1. Not Just Decisions, the Right Decisions; Not Just Stuff but the Right Stuff Sally Phillips, RN, PhD March 6, 2009 Emergency Management Summit

2. Tiered Response Individual Hospital planning and response Individual Hospital planning and response Health care system planning and response Health care system planning and response Regional health care system planning and response Regional health care system planning and response State level planning and response State level planning and response Intrastate and Interstate planning and response Intrastate and Interstate planning and response Federal Response Federal Response

3. Decisions and Stuff Capabilities and Capacities( EXAMPLES) Capabilities and Capacities( EXAMPLES) – Workforce equipment, training, increase numbers, administrative changes – Supplies- Caches (ventilators, medications, and associated space, resupply and receiving augmented support) – Beds and space expansions – Labs Requirements to respond Requirements to respond – Planning Scenarios System wide expansions and policies System wide expansions and policies – Home care, primary care, ambulatory services – Other facilities in system Partners in individual hospital mission Partners in individual hospital mission – EMS

4. AHRQ Emergency Preparedness Resource Inventory (EPRI)

5. EPRI Goals Enable regions to compile an inventory of critical resources via a public domain database tool Enable regions to compile an inventory of critical resources via a public domain database tool Provide flexible access to inventory data via a web site Provide flexible access to inventory data via a web site Provide ability to make emergency requests and tabulate responses Provide ability to make emergency requests and tabulate responses – What resources do you need? – What resources can you share?

6. EPRI Inventory Structure Resource Type (Examples) Resources (Examples) Hospital Beds ICU Beds Physicians Trauma Surgeons Antibiotics Oral Cipro 500 Mg Doses Facility Capabilities Food Preparation Capability Resource Types, Resources Location Types, Locations Location Type (Examples) Locations (Examples) Hospitals Hospital ABC Nursing Homes Nursing Home XYZ EMS Agencies EMS Agency ABC Resources are “Assigned” to Location Types

7. EPRI Home Page

8. Inventory Data Entry and Data Quality

9. Resource Requirement Models AHRQ Surge Model AHRQ Surge Model – Estimates hospital resources needed to treat casualties from nine different WMD scenarios Mass Evacuation Transportation Model Mass Evacuation Transportation Model – Estimates transportation resources needed to evacuate patients from healthcare facilities

10. Models and Tools for Mass Casualty Surge Requirements Resources for WMD response

11. Surge Model Scenarios Biological Biological – Anthrax – Smallpox – Flu Pandemic – Food Contamination – Plague Chemical Chemical – Chlorine – Mustard – Sarin Nuclear / Radiological Nuclear / Radiological – 1 KT or 10 KT nuclear device – Radiological dispersion device (“Dirty bomb”) – Radiological point source Conventional explosive Conventional explosive

12. Surge Model Components Surge arrivals Hospital or network capacity Event Pre-hospital management Treated Died Surge Model Casualty Module Surge Model Hospital Module

13. Factors Considered Attack location characteristics (e.g., population density) Attack location characteristics (e.g., population density) Time delay between attack and when symptoms present (biological and radiological scenarios) Time delay between attack and when symptoms present (biological and radiological scenarios) Optional mass prophylaxis (biological and radiological scenarios) Optional mass prophylaxis (biological and radiological scenarios) Condition of casualties upon arrival at the ED (e.g., mild vs. severe symptoms) Condition of casualties upon arrival at the ED (e.g., mild vs. severe symptoms)

14. Hospital Resources in the Surge Model Durable equipment Durable equipment Human resources Human resources Pharmacy Pharmacy Consumable supplies Consumable supplies Personal protective equipment Personal protective equipment Psychological Support Psychological Support Housekeeping Housekeeping Lab / Radiology Lab / Radiology Mortuary Mortuary Nutrition Nutrition

15. Casualty Arrivals at Hospitals (Prophylaxis reduces hospitalizations from 5,000 to 1,048)

16. Hospitalized Patients by Day and Unit

17. Resource Requirements for this Scenario CategoryNameUnits Day of Peak Need Amount Needed on Peak Day Ancillary: Psychologist Psychological support FTE421 Capacity: Floor Med/Surg Bed Unit of Use 10588 Capacity: Ventilator Mechanical ventilator Machine Time 494 Engineering: Facility EngineeringFTE433 Epidemiology: Infection Control Patient infection control FTE451 Equipment:O2 Monitoring Oxygenation monitoring equipment Machine Time 4164 Equipment: Vent Tubing Ventilator equipment Unit of Use 494 Housekeeping: Janitorial Janitorial/HousekeepingFTE469 Housekeeping: Laundry Sheet change Unit of Use 4732 Lab/Radiology: Laboratory Laboratory machines Machine Time 415 Pharmacy: Antibiotics Cirprofloxacin or Doxycycline 400mg/100 mg bid 4732 Pharmacy: Antibiotics Rifampin or other 2nd line agent 600mg po bid 4199

18. Resource Requirements for this Scenario CategoryNameUnits Day of Peak Need Amount Needed on Peak Day PPE: Universal Universal Precautions PPE Unit of Use 4732 Radiology: CXR Radiology machines EA (Each) 38 Staff: CCM Intensivists (CCM) FTE416 Staff: MD Non-intensivists (MD) FTE328 Staff: Pharmacist Pharmacists (PharmD/RPh) FTE529 Staff: Rad Tech Radiologic Technicians FTE38 Staff: RN Non-critical care nurses (RN/LPN) FTE3126 Staff: RT Respiratory Therapists (RT) FTE433 Supplies: IV set Antibiotics intravenous infusion set Unit of Use 4465 Supplies: IV Set Intravenous infusions set Unit of Use 4543 Supplies: Laboratory Laboratory supplies Unit of Use 4349 Supplies: Oxygen Oxygen (O2) Unit of Use 4283

19. Comparison of Required and Available Resources Display of staffing levels from HHS Area Resource File Display of staffing levels from HHS Area Resource File

21. Surge Model Treatment Paths Emergency Department Floor ICU Arriving Casualty Dead Or Discharged Patients x1

22. Surge Model uses NIGMS MIDAS (Epicast) Flu Model Output

23. Example of Surge Model Output: Ventilator Requirement over Time

24. Calculating Patient Type-Specific Resource Consumption First define average resource requirements per unit, per patient type, and per time interval First define average resource requirements per unit, per patient type, and per time interval Calculate, based on LOS and death/transfer rates, the number of patients in any resource consumption category at any given time Calculate, based on LOS and death/transfer rates, the number of patients in any resource consumption category at any given time

25. Hospital Bed Availability and Patient Tracking System (HAvBED) Prototype “real-time” standardized data reporting tool Prototype “real-time” standardized data reporting tool – Enhance system/region’s ability to care for surge of patients from public health emergency (e.g., flu) – Provides timely reporting of bed status data in an emergency (includes GIS) Nationwide scope: prototype participants (Dec, 2005) Nationwide scope: prototype participants (Dec, 2005) Standard Bed Reporting categories Standard Bed Reporting categories http://ahrq.gov/research/havbed/definitions.htm Sustainable Bed Availability Reporting System (HAvBED2) Delivered to DHHS 12/07 Sustainable Bed Availability Reporting System (HAvBED2) Delivered to DHHS 12/07

26. Discharge Criteria for Creation of Hospital Surge Capacity The Grant focus was the development of: an easy-to-apply method for pre-designating hospitalized patients suitable for early discharge in the event of a disaster. an easy-to-apply method for pre-designating hospitalized patients suitable for early discharge in the event of a disaster. a tool tested and evaluated in comparison with the current ad hoc method of identification of such patients. a tool tested and evaluated in comparison with the current ad hoc method of identification of such patients. Kelen, G. Johns Hopkins University Current development of a decision support tool underway with the Disaster Alternative Care Site Project with ASPR on this topic

27. Project Xtreme Cross Training Video Model for Health Professional’s Cross Training for Mass Casualty Respiratory Needs Tool for assisting with mechanical ventilator staff surge Tool for assisting with mechanical ventilator staff surge Curriculum developed for ‘just in time’ training for SNS Curriculum developed for ‘just in time’ training for SNS Identifies appropriate health care professionals to be trained and used in a surge situation Identifies appropriate health care professionals to be trained and used in a surge situationhttp://ahrq.gov/prep/projxtreme/

28. Mass Evacuation Transportation Model A planning tool for estimating the transportation resources required to evacuate healthcare facilities – Estimate evacuation time, given transportation constraints – Or, estimate transportation assets needed to evacuate within a time constraint

29. The Model Considers Location of evacuating and receiving facilities Location of evacuating and receiving facilities Patient transportation requirements Patient transportation requirements Availability of transport vehicles Availability of transport vehicles Surge capacity of receiving facilities Surge capacity of receiving facilities Traffic congestion Traffic congestion

30. Illustrative Hospital Evacuation

32. Model Pilot Tests New York City (April 2006) New York City (April 2006) – Category 4 hurricane – Evacuation of 24 hospitals and 61 nursing homes in coastal areas (approximately 24,000 patients) – Planned evacuation (72 hours notice) Los Angeles (May 2007) Los Angeles (May 2007) – Major earthquake – Evacuation of 3 hospitals (900 patients)

33. Changes to ALS Availability (Los Angeles)

34. Changes to Standard of Care (Los Angeles)

36. Mass Medical Care with Scarce Resources: Community Planning Guide Provides community planners, as well as planners at the institutional, State, and Federal levels, with information to help plan for and respond to a mass casualty event Provides community planners, as well as planners at the institutional, State, and Federal levels, with information to help plan for and respond to a mass casualty event Guide is written by leading experts in 6 areas related to mass casualty care: prehospital care, hospital and acute care, alternative care sites, palliative care, ethical issues, and legal considerations. Guide is written by leading experts in 6 areas related to mass casualty care: prehospital care, hospital and acute care, alternative care sites, palliative care, ethical issues, and legal considerations.http://www.ahrq.gov/research/mce/

37. Mass Medical Care with Scarce Resources: A Community Planning Guide Collaboration between AHRQ and ASPR Ethical Considerations in Community Disaster Planning Ethical Considerations in Community Disaster Planning Assessing the Legal Environment Assessing the Legal Environment Prehospital Care Prehospital Care Hospital/Acute Care Hospital/Acute Care Alternative Care Sites Alternative Care Sites Palliative Care Palliative Care Influenza Pandemic Case Study Influenza Pandemic Case Study

38. Ethical Principles Greatest good for greatest number Greatest good for greatest number Ethical process requires Ethical process requires – Openness – Explicit decisions – Transparent reporting – Political accountability Difficult choices will have to be made; the better we plan the more ethically sound the choices will be Difficult choices will have to be made; the better we plan the more ethically sound the choices will be

39. Legal Issues Advance planning and issue identification are essential, but not sufficient Advance planning and issue identification are essential, but not sufficient Legal Triage – planners should partner with legal community for planning and during disasters Legal Triage – planners should partner with legal community for planning and during disasters

40. Questions and Discussion

41. http://www.ahrq.gov/prep/

42. Publications & Tools To order a copy of reports, tools, or resources: To order a copy of reports, tools, or resources: – contact the AHRQ Publications Clearinghouse at 800-358-9295 – Send an E-mail to ahrqpubs@ahrq.hhs.gov. ahrqpubs@ahrq.hhs.gov

43. For More Information Contact: Sally Phillips, RN, PhD Email: sally.phillips@ahrq.hhs.gov