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Hospital Preparedness for Emergency Response: United States, 2008 Richard Niska, MD, MPH, FACEP Captain, USPHS Iris M. Shimizu, PhD National Center for Health Statistics 22 June 2011

Hospital Preparedness for Emergency Response: United States, 2008

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Hospital Preparedness for Emergency Response: United States, 2008. Richard Niska, MD, MPH, FACEP Captain, USPHS Iris M. Shimizu, PhD National Center for Health Statistics 22 June 2011. Objective. Summary of hospital preparedness for responding to public health emergencies: Mass casualties - PowerPoint PPT Presentation

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Page 1: Hospital Preparedness for Emergency Response: United States, 2008

Hospital Preparedness for Emergency Response:

United States, 2008

Richard Niska, MD, MPH, FACEPCaptain, USPHS

Iris M. Shimizu, PhD

National Center for Health Statistics

22 June 2011

Page 2: Hospital Preparedness for Emergency Response: United States, 2008

Objective

Summary of hospital preparedness for responding to public health emergencies:

Mass casualties Epidemics of naturally occurring diseases

Page 3: Hospital Preparedness for Emergency Response: United States, 2008

Prior work

Bioterrorism and Mass Casualty Preparedness Supplement 2003-2004 National Hospital Ambulatory Medical Care

Survey (NHAMCS) Funded by Office of the Assistant Secretary

for Planning and Evaluation (OASPE)

Page 4: Hospital Preparedness for Emergency Response: United States, 2008

Publications from 2003-2004 supplement

Hospital collaboration with public safety organizations on bioterrorism response. Prehospital Emergency Care; 2008; 12:12-17.

Emergency response planning in hospitals, US: 2003-04. Advance Data from Vital and Health Statistics; 2007; 391. www.cdc.gov/nchs/data/ad/ad391.pdf

Percentage of hospitals with staff members trained to respond to selected terrorism-related diseases or exposures – NHAMCS, US, 2003-04. MMWR. 2007; 56(16):401. www.cdc.gov/mmwr/preview/mmwrhtml/mm5616a6.htm

Training for terrorism-related conditions in hospitals: US, 2003-04. Advance Data from Vital and Health Statistics, 2006; 380. www.cdc.gov/nchs/data/ad/ad380.pdf

Percent of hospitals having plans or holding drills for attacks by explosion or fire. MMWR, 2005; 54(42). www2c.cdc.gov/podcasts/download.asp?f=1096061&af=h&t=1

Bioterrorism and mass casualty preparedness in hospitals: US, 2003. Advance Data from Vital and Health Statistics, 2005; 364. www.cdc.gov/nchs/data/ad/ad364.pdf

Page 5: Hospital Preparedness for Emergency Response: United States, 2008

Current work

Pandemic Emergency Response Preparedness Supplement – 2008 Parent survey: NHAMCS Again funded by OASPE

Page 6: Hospital Preparedness for Emergency Response: United States, 2008

Methods:NHAMCS

NHAMCS uses a national probability sample: U.S. nonfederal general and short-stay hospitals Data weighted to produce national estimates

Collects facility & visit level hospital characteristics Facility level: emergency response supplement Visit level: emergency and outpatient department records

Page 7: Hospital Preparedness for Emergency Response: United States, 2008

Methods:Emergency response supplement

Eight-page survey instrument

Delivered on site to hospital administrator by U.S. Census Bureau field representative

Self-administered by hospital staff member deemed appropriate by administrator

Collected later by Census field representative

Page 8: Hospital Preparedness for Emergency Response: United States, 2008

Emergency response plans

Scenarios: Hospital overcrowding Disasters Mass casualties Disease outbreaks Terrorism

Choices: in emergency response plan implemented in actual incident during 2007 not in emergency response plan

Page 9: Hospital Preparedness for Emergency Response: United States, 2008

Perc

ent

95% confidence intervals

Percent of hospitals with emergency response plans for selected types of incidents:

United States, 2008

(1) NUC-RAD = Nuclear-radiological. (2) EXP-INC = Explosive-incendiarySOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 10: Hospital Preparedness for Emergency Response: United States, 2008

Collaboration with outside entities

Memorandum of understanding (MOU) with other hospitals to accept patients in transfer from the emergency department when no beds are available:

adults pediatric patients to children’s hospitals

MOU with regional burn center to accept transfers in the aftermath of an explosive or incendiary incident

MOU with other outpatient facilities to augment outpatient services

Regional communication systems to track: emergency department closures or diversions available intensive care unit beds (adult, pediatric, neonatal) available hospital beds (adult, pediatric, neonatal) specialty coverage

Mutual aid agreements with other agencies to share supplies and equipment

Page 11: Hospital Preparedness for Emergency Response: United States, 2008

Perc

ent

95% confidence intervals

Percent of hospitals having memorandum of understanding to accept emergency department transfers during overcrowding incidents or public

health emergencies, by receiving hospital type:United States, 2008

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 12: Hospital Preparedness for Emergency Response: United States, 2008

Expansion of on-site surge capacity

Cancellation of elective procedures and admissions

Isolation of airborne disease patients in negative pressure areas

Conversion of inpatient units to augment intensive care unit (ICU) capacity

Alternate care areas with beds, staffing and equipment inpatient unit hallways decommissioned ward space non-clinical space

Setting up temporary facilities when the hospital is unusable (without power, flooded, etc.)

Page 13: Hospital Preparedness for Emergency Response: United States, 2008

Perc

ent

95% confidence intervals

Percent of hospitals with plans for selected components of on-site surge capacity expansion:

United States, 2008

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 14: Hospital Preparedness for Emergency Response: United States, 2008

Priority setting for limited resources

Delivery of potassium iodide in response to radioactive release

Adjusted standards of care for initiation and withdrawal of mechanical ventilation

Triage processes for limited intensive care resources

Regional coordination of standards of care during a pandemic or other mass casualty incident

Page 15: Hospital Preparedness for Emergency Response: United States, 2008

Percent of hospitals having written plan for adjusted standards of care for mechanical ventilators during a

public health emergency:United States, 2008

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 16: Hospital Preparedness for Emergency Response: United States, 2008

Expanding on-site health care work force

Continuity of operations

Mutual aid agreements to share health care providers

Advance registration of volunteer health professionals

Staff absenteeism due to personal impact from the emergency

On-site child care to maintain staff in hospital

Page 17: Hospital Preparedness for Emergency Response: United States, 2008

Percent of hospitals having written plan for advance registration of volunteer health professionals during a

public health emergency:United States, 2008

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 18: Hospital Preparedness for Emergency Response: United States, 2008

Mass casualty management

Within-hospital transport of large patient numbers

Inter-hospital transport of large patient numbers

Hospital evacuations

Establishing an on-site large capacity morgue

Page 19: Hospital Preparedness for Emergency Response: United States, 2008

Hospital evacuations Within-hospital transfer of many pa-

tients

Inter-hospital trans-fer of many patients

Establishing large capacity morgue

0102030405060708090

100

94.6 83.9 77.062.6Pe

rcen

t

95% confidence intervals

Percent of hospitals with plans for selected components of mass casualty management:

United States, 2008

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 20: Hospital Preparedness for Emergency Response: United States, 2008

Pediatric

Guidelines on increasing pediatric surge capacity

Protocol to identify and protect displaced children rapidly

Tracking accompanied and unaccompanied children

Reunification of children with families

Supplies for sheltering healthy displaced children

Page 21: Hospital Preparedness for Emergency Response: United States, 2008

Tracking system for children

Reunification with families

Increasing pe-diatric surge

capacity

Identifying and protecting dis-placed children

Supplies for sheltering

0102030405060708090

100

42.6 34.0 32.4 31.1 29.4

Perc

ent

95% confidence intervals

Percent of hospitals with plans for selected components related to pediatrics:

United States, 2008

Page 22: Hospital Preparedness for Emergency Response: United States, 2008

Special populations

Communication with: deaf patients blind patients non-English-speaking patients

Sheltering of: mobility-impaired patients technology-dependent patients pregnant women patients with special health care needs mentally challenged patients

Page 23: Hospital Preparedness for Emergency Response: United States, 2008

Communication with non-English speakers

Communication with deaf patients

Communication with blind patients

0102030405060708090

100

73.358.3 47.5

Perc

ent

95% confidence intervals

Percent of hospitals with plans for selected components of communication with special populations:

United States, 2008

Page 24: Hospital Preparedness for Emergency Response: United States, 2008

Mobility-impaired

Special health care needs

Pregnant women

Mentally chal-lenged

Technology-dependent

0102030405060708090

100

47.6 46.7 39.2 39.0 33.7

Perc

ent

95% confidence intervals

Percent of hospitals with plans for selected components of sheltering special populations patients:

United States, 2008

Page 25: Hospital Preparedness for Emergency Response: United States, 2008

Communications

Notification of alerts from health departments

Participation with local public health departments in education on influenza vaccination

Page 26: Hospital Preparedness for Emergency Response: United States, 2008

Mass casualty drills

In how many drills has your hospital participated in the last year?

Internal drills

Drills in collaboration with other organizations law enforcement, health department, emergency management, fire

department, emergency medical services, hazardous materials teams, decontamination teams

Full scale simulations How many victims (adult, pediatric, elderly)? How long did the drill last?

Table-top exercises

Page 27: Hospital Preparedness for Emergency Response: United States, 2008

Drill scenarios

General disaster and emergency response Biologic accidents or attacks

• acute decontamination of aerosol exposure• delayed disease outbreak management

Severe epidemic or pandemic Mass vaccinations Mass medication distribution to:

• hospital personnel• community

Chemical accidents or attacks Nuclear or radiological accidents or attacks Decontamination procedures Explosive or incendiary accidents or attacks

Page 28: Hospital Preparedness for Emergency Response: United States, 2008

Perc

ent

95% confidence intervals

Percent of hospitals participating in selected mass casualty drill scenario types:

United States, 2008

SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 29: Hospital Preparedness for Emergency Response: United States, 2008

Ambulance diversion

Total number of hours in 2007 that: Emergency department (ED) was on ambulance

diversion Hospital was on trauma diversion Hospital was on diversion for critical care cases

Page 30: Hospital Preparedness for Emergency Response: United States, 2008

None One to 220 hours More than 220 hours Unknown0102030405060708090

100

58.7

16.3 16.28.7

Perc

ent

95% confidence intervals

Percent of hospitals on ambulance diversion status, by number of hours spent on diversion:

United States, 2008

Cut point based on mean of 220.4 hours spent on diversion. Distribution highly skewed with median and mode both equal to zero (no diversion hours).SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey, 2008

Page 31: Hospital Preparedness for Emergency Response: United States, 2008

Key points:Explosions and fires

Preparedness for explosions and fires less frequent than for other mass casualties

Explosive terrorism infrequent in U.S. No incidents since 2001 More common internationally

Fires more common 15,500 fires in high-rises (1996-1998) 6% of these were in hospitalsU.S. Fire Administration. High-rise fires. Topical Fire Research Series

2(18):1-7. 2002.

Page 32: Hospital Preparedness for Emergency Response: United States, 2008

Key points:Emergency department crowding

ACEP recommends that hospitals develop adequate inpatient surge capacity by: canceling elective admissions and

procedures 83.6% of hospitals have plans for this

opening unused areas 52.3% have plans to use inpatient hallways

using alternate areas for extra critical care space

50.7% of hospitals have thisAmerican College of Emergency Physicians (ACEP). National

strategic plan for emergency department management of outbreaks of novel H1N1 influenza.

Page 33: Hospital Preparedness for Emergency Response: United States, 2008

Key points:Emergency department crowding

Study of adverse events from admitting ED-boarded patients to inpatient hallway beds during overcrowding situations.

Compared to patients admitted to standard beds: In-hospital mortality significantly lower for

hallway patients ICU transfers significantly lower for hallway

patients Conclusion: hallway boarding not harmfulViccellio et al. The association between transfer of emergency

department boarders to inpatient hallways and mortality: a 4-year experience. Ann Emerg Med 54(4):511-3. 2009.

Page 34: Hospital Preparedness for Emergency Response: United States, 2008

Key points:Crisis standards of care

IOM recommends development of consistent state crisis standards of care.

Institute of Medicine (IOM) of the National Academies. Guidance for establishing crisis standards of care for use in disaster situations. Report Brief 1-4. 2009.

Only 43% of hospitals plan for adjusted standards of care for ventilators during mass casualties.

Model for developing such standards: Triage system for using ventilators based on

clinical factors related to survival potential Implemented through health department Supported by governor declaration Liability protections in placeHick & O’Laughlin. Concept of operations for triage of mechanical

ventilation in an epidemic. Acad Emerg Med 13(2):223-9. 2006.

Page 35: Hospital Preparedness for Emergency Response: United States, 2008

Key points:Epidemic drills

ACEP also recommends staging exercises to test validity of pandemic flu training and plans.

59% of hospitals staged severe epidemic drills. 33% included mass vaccinations. 23% included community medication distribution.

Survey of health care epidemiologists 60% felt hospital was well-prepared for pandemic 31% reported shortages of antiviral medications Important priorities:

Pandemic flu plan revisions Mandatory flu vaccination for health care workers

Lautenbach et al. Initial response of health care institutions to emergence of H1N1 influenza: experiences, obstacles, and perceived future needs. Clin Infect Dis 50(4):528-30. 2010.

Page 36: Hospital Preparedness for Emergency Response: United States, 2008

Key points:Advance registration of health professionals

Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP)

Office of Assistant Secretary of Preparedness & Response (OASPR)

Grant program for health care facilities to verify credentials of volunteers during emergencies

Only 56% of hospitals had plans for advance registration of outside health care professionals.

Page 37: Hospital Preparedness for Emergency Response: United States, 2008

The report and contact information

Niska RW, Shimizu IM. Hospital preparedness for emergency response: United States, 2008. National health statistics reports; no 37. Hyattsville, MD: National Center for Health Statistics. 2011.

http://www.cdc.gov/nchs/data/nhsr/nhsr037.pdf

Contact: CAPT Rick Niska, MD, MPH [email protected]