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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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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
Objective
Summary of hospital preparedness for responding to public health emergencies:
Mass casualties Epidemics of naturally occurring diseases
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)
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
Current work
Pandemic Emergency Response Preparedness Supplement – 2008 Parent survey: NHAMCS Again funded by OASPE
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
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
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
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
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
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
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.)
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
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
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
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
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
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
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
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
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
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
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
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
Communications
Notification of alerts from health departments
Participation with local public health departments in education on influenza vaccination
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
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
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
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
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
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.
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.
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.
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.
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.
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.
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]