

Concepts and PrinciplesConcepts and Principles

StandardizationStandardization Incident Management SystemIncident Management System Multiagency Coordination SystemMultiagency Coordination System Public Information SystemsPublic Information Systems Interoperability (eg: personnel and Interoperability (eg: personnel and

resource typing)resource typing) ScalabilityScalability FlexibilityFlexibility Tiers of capacity (spillover to next level)Tiers of capacity (spillover to next level)

HCF A HCF CHCF B Healthcare Facility 1st Tier

2nd TierHealthcare “Coalition” (Compact)

Jurisdiction I

(PH/EM/Public Safety)

Non-HCF Providers

Medical Support

3rd TierJurisdiction Incident

Management (County)

4th Tier

Jurisdiction II

(PH/EM/Public Safety)

Coordination of Intrastate Regions (MDH)

5th Tier

Federal Response 6th Tier

State / Interstate Coordination (MDH)State A State B

Federal Response

(Regional & National)

Tiers of Response – Patient Care

Minnesota Local Public Health Regions

HRSAHRSAGrantGrant

Minnesota Hospital Minnesota Hospital ResourcesResources

140 acute care hospitals140 acute care hospitals State total 16,414 licensed bedsState total 16,414 licensed beds Less than 50% of these operatingLess than 50% of these operating

Loss of 36 hospitals, 3000 beds in past Loss of 36 hospitals, 3000 beds in past 20 yrs20 yrs

Nearly half of MN hospitals are either Nearly half of MN hospitals are either ‘critical access’ or considering such ‘critical access’ or considering such designationdesignation

Staff shortages, particularly nursing Staff shortages, particularly nursing staffstaff

Metropolitan Hospital Metropolitan Hospital CompactCompact Since April 9, 2002Since April 9, 2002 27 hospitals, approximately 4800 27 hospitals, approximately 4800

operating bedsoperating beds 7 counties7 counties Agreement provides for:Agreement provides for:

Staff and supply sharingStaff and supply sharing Staffing off-site facilities for first 48hStaffing off-site facilities for first 48h Communications, JPICCommunications, JPIC Regional Hospital Resource Center (HCMC)Regional Hospital Resource Center (HCMC)

Regional CoordinationRegional Coordination

Regional Hospital Resource Center (RHRC)Regional Hospital Resource Center (RHRC) Acts as ‘broker’ for patient transfersActs as ‘broker’ for patient transfers Coordinates hospital response and requests Coordinates hospital response and requests

within regionwithin region Represents hospital needs and issues to RCCRepresents hospital needs and issues to RCC

Regional Coordination Center (RCC or MAC)Regional Coordination Center (RCC or MAC) Multi-agency coordination center for policy and Multi-agency coordination center for policy and

strategic guidancestrategic guidance NO jurisdictional authorityNO jurisdictional authority Functions and scope determined by incidentFunctions and scope determined by incident

Hospital ResponseHospital Response At least 50% arrive self-referredAt least 50% arrive self-referred On average, 67% of patients in any On average, 67% of patients in any

given disaster are cared for at the given disaster are cared for at the hospital nearest the event (range 41-hospital nearest the event (range 41-97%)97%)

Redistribution from the hospital Redistribution from the hospital closest to the incident scene to other closest to the incident scene to other facilities may be as (or more) facilities may be as (or more) important than transport from the important than transport from the scenescene

Facility-based SurgeFacility-based Surge Usually can free up 15% of beds at a given Usually can free up 15% of beds at a given

facilityfacility Get ‘em up and get ‘em out (ED, clinics)Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home)Discharges and transfers (eg: nursing home) Board patients in hallsBoard patients in halls Cancel elective proceduresCancel elective procedures Convert procedure/PACU areas to patient Convert procedure/PACU areas to patient

carecare Accommodate vents on floor (or BVM or Accommodate vents on floor (or BVM or

austere O2 flow powered ventilators)austere O2 flow powered ventilators) Supply and staffing issues (72h ahead)Supply and staffing issues (72h ahead)

Per 1000 patients Per 1000 patients injuredinjured

250 dead at scene250 dead at scene 750 seek medical care750 seek medical care

188 admitted188 admitted 47 to ICU47 to ICU

‘‘Rule of 85/15%’ has applied to all Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11disasters thus far inc NYC 9-11

Community-Community-Based Based SurgeSurge ClinicsClinics HomecareHomecare Nursing homesNursing homes Procedure centersProcedure centers Family-based careFamily-based care Off-site hospitals (Acute Care Center)Off-site hospitals (Acute Care Center) Off-site clinics (Neighborhood Emergency Off-site clinics (Neighborhood Emergency

Help Centers) (assessment and clinic level Help Centers) (assessment and clinic level care)care)

Local / Regional referral / NDMSLocal / Regional referral / NDMS

Potential Alternative Potential Alternative Care SitesCare Sites Aircraft hangersAircraft hangers Military facilitiesMilitary facilities ChurchesChurches National Guard National Guard

armoriesarmories Community/Community/

recreation centersrecreation centers Surgical centers / Surgical centers /

medical clinicsmedical clinics Convalescent care Convalescent care

facilitiesfacilities

Sports facilities / Sports facilities / stadiumsstadiums

FairgroundsFairgrounds TrailersTrailers Government Government

buildingsbuildings TentsTents Hotels/motelsHotels/motels WarehousesWarehouses Meeting hallsMeeting halls

Factors to considerFactors to consider Ability to lock Ability to lock

down/Securitydown/Security HVACHVAC Lab/specimen handlingLab/specimen handling LightingLighting LaundryLaundry Loading DockLoading Dock Equipment storageEquipment storage Oxygen delivery capabilityOxygen delivery capability Waste disposalWaste disposal ParkingParking Communications Communications

capabilitycapability

Patient deconPatient decon Door sizeDoor size Pharmacy areasPharmacy areas Electrical power with Electrical power with

backupbackup Proximity to hospitalProximity to hospital Family areasFamily areas Toilets/showers/wasteToilets/showers/waste Food supply / prep areaFood supply / prep area Water supplyWater supply Wired for IT/Internet Wired for IT/Internet

accessaccess

Off-site hospitalOff-site hospital

Triage / admission criteriaTriage / admission criteria Level of care – basic nursing, drip Level of care – basic nursing, drip

meds, IVs, NG feedsmeds, IVs, NG feeds MedicationsMedications Documentation / order managementDocumentation / order management LaboratoryLaboratory Food / water / sanitaryFood / water / sanitary Linen and medical waste handlingLinen and medical waste handling Oxygen?Oxygen?

Personnel AugmentationPersonnel Augmentation Hospital personnelHospital personnel Clinic personnelClinic personnel Medical Reserve CorpsMedical Reserve Corps Non-clinical practice professionalsNon-clinical practice professionals Retired professionals (eg: HC Medical Retired professionals (eg: HC Medical

Society)Society) Trainees in health professionsTrainees in health professions Ski patrol, civil air patrol, other service Ski patrol, civil air patrol, other service

organizationsorganizations Lay public (CERT teams, etc)Lay public (CERT teams, etc) Federal / interstate personnelFederal / interstate personnel

Sample SiteSample Site

Sample SiteSample Site FoodFood RestroomsRestrooms Staff rehab areasStaff rehab areas SecureSecure HVAC system specsHVAC system specs Paging Paging

/messaging /radio/messaging /radio PowerPower Phone, T1 lines, etc.Phone, T1 lines, etc. City owned!City owned!

ResourcesResources

Off-site matrix: Off-site matrix: www.denverhealth.org/bioterror/toolswww.denverhealth.org/bioterror/tools

MaHIM: MaHIM: www.gwu.edu/~icdrmwww.gwu.edu/~icdrm Model hospital planning: Model hospital planning: www.er1.orgwww.er1.org Off-site facilities and community Off-site facilities and community

planning: planning: www2.sbccom.army.mil/hld/bwirp/www2.sbccom.army.mil/hld/bwirp/

Annals of Emergency Medicine Annals of Emergency Medicine www.mosby.com/aemwww.mosby.com/aem ‘articles in press’ ‘articles in press’ (left side)(left side)