Not Just Decisions, the Right Not Just Decisions, the Right Decisions; Not Just Stuff but the Decisions; Not Just Stuff but the

Right StuffRight StuffSally Phillips, RN, PhDSally Phillips, RN, PhD

March 6, 2009March 6, 2009Emergency Management SummitEmergency Management Summit

Tiered ResponseTiered Response

Individual Hospital planning and Individual Hospital planning and responseresponseHealth care system planning and Health care system planning and responseresponseRegional health care system planning Regional health care system planning and responseand responseState level planning and responseState level planning and responseIntrastate and Interstate planning and Intrastate and Interstate planning and responseresponseFederal ResponseFederal Response

Decisions and StuffDecisions and StuffCapabilities and Capacities( EXAMPLES)Capabilities and Capacities( EXAMPLES)–– Workforce equipment, training, increase numbers, Workforce equipment, training, increase numbers,

administrative changesadministrative changes–– SuppliesSupplies-- Caches (ventilators, medications, and Caches (ventilators, medications, and

associated space, resupply and receiving associated space, resupply and receiving augmented support)augmented support)

–– Beds and space expansionsBeds and space expansions–– Labs Labs

Requirements to respondRequirements to respond–– Planning ScenariosPlanning Scenarios

System wide expansions and policiesSystem wide expansions and policies–– Home care, primary care, ambulatory servicesHome care, primary care, ambulatory services–– Other facilities in systemOther facilities in system

Partners in individual hospital missionPartners in individual hospital mission–– EMSEMS

AHRQ Emergency AHRQ Emergency Preparedness Resource Preparedness Resource

Inventory (EPRI)Inventory (EPRI)

EPRI GoalsEPRI Goals

Enable regions to compile an inventory Enable regions to compile an inventory of critical resources via a public domain of critical resources via a public domain database tooldatabase toolProvide flexible access to inventory data Provide flexible access to inventory data via a web sitevia a web siteProvide ability to make emergency Provide ability to make emergency requests and tabulate responsesrequests and tabulate responses–– What resources do you need?What resources do you need?–– What resources can you share?What resources can you share?

EPRI Inventory StructureEPRI Inventory Structure

Resource Type Resource Type (Examples)(Examples) Resources Resources (Examples)(Examples)Hospital BedsHospital Beds ICU BedsICU BedsPhysiciansPhysicians Trauma SurgeonsTrauma SurgeonsAntibioticsAntibiotics Oral Oral CiproCipro 500 Mg Doses500 Mg DosesFacility CapabilitiesFacility Capabilities Food Preparation CapabilityFood Preparation Capability

• Resource Types, Resources

• Location Types, Locations

Location Type Location Type (Examples)(Examples) Locations Locations (Examples)(Examples)HospitalsHospitals Hospital ABCHospital ABCNursing Homes Nursing Homes Nursing Home XYZNursing Home XYZEMS AgenciesEMS Agencies EMS Agency ABCEMS Agency ABC

• Resources are “Assigned” to Location Types

EPRI Home PageEPRI Home Page

Inventory Data Entry and Inventory Data Entry and Data QualityData Quality

Resource Resource Requirement Models Requirement Models

AHRQ Surge ModelAHRQ Surge Model–– Estimates hospital resources needed to Estimates hospital resources needed to

treat casualties from nine different WMD treat casualties from nine different WMD scenariosscenarios

Mass Evacuation Transportation Mass Evacuation Transportation ModelModel–– Estimates transportation resources Estimates transportation resources

needed to evacuate patients from needed to evacuate patients from healthcare facilitieshealthcare facilities

Models and Tools for Mass Casualty Surge Requirements

Resources for WMD response

Surge Model ScenariosSurge Model ScenariosBiologicalBiological–– AnthraxAnthrax–– SmallpoxSmallpox–– Flu PandemicFlu Pandemic–– Food ContaminationFood Contamination–– Plague Plague

ChemicalChemical–– ChlorineChlorine–– MustardMustard–– SarinSarin

Nuclear / RadiologicalNuclear / Radiological–– 1 KT or 10 KT nuclear device1 KT or 10 KT nuclear device–– Radiological dispersion device (Radiological dispersion device (““Dirty bombDirty bomb””))–– Radiological point sourceRadiological point source

Conventional explosiveConventional explosive

Surge Model ComponentsSurge Model Components

Surge arrivals

Hospital or network capacity

Event

Pre-hospital management

Treated

Died

Surge ModelCasualty Module

Surge ModelHospital Module

Factors ConsideredFactors Considered

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

Hospital Resources in the Hospital Resources in the Surge ModelSurge Model

Durable Durable equipmentequipmentHuman Human resourcesresourcesPharmacyPharmacyConsumable Consumable suppliessuppliesPersonal Personal protective protective equipmentequipment

Psychological Psychological SupportSupportHousekeepingHousekeepingLab / RadiologyLab / RadiologyMortuaryMortuaryNutritionNutrition

Casualty Arrivals at Hospitals Casualty Arrivals at Hospitals (Prophylaxis reduces hospitalizations (Prophylaxis reduces hospitalizations

from 5,000 to 1,048)from 5,000 to 1,048)

Hospitalized Patients by Day Hospitalized Patients by Day and Unitand Unit

Resource Requirements for Resource Requirements for this Scenariothis Scenario

CategoryCategory NameName UnitsUnits Day of Day of Peak NeedPeak Need

Amount Needed Amount Needed on Peak Dayon Peak Day

Ancillary: PsychologistAncillary: Psychologist Psychological supportPsychological support FTEFTE 44 2121Capacity: FloorCapacity: Floor Med/Med/SurgSurg BedBed Unit of UseUnit of Use 1010 588588Capacity: VentilatorCapacity: Ventilator Mechanical ventilatorMechanical ventilator Machine Machine

TimeTime44 9494

Engineering: FacilityEngineering: Facility EngineeringEngineering FTEFTE 44 3333Epidemiology: Infection Epidemiology: Infection ControlControl

Patient infection controlPatient infection control FTEFTE 44 5151

Equipment:O2 MonitoringEquipment:O2 Monitoring Oxygenation monitoring Oxygenation monitoring equipmentequipment

Machine Machine TimeTime

44 164164

Equipment: Vent TubingEquipment: Vent Tubing Ventilator equipmentVentilator equipment Unit of UseUnit of Use 44 9494Housekeeping: JanitorialHousekeeping: Janitorial Janitorial/HousekeepingJanitorial/Housekeeping FTEFTE 44 6969Housekeeping: LaundryHousekeeping: Laundry Sheet changeSheet change Unit of UseUnit of Use 44 732732Lab/Radiology: LaboratoryLab/Radiology: Laboratory Laboratory machinesLaboratory machines Machine Machine

TimeTime44 1515

Pharmacy: AntibioticsPharmacy: Antibiotics CirprofloxacinCirprofloxacin or or DoxycyclineDoxycycline

400mg/100400mg/100 mg bidmg bid

44 732732

Pharmacy: AntibioticsPharmacy: Antibiotics RifampinRifampin or other 2nd line or other 2nd line agentagent

600mg 600mg popo bidbid

44 199199

Resource Requirements for Resource Requirements for this Scenariothis Scenario

CategoryCategory NameName UnitsUnits Day of Day of Peak NeedPeak Need

Amount Needed Amount Needed on Peak Dayon Peak Day

PPE: Universal PPE: Universal Universal Precautions PPEUniversal Precautions PPE Unit of UseUnit of Use 44 732732Radiology: CXRRadiology: CXR Radiology machinesRadiology machines EA (Each)EA (Each) 33 88Staff: CCMStaff: CCM IntensivistsIntensivists (CCM)(CCM) FTEFTE 44 1616Staff: MDStaff: MD NonNon--intensivistsintensivists (MD)(MD) FTEFTE 33 2828Staff: PharmacistStaff: Pharmacist Pharmacists Pharmacists

((PharmD/RPhPharmD/RPh))FTEFTE 55 2929

Staff: Staff: RadRad TechTech Radiologic TechniciansRadiologic Technicians FTEFTE 33 88Staff: RNStaff: RN NonNon--critical care nurses critical care nurses

(RN/LPN)(RN/LPN)FTEFTE 33 126126

Staff: RTStaff: RT Respiratory Therapists Respiratory Therapists (RT)(RT)

FTEFTE 44 3333

Supplies: IV setSupplies: IV set Antibiotics intravenous Antibiotics intravenous infusion setinfusion set

Unit of UseUnit of Use 44 465465

Supplies: IV SetSupplies: IV Set Intravenous infusions setIntravenous infusions set Unit of UseUnit of Use 44 543543Supplies: LaboratorySupplies: Laboratory Laboratory suppliesLaboratory supplies Unit of UseUnit of Use 44 349349Supplies: OxygenSupplies: Oxygen Oxygen (O2)Oxygen (O2) Unit of UseUnit of Use 44 283283

Comparison of Required Comparison of Required and Available Resourcesand Available Resources

Display of staffing levels from HHS Area Display of staffing levels from HHS Area Resource FileResource File

Adult Med/Surg Bed Adult Mechanical ventilator Adult ICU Bed Pediatric Mechanical ventilatorPediatric Med/Surg Bed Adult Ventilator Circuit Pediatric ICU Bed Pediatric Ventilator CircuitBurn Bed Closed circuit suction catheter 14FOperating Room Closed circuit suction catheter 8-12FAirborne Isolation Room Humidification and Flitration Unit (HMEF)Intensivists (CCM) Endotracheal tube, 3mm IDCritical care nurses (CCN) Endotracheal tube, 4mm IDSurgeons Endotracheal tube, 5mm IDNon-intensivists (MD) Endotracheal tube, 6mm IDNon-critical care nurses (RN/LPN) Endotracheal tube, 7mm IDPharmacists (PharmD/RPh) Endotracheal tube, 8mm IDRespiratory Therapists (RT) Laryngoscope blades, adultMortuary Laryngoscope blades, pediatric Ventilator Oxygen (O2) Laryngoscope handlesNC Oxygen (O2) Endotracheal stylettePulse oximeter Resuscitation Bag, adultFinger pulse oximeter strip Resuscitation Bag, pediatricEnd tidal CO2 detector, adult Radiology machinesEnd tidal CO2 detector, pediatric Radiology suppliesTemperature monitoring equipment Chemistry Laboratory machinesUrine output--Foley catheter 8F-12F Chemistry Lab suppliesUrine output--monitor bag Hematology Laboratory machinesBP cuffs, adult Hematology Lab suppliesBP cuffs, pediatric Micro/Virology Laboratory machines

Microbiology/Virology Lab supplies

Surge Model Treatment PathsSurge Model Treatment Paths

EmergencyDepartment

Floor

ICU

ArrivingCasualty Dead

OrDischarged

Patients

ED EDED Floor Floor ED ED

ED ED Floor ICU ICU ED ICU ICUED ED Floor Floor ICU Floor Floor ICU Floor Floor E[LoS] E[LoS] E[LoS]Disch Death Disch Death Death Disch Death Death Disch Death P(Disch) P(Death) Sum Disch Dead Overall

0% 0% 89% 5% 1% 4% 0% 0% 1% 0% 94% 6% 100% 6.48 5.10 6.390% 0% 4% 0% 0% 1% 0% 21% 71% 4% 75% 25% 100% 13.64 6.35 11.84

Path Probabilities Expected Length of StayOverall probabilities

LoS value Mortality rateMean Low

SCENARIO STREAMFlu Moderate Hospitalized moderateFlu Severe ICU severe

Calculate

x1

Surge Model uses NIGMS MIDAS Surge Model uses NIGMS MIDAS ((EpicastEpicast) Flu Model Output) Flu Model Output

Example of Surge Model Output: Example of Surge Model Output: Ventilator Requirement over TimeVentilator Requirement over Time

Calculating Patient TypeCalculating Patient Type--Specific Specific Resource ConsumptionResource Consumption

First define average resource First define average resource requirements per requirements per unitunit, per , per patient typepatient type, , and per and per time interval time interval Calculate, based on LOS and Calculate, based on LOS and death/transfer rates, the number of death/transfer rates, the number of patients in any resource consumption patients in any resource consumption category at any given timecategory at any given time

Hospital Bed Availability and Patient Hospital Bed Availability and Patient Tracking System (HAvBED)Tracking System (HAvBED)

Prototype Prototype ““realreal--timetime”” standardized data reporting toolstandardized data reporting tool–– Enhance system/regionEnhance system/region’’s ability to care for surge of s ability to care for surge of

patients from public health emergency (e.g., flu)patients from public health emergency (e.g., flu)–– Provides timely reporting of bed status data in an Provides timely reporting of bed status data in an

emergency (includes GIS)emergency (includes GIS)Nationwide scope: prototype participants (Dec, 2005)Nationwide scope: prototype participants (Dec, 2005)Standard Bed Reporting categoriesStandard Bed Reporting categories

http://ahrq.gov/research/havbed/definitions.htmhttp://ahrq.gov/research/havbed/definitions.htmSustainable Bed Availability Reporting System Sustainable Bed Availability Reporting System (HAvBED2)(HAvBED2)

Delivered to DHHS 12/07Delivered to DHHS 12/07

Discharge Criteria for Creation Discharge Criteria for Creation of Hospital Surge Capacity of Hospital Surge Capacity

The Grant focus was the development of: The Grant focus was the development of: an easyan easy--toto--apply method for preapply method for pre--designating designating hospitalized patients suitable for early hospitalized patients suitable for early discharge in the event of a disaster. discharge in the event of a disaster. a tool tested and evaluated in comparison with a tool tested and evaluated in comparison with the current ad hoc method of identification of the current ad hoc method of identification of such patients. such patients.

Kelen, G. Johns Hopkins UniversityKelen, G. Johns Hopkins University

Current development of a decision support Current development of a decision support tool underway with the Disaster Alternative tool underway with the Disaster Alternative Care Site Project with ASPR on this topicCare Site Project with ASPR on this topic

Project Project XtremeXtreme Cross Cross Training VideoTraining Video

Model for Health ProfessionalModel for Health Professional’’s s Cross Training for Mass Casualty Cross Training for Mass Casualty Respiratory NeedsRespiratory Needs

Tool for assisting with mechanical Tool for assisting with mechanical ventilator staff surgeventilator staff surgeCurriculum developed for Curriculum developed for ‘‘just in just in timetime’’ training for SNStraining for SNSIdentifies appropriate health care Identifies appropriate health care professionals to be trained and used professionals to be trained and used in a surge situationin a surge situation

http://http://ahrq.gov/prep/projxtremeahrq.gov/prep/projxtreme//

Mass Evacuation Mass Evacuation Transportation ModelTransportation Model

A planning tool for estimating the A planning tool for estimating the transportation resources required to transportation resources required to evacuate healthcare facilitiesevacuate healthcare facilities–– Estimate evacuation time, given Estimate evacuation time, given

transportation constraintstransportation constraints–– Or, estimate transportation assets Or, estimate transportation assets

needed to evacuate within a time needed to evacuate within a time constraintconstraint

The Model ConsidersThe Model Considers

Location of evacuating and receiving Location of evacuating and receiving facilities facilities Patient transportation requirementsPatient transportation requirementsAvailability of transport vehiclesAvailability of transport vehiclesSurge capacity of receiving facilitiesSurge capacity of receiving facilitiesTraffic congestionTraffic congestion

Illustrative Hospital EvacuationIllustrative Hospital Evacuation

Illustrative Hospital EvacuationIllustrative Hospital Evacuation

Model Pilot TestsModel Pilot Tests

New York City (April 2006)New York City (April 2006)–– Category 4 hurricaneCategory 4 hurricane–– Evacuation of 24 hospitals and 61 nursing Evacuation of 24 hospitals and 61 nursing

homes in coastal areas (approximately homes in coastal areas (approximately 24,000 patients) 24,000 patients)

–– Planned evacuation (72 hours notice)Planned evacuation (72 hours notice)

Los Angeles (May 2007)Los Angeles (May 2007)–– Major earthquakeMajor earthquake–– Evacuation of 3 hospitals (900 patients)Evacuation of 3 hospitals (900 patients)

Changes to ALS Changes to ALS Availability (Los Angeles)Availability (Los Angeles)

00.5

11.5

22.5

33.5

44.5

5

0 10 20 30 40 50 60 70

Number of ALS units

Evac

uatio

n Ti

me

(day

s)

Changes to Standard of Changes to Standard of Care (Los Angeles)Care (Los Angeles)

0

20

40

60

80

100

120

Standard 50% ALS->BLS ALS<->BLS

Hou

rs ALS

BLS

Mass Medical Care with Scarce Mass Medical Care with Scarce Resources: Community Planning Resources: Community Planning

GuideGuideProvides community planners, as Provides community planners, as well as planners at the well as planners at the institutional, State, and Federal institutional, State, and Federal levels, with information to help levels, with information to help plan for and respond to a mass plan for and respond to a mass casualty eventcasualty eventGuide is written by leading experts Guide is written by leading experts in 6 areas related to mass in 6 areas related to mass casualty care: casualty care: prehospitalprehospital care, care, hospital and acute care, hospital and acute care, alternative care sites, palliative alternative care sites, palliative care, ethical issues, and legal care, ethical issues, and legal considerations. considerations.

http://http://www.ahrq.gov/research/mcewww.ahrq.gov/research/mce/ /

Mass Medical Care with Scarce Mass Medical Care with Scarce Resources: A Community Planning Resources: A Community Planning

GuideGuideCollaboration between AHRQ and ASPRCollaboration between AHRQ and ASPR

Ethical Considerations in Community Ethical Considerations in Community Disaster PlanningDisaster PlanningAssessing the Legal Environment Assessing the Legal Environment PrehospitalPrehospital CareCareHospital/Acute CareHospital/Acute CareAlternative Care SitesAlternative Care SitesPalliative CarePalliative CareInfluenza Pandemic Case StudyInfluenza Pandemic Case Study

Ethical Principles Ethical Principles Greatest good for greatest numberGreatest good for greatest numberEthical process requiresEthical process requires–– OpennessOpenness–– Explicit decisionsExplicit decisions–– Transparent reportingTransparent reporting–– Political accountabilityPolitical accountabilityDifficult choices will have to be made; Difficult choices will have to be made; the better we plan the more ethically the better we plan the more ethically sound the choices will be sound the choices will be

Legal IssuesLegal Issues

Advance planning and issue Advance planning and issue identification are essential, but identification are essential, but not sufficientnot sufficient

Legal Triage Legal Triage –– planners should planners should partner with legal community for partner with legal community for planning and during disastersplanning and during disasters

Questions and DiscussionQuestions and Discussion

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

Publications & ToolsPublications & Tools

To order a copy of reports, tools, To order a copy of reports, tools, or resources:or resources:–– contact the AHRQ Publications contact the AHRQ Publications

Clearinghouse at 800Clearinghouse at 800--358358--92959295–– Send an ESend an E--mail to mail to

ahrqpubs@ahrq.hhs.govahrqpubs@ahrq.hhs.gov..

For More InformationFor More InformationContact: Sally Phillips, RN, PhDContact: Sally Phillips, RN, PhD

Email: Email: sally.phillips@ahrq.hhs.govsally.phillips@ahrq.hhs.gov