Medical Surge Capacity Bill Jermyn, DO, FACEP 11/24/2018

What Do We Have Today? I have no clear cut answers for you. This is an awareness message. Not what you wanted to hear. As with everything else, we are better off than 4 years ago, but not yet prepared for a big event. 11/24/2018

What Do We Need for Surge Capacity? Physical space Equipment Staff 11/24/2018

Physical Space Many regions and hospitals have made plans for alternative sites to deliver care Examples are auditoriums, gymnasiums, ambulatory care settings, etc Actually getting possession may be problematic Hospitals unlikely to be able to provide a significant number of beds According to AHA: avg. open beds are only 4-6% of bed capacity 11/24/2018

Equipment HRSA funded trailers are either dispersed or planned for dispersal across the state Surge Trailers: cots and minimal supplies Mass Casualty Trailers: cots, generators, and trauma supplies Decontamination and PPE Trailers: Some supplies, wash down equipment, PPE, etc Most hospitals have adopted “just in time” supply strategies 11/24/2018

Staff Probably the most critical component and the area least prepared Complicated problem with no easy solutions—legal liability (civil and criminal), scope of practice, credentialing, payment, logistics FYI: Post-SARS, Toronto doesn’t plan for outside facilities since there is no one to staff them 11/24/2018

Staff 20 years ago there was an RN surplus Today, estimated shortfall is 126,000 RN’s By 2020, 750,000 RN’s Daily shortage of surgeons and on-call specialists for trauma call Emergency Physicians are barely replacing themselves 11/24/2018

What Happened? Since 1986, move to outpatient therapy and earlier discharges from the hospital (HMO’s, PPO’s, etc) Result was fewer hospital beds Community Hospitals: 1975: 424 beds/100,000 population 2003: 280 beds/100,000 population 11/24/2018

What Happened? 1990-1999: Hospitals lost 103,000 inpatient medical/surgical beds and 7,800 ICU beds nationally. 1992-2003: ED visits increased by 26% (90 to 114 million/year) while the number of ED’s dropped by 14%. This has significantly increased the patient load of the remaining facilities. 11/24/2018

What Do We Have Now? Day to day capacity is strained-crowding and ambulance diversion (every minute of every day) Boarding, crowding, and diversion National problem Limited training for medical personnel to function in a disaster scenario 11/24/2018

What Do We Have Now? Gina Lagarde, MD, MBA-LA Office of Public Health- Post-Katrina/Rita:“…care to patients in nontraditional settings was not understood.” Hawaiian Medical Society polled thousands of healthcare workers post 9/11. Only 50% felt prepared enough to even come to work after potential chemical or biological exposures 11/24/2018

What Do We Have Now? 2003 ACEP survey: 80% respondents said their ED’s lacked surge capacity because of crowding, boarding, and a lack of on-call specialists Shift to outpatient therapy has severely taxed our ability to respond when the system fails 11/24/2018

2001 “…emergency departments are overwhelmed ….” “The problem is that the supply of care has been choked back.” “…another could be to recognize emergency medical care as an essential public service, one that should be provided to every community….” 11/24/2018

2003 “Emergency Department crowding is not an issue that can be solved in the ED alone.Rather, it is a complex issue that reflects the broader health care market. It is clear that, as a key part of the health care safety net, ED’s in many of the nation’s largest cities are under strain.” GAO March 2003 HOSPITAL EMERGENCY DEPARTMENTS Crowded Conditions Vary among Hospitals and Communities GAO-03-460 11/24/2018

January 2006 “Local emergency departments are at the front line of this national crisis.” “…they must wait in emergency department hallways for hours and sometimes days.” “…emergency medicine systems in many states are under extreme stress.” ‘Policymakers, physicians, and the general public should take note and take steps to address the shortcomings….” The National Report Card on the State of Emergency Medicine American College of Emergency Physicians www.acep.org 11/24/2018

14 June 2006 “…the nation’s emergency medical system is overburdened, underfunded, and highly fragmented….” “This crisis is multifaceted and impacts every aspect of emergency care—from prehospital EMS to hospital-based and trauma care. The American public places its faith in the ability of the emergency care system to respond appropriately whenever and wherever a serious illness or injury occurs. But while the public is largely unaware of the crisis, it is real and growing.” 11/24/2018

Outpatient and “Special Needs” Estimated 150,000 home health patients in MO Dialysis patients Dementia patients Assisted living, rehabilitation facilities, skilled nursing facilities, and nursing homes Elderly and chronically ill will increase as baby boomers mature Home oxygen therapy, nebulizer patients, etc Estimates run 45-55% of the population 11/24/2018

Why? Healthcare is not funded for surge capacity. Encouraged to be 100% efficient. We need to develop a way to assist healthcare with their ability to surge properly. 11/24/2018

11/24/2018

Take Home Physical space and equipment are being addressed Staffing remains a problem Hospitals will be unable to provide much capacity without significant help Medical system at capacity daily Shelters only provide a place to lay down; need to plan for field hospital care 11/24/2018

Take Home Liability and altered standards of care issues need to be addressed Credentialing process is needed Backfill needs to be supported Pediatrics are forgotten too often Need to plan for care for families of workers The normal flow of emergencies will not cease during a disaster scenario 11/24/2018