1. SC’s Critical Access & Rural Hospitals; Assessing Their Capability to Handle a Surge in Ventilator Patients Rich Branson MSc RRT FAARC Professor of Surgery University of Cincinnati Scott M. Lane, RRT, RCP Chairman, SCSRC Disaster Preparedness Committee Brooke Yeager, MSc, RRT, RCP President-Elect SCSRC

2. Chest. 2014 Aug 21. doi: 10.1378/chest.14-0733. [Epub ahead of print]

5. Critical Access Hospitals A Medicare participating hospital must meet the following criteria to be designated as a CAH: Be located in a State that established a State rural health plan for the State Flex Program Be located in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural for purposes of becoming a CAH; Demonstrate compliance with 42 CFR Part 485 subpart F at the time of application for CAH certification; Furnish 24-hour emergency care services 7 days a week, using either on-site or on-call staff, with specific on-site response timeframes for on-call staff Maintain no more than 25 inpatient beds that may also be used for swing bed services; however, it may also operate a distinct part rehabilitation or psychiatric unit, up to 10 beds; Have an average annual length of stay of 96 hours or less per patient for acute care

6. Participants The five critical access hospitals surveyed were: – Abbeville – Allendale – Edgefield – Fairfield – Williamsburg The rural hospitals surveyed were: – Cannon Memorial – Chesterfield – Coastal Carolina- No response – Lake City- - No response – Southern Palmetto Hospital- No response

7. The Survey Does your facility have a disaster plan?

8. The Survey Does your facility have a disaster plan? All CAH and Rural hospitals who responded had a disaster plan. This finding was suspected as this is a JCAHO requirement

9. The Survey The Space How many ICU beds are in your facility? How many recovery rooms or PACU beds are in your facility? How many emergency room beds are in your facility? The Staff Is there 24 hour day, in-house physician coverage? Is there 24 hour day, in-house respiratory therapy coverage? If not, how many hours? The Stuff How many ventilators does your facility own?

10. The Survey The Space How many ICU beds are in your facility? CAH – 3 none2 4-6 beds Rural – 4-6 beds How many recovery rooms or PACU beds are in your facility? CAH – four hospitals– none1– 4 beds, Rural – 2-4 beds How many emergency room beds are in your facility? CAH – 5-9, Rural 8-9

11. The Survey The Staff Is there 24 hour day, in-house physician coverage?Yes all_____ Is there 24 hour day, in-house respiratory therapy coverage CAH 3 Y Rural Y If not, how many hours?CAH 8 or 16 H The Stuff How many ventilators does your facility own? – CAH 1-4 (2), Rural 3-4

12. Bed Space

13. Total Additional Ventilators

14. The Survey Is your facility affiliated with a health system ? If yes, does this affiliation include transfer of patients during a disaster? If yes, does this affiliation include staff sharing? Could your facility accept patients from other areas in the event of a MCRF event? How many additional mechanically ventilated patients could your facility care for over an 8-12 week cycle?

15. The Survey Is your facility affiliated with a health system ? CAH – 4 N 1 Y, Rural – 2 Y If yes, does this affiliation include transfer of patients during a disaster? 1 Y If yes, does this affiliation include staff sharing?_No_ Could your facility accept patients from other areas in the event of a MCRF event?CAH 2- Y, 2 N, 1 Maybe____ How many additional mechanically ventilated patients could your facility care for over an 8-12 week cycle?_2-4 (two CAH 0)

16. The Survey Do you have an written agreement or contract with a medical equipment supplier to supply extra ventilators during a surge? __________

17. The Survey Do you have an written agreement or contract with a medical equipment supplier to supply extra ventilators during a surge? All No____

18. Increasing Capacity Neither the rural or CAH hospitals could contribute significantly to the Critical Care Capacity in the State. Additional patients at the CAH would require sending staff and stuff (ventilators) Critical care is best accomplished in centers with capacity and expertise Movement of less severely ill patients to CAH or rural hospitals seems prudent to clear space in larger centers

19. Conclusions CAH and rural hospitals should consider developing patient transfer agreements with larger health systems for diversion of patients in a mass casualty situation. Health systems should develop systems to direct patients requiring the highest levels of care to tertiary centers avoiding crowding of CAH and rural emergency departments. Transport teams with experience and equipment capable of caring for critically ill mechanically ventilated patients with respiratory failure should be developed for safe patient transfer. These teams should include a respiratory therapist.