To introduce local Health Officers, Public Health Directors, LEMSA Administrator, and LEMSA Medical Director and other staff to the Altered Standard

Welcome & Introductions

March 28, 2012 (10am – Noon)

Altered Standard of Care Preplanning Guide

Exercise

To introduce local Health Officers, Public Health Directors, LEMSA Administrator, and LEMSA Medical Director and other staff to the Altered Standard of Care Pre-Planning Guide.

Purpose

Altered Standard of Care Pre-Planning Guide

WHAT IS IT?

The Altered Standard of Care Pre-Planning Guide is designed as a tool to assist local emergency planners with modifying the current EMS delivery system in response to a catastrophic incident.


• Developed with HPP Year 8 grant funds • Based upon best practices and source

documents including:

– Santa Clara County Altered Standards Tool, – San Francisco County Altered EMS Protocols, – CDC and NHTSA guidelines


• Designed as an all-hazards tool for any type of disaster, including:

– Severe flooding– Earthquakes– Pandemic Outbreak– Other catastrophic incidents


EXERCISE SCENARIO

Pandemic Outbreak(Week 6)

*Worldwide, National, and State data is based upon actual response information from the H1N1 outbreak

WORLD WIDE IMPACT

Worldwide Impact• In early February, confirmed reports from the

U.S. Centers for Disease Control revealed a novel strain of the influenza virus.

Worldwide ImpactThe World Health Organization declared a global pandemic alert as more than 214 countries and overseas territories or communities worldwide have reported laboratory confirmed cases of the novel virus.

Worldwide ImpactAs of last week, most developed countries reported widespread infection, including at least 18,449 deaths.

Worldwide ImpactCommunity Mitigation measures include school closures, cancellation of mass gatherings, isolation and quarantine, and other social distancing measures.

Worldwide Impact• Health care systems experiencing significant

stress; reporting regional surges in hospital, emergency department, and outpatient visits.

• Some countries reporting hospital bed, equipment and medication shortages.

NATIONAL IMPACT

National ImpactCDC is reporting that the most impacted populations include:

– Children and young adults– Persons with underlying chronic medical conditions

(e.g. chronic lung disease, heart disease, immunosuppression, neurological and neurodevelopment diseases)

– Pregnant women– Indigenous populations– Possible risk groups: Obesity (Body Mass Index ≥35),

Extreme/Morbid obesity (Body Mass Index ≥40)

National ImpactOseltamivir (Tamiflu) and zanamivir are the only FDA-approved antiviral drugs effective against this virus.

Presidential Proclamation

President Obama has signed a proclamation declaring this influenza pandemic a National Emergency to facilitate our ability to respond to the pandemic by enabling – if warranted – the waiver of certain statutory Federal requirements for medical treatment facilities.

Presidential Proclamation

In particular, this proclamation is aimed at providing HHS the ability to waive legal requirements that could otherwise limit the ability of our nation’s health care system to respond to the surge of patients with the novel influenza virus.

HHS has approved: • Hospitals request to set up an alternative

screening location for patients away from the hospital’s main campus (requiring waiver of sanctions for certain directions, relocations or transfers under EMTALA).

• Hospitals request to facilitate transfer of patients from ERs and inpatient wards between hospitals (requiring waiver of sanctions under EMTALA regulations).

HHS has approved: • Critical Access Hospitals requesting waiver of 42

CFR 485.620, which requires a 25-bed limit and average patient stays less than 96 hours.

• Skilled Nursing Facilities requesting a waiver of 42 CFR 483.5, which requires CMS approval prior to increasing the number of the facility’s certified beds.

State Impact

State ImpactGubernatorial Declaration

NOW, THEREFORE, I, EDMUND G. BROWN JR., Governor of the State of California, in accordance with the authority vested in me by the California Constitution and the California Emergency Services Act, and in particular California Government Code sections 8558(b) and 8625, find that conditions of extreme peril to the safety of person and property exists within the State of California and HEREBY PROCLAIM A STATE OF EMERGENCY in California.

State ImpactGubernatorial Declaration (Cont.)

IT IS HEREBY ORDERED that all agencies and departments of state government utilize and employ state personnel, equipment, and facilities as necessary to assist the State Department of Public Health and the Emergency Medical Services Authority in immediately performing any and all activities designed to prevent or alleviate illness and death due to the emergency, consistent with the State Emergency Plan as coordinated by the California Emergency Management Agency.

LOCAL IMPACT

Local ImpactButte: Both Oroville Hospital and Feather River Hospital reporting >100% capacity. Ambulance turn-around times greatly delayed (60 - 90 minutes).

Local ImpactColusa: Colusa Regional Medical Center has converted the Physical therapy and Outpatient areas into additional inpatient beds, and also reports significant delays in ambulance response.

Local Impact• Nevada: Tahoe Forest and Sierra Nevada Memorial

Hospital are both using surge tents and have created surge beds within their facilities. Dispatch is complaining about lack of available ambulances and lack of mutual-aid resources.

Local Impact• Placer: All three hospitals have implemented internal

surge plans. Kaiser and Sutter Roseville have been in discussions with Public Health to convert a portion of the Maidu Center into an ACS for additional inpatient beds.

Local Impact• Shasta: Fire personnel in Redding reported an incident

in which they performed CPR on-scene for 29 minutes before ambulance arrival. 5 ambulances are currently being held at Shasta Regional Medical Center with patients on their gurneys, 2 of these have been waiting more than 90 minutes.

Local Impact• Siskiyou: Mercy Medical Center Mt, Shasta and

Fairchild Medical Center are reporting zero inpatient beds, and are holding multiple admissions in the ED. 911 callers are complaining of being put on hold, and ambulances have delayed turnaround times.

Local Impact• Sutter: Fremont Medical Center has a full census, and is

reported no available beds. Bi-county ambulance has staffed two additional units, and are complaining about the ED status and turnaround times at Rideout.

Local Impact• Tehama: Due to the recent MCI at the Red Bluff Airport,

St Elizabeth Hospital has been dealing with several trauma patients, and has no inpatient beds available. Fire personnel have been unavailable to assist on medical calls due to the MCI and fire.

Local Impact• Yolo: The Yolo Emergency Communications Agency

has implemented their Emergency Rule Stage 3 for suspending pre-arrival instructions to attempt to respond to the increased 911 medical-aid requests. Sutter Davis and Woodland Memorial have both activated internal surge plans, and are holding admits in the ED. AMR Yolo is reporting significant delays at the ERs, and are unable to staff additional units due to sick calls.

Local ImpactYuba: Rideout is reporting a significant staffing crisis due to sick call-ins. The HERT team has set up surge tents in the parking lot to receive/triage patients. However, ambulance personnel are reporting that there are no nurses staffing the triage area, and there are three ambulances waiting outside for more than an hour.

S-SV EMS Agency• In response to overwhelming numbers of local requests

from MHOACs, Public Health Departments, ambulances, and hospitals; S-SV has been in contact with EMSA and the RDMHSs in Region III and Region IV regarding ambulance mutual-aid, and no additional resources are available at this time.

S-SV EMS Agency• Since outside resources are unavailable, each

operational area must determine how to continue to support the 911 system with the current local resources.

“How can the EMS SystemContinue to sustain this demand?”

ALTERED STANDARD

ORDERS FORM

Altered Standard Order Form

Public Access

Control Facility

EMS Providers

• It’s a tool…not a policy• Once reviewed, and signed by the MHOAC or EMS

Agency Medical Director it becomes an Emergency Policy and Protocol

ASO Form Summary

EMERGENCYPolicy and Protocol

System Changes• In response to this Pandemic Outbreak,

the EMS Agency staff has met, and would like to present their proposal to the Health Officers to get feedback and consensus.

System Changes• We are going to review those proposals in

two segments:– Public Access Changes, and– Field Protocol Changes

• Following each segment, there will be a time for open discussion.

Prioritizing the Needs

IMMEDIATE DELAYED MINOR DECEASED

Proposed Changes to the Public Access System

• Public Access Number/ Website• Scheduled Transport Center• Altered 911/EMD triage

By establishing a Scheduled Transport Center the stress on the 911 system will be significantly decreased, and will allow dispatchers to manage a higher call volume and improve call turn-around times.

Scheduled Transport Center

Activating this separate center will allow the Transport Center staff to explore all the alternatives for the transportation needs of the calling party.


The Scheduled Transport Center is designed to coordinate all medical transportation requests from all system access points including:

• hospitals, • health facilities,• Public Access Number, • 911, and • the field.


The Scheduled Transport Center responsibilities include:

• Augmenting medical transportation with alternative vehicles: buses, taxis, etc.

• Developing and implementing a medical transportation scheduling process

• Working with Control Facilities to coordinate the destinations of all transport resources including

those to possible Alternate Care Sites, clinics, etc.


Direct the patient to use this transportation resource to seek medical attention

YES

Does the patient have access to public transportation?

NO

Does the patient have friends/family that can

transport them?

NO

Does the patient have their own vehicle?

For Ambulatory Patients

YES

YES

NO

Schedule transport service (taxi, bus, or BLS transport)


Schedule wheelchair transport

Schedule BLS transport

NO

Is patient able to sit in a wheelchair

For Non-Ambulatory Patients

YES


Two way radio communication between the:

• Public Access Number• 911


PUBLIC ACCESS NUMBER

Creating a Public Access Number would greatly relieve the stress on the 911 system by referring the public to the appropriate resources without

having to call 911 and utilize emergency responders unnecessarily.

Public Access Number

Public Access NumberIn July 2000, the Federal Communications Commission (FCC) reserved the 211 dialing code for community information and referral services.

The FCC intended the 211 code as an easy-to-remember and universally recognizable number that would enable a critical connection between individuals and families in need and the appropriate community-based organizations and government agencies.

211 as an option.

The 211 center’s referral specialists:• interview callers, • access databases of resources available

from private and public health and human service agencies,

• match the callers’ needs to available resources, and

• link or refer them directly to an agency or organization that can help.


During a disaster or emergency activation, call-takers for the Public Access Number should be trained to triage calls in a similar fashion as 911 call-takers.

Consideration should be given to staffing the call center with Registered Nurses.


Obtain:• Incident Location• Call back number• Patient age• Level of Consciousness• Status of breathing• Chief Complaint

Call Taker

211 or Other Public Access Number

Public Access ALGORITHM


If a call comes into the Public Access Number that is a medical emergency, the call taker will Instruct the caller to “Hang up and call 911”

At home care Higher level of care

No medical need

Assess the level of medical need

NO

Provide Paramedic Response

Medical Emergency?

YES

Caller instructed to call 911

Public Access Algorithm

If it is determined that the caller has only minor medical care needs, they may be:

• Given self care or family care instructions

• Directed to sources of health information on the internet

At Home Care

Examples of medical web support include:

• WebMD.com• CDC.Gov (Centers for Disease Control)• Bepreparedcalifornia.ca.gov (CDPH), and • Local Public Health Department websites

At Home Care

If it is determined that the caller needs to be seen by a medical practitioner they should be assessed for their ability to obtain necessary transportation.

If the patient is unable to transport themselves or have family transport them to their personal physician, they should be transferred to the Scheduled Call Center.

Higher Level of Care

If it is determined that the caller has no medical need, they may be:

• Transferred to other social or public service call center,

• Referred to other public information websites,

• Referred to appropriate agency or county services.

No Medical Need

ALTERED 911 EMD TRIAGE

• Discontinue Use of Emergency Medical Dispatching (EMD) Procedures

• Discontinue Use of Pre-Arrival Instructions (PAI)

• Implement Altered Triage Algorithm

Altered 911 EMD Triage

This triage system will use the following categories to rank patients according to severity of need:

requires immediate medical intervention

needs medical attention, however, the response can be somewhat delayed.

May be assisted with self-care or system resources other than 911 medical resources.

Needs non-medical community services.

Immediate:

Delayed:

Minor:

Deceased:

www.disasterdoug.com

Altered Triage

Example of AlteredEmergency Medical

Dispatch TriageIMMEDIATE DELAYED MINOR DECEASED

211 or (7 digit) Public Access

CenterNurse Support

Line

Schedule BLS Transport

(pt call-back-confirm)

NO

Transport CenterCheck availability of: Family/Friend Public Transport Dial-a-Ride Taxi Flu Bus?

NO

YES

Paramedic(QRV)

YE

S1. “Can pt. talk”2. “Can pt. walk”

unassisted

ON

SOBAcute ALOC

Severe Bleeding

Medical Dispatch YESIs it a Medical Emergency?

911 Call Center

Reporting PartyCalls 911

(if any delay in ALS response, a BLS unit is dispatched.)

Altered 911 EMDAlgorithm


Public Access Summary• The county establishes a Public Access

Number / Website.

• The EMS Agency to work with providers to establish the Scheduled Transport Centers.

• Implement Altered EMD Triage Protocols

DISCUSSION11:15

ALTERED FIELD RESPONSE

Proposed Altered Field Response

• Establishing Quick Response Vehicles (QRVs)• Change in Field Treatment Protocols (e.g. Treat-and-

Release, Flu Cache)• Family/Patient Brochure• Just-in-Time Training

Quick Response Vehicles

(QRVs)

One solution may be to convert all ALS ambulances to BLS transport units, allowing us to place paramedics on Quick Response Vehicles (QRVs) This implementation will quickly expand available EMS resources.

Altered Field Response


A Quick Response Vehicle or QRV is a vehicle that is staffed with at least one paramedic, and equipped with Advanced Life Support (ALS) equipment/supplies per local EMS Agency protocol. Such vehicles may include: Ambulance supervisor vehicles, shared resources from other emergency response agencies (fire, law, public works).

Quick response vehicle (QRV)

Establishing QRVs will allow the paramedic to:

• Rapidly respond to 911 medical calls• Provide ALS intervention as needed• Transfer care to a BLS transport unit• Clear the scene quickly to be able to respond

to the next call

AlteredField Response


ALTERED FIELD TRIAGE

This triage system will use the following categories to rank patients based upon the severity of need.

requires immediate medical intervention

needs medical attention, however, the response can be somewhat delayed.

May be assisted with self-care or system resources other than 911 medical resources.

Needs non-medical community services.

Immediate:

Delayed:

Minor:

Deceased:

Example of Altered911 Field Triage

IMMEDIATE DELAYED MINOR DECEASED

Witnessed= Use First Round

ACLS protocolsUnwitnessed = refer to public

access number

Refer to Public Access Number

Treat and Release or

Refer

Treat and Transport

Patients presenting with life threatening conditions such as Acute MI, uncontrolled hemorrhage, severe shortness of breath, ALOC, etc., will require treatment and transportation.

IMMEDIATE


Patients who respond to treatment on scene and afterward present with normal mental status, normal vital signs, and blood sugar will be given a patient brochure then released or referred.

DELAYED

Options for referring patients may include:• The Public Access Number• Doctors office• Self-care

Treat & Release or Refer


Upon arrival, if the patient does not present with life-threatening conditions and does not require any EMS medical intervention, the patient would be given a Patient/Family Brochure and released on scene.

MINOR


Only if the patient had a witnessed cardiac arrest would the field responders intervene. The patient would be given first round ACLS care and if there is no response the patient would be determined dead in the field. Family would be given a patient brochure with the Public Access Number prior to clearing the scene.

DECEASED


The EMS Authority is considering approval of expanding the paramedic scope to include a Disaster Flu Cache.

This cache may include flu treatment items such as: powdered Gatorade, Compazine suppositories, ibuprofen, etc.

The S-SV Medical Director will continue to work with EMSA to determine if this is viable locally.

Disaster Flu Cache


Proposed Altered EMS ResponseFamily/Patient Brochure

A Family/Patient Brochure should be designed to be distributed by EMS field personnel to patients and family members, including:

• Family members of patients transported to the hospital

• Patients treated and released on scene• Family of deceased patients• Patients with non-medical emergencies

Patient Brochure


The Patient/ Family Brochure should contain:• information about the current situation,

explaining the significant impact of the incident on the population

• health threats, including current and projected effects

• impact on the hospitals, describing limited resources and alternatives

• EMS system changes, including changes in 911 protocols, as well as, what to expect when EMS responders arrive.

Patient Brochure


The Patient/ Family Brochure should contain:• Information regarding the local Public

Access Number for individuals with non-medical emergencies

• Information regarding Web-based health information such as the CDC website, local Public Health website, or other private sites such as WebMD, etc.

• Information regarding self-care such as at-home treatment for fever, flu symptoms, minor first-aid, etc.

Patient Brochure


JUST IN TIME TRAINING

After establishing Altered Standard Orders, responders must be provided with training including:

• Rolls and responsibilities of EMS system providers,

• Changes made to system protocols, and • Changes made to overall system design

Just-In-Time (JITT)Training


Just-In-Time training would normally be conducted by supervisors or management at each provider agency.



Following any Just-In-Time Training, personnel should be provided an opportunity to:

• Practice any new skills• Become familiar with any new equipment

or tools• Review new or revised protocols



Practicing these skills will give the responder confidence when performing the skills. They will also be able to focus clearly on the task at hand.

Practicing skills

Altered Field Response

Summary• Establish Quick Response Vehicles (QRVs) • Alter Field Treatment Protocols (e.g. Treat-and-

Release, Flu Cache)• Develop Patient/Family Brochure• Conduct Just-in-Time Training

Discussion

DISCUSSION

Wrap-Up

• Online training tools: S-SV EMS Agency website at www.ssvems.com (under the HPP Current & Past Projects link)

• AAR form / evaluation tool will be emailed to HPP Coordinators and then distributed

• After Action Review: April 11th HPP Project meeting (AAR and CAP)

http://www.ssvems.com/

Thank you for participating in the…

Altered Standard of Care Pre-Planning Guide Exercise.

Documents

To introduce local Health Officers, Public Health Directors, LEMSA Administrator, and LEMSA Medical Director and other staff to the Altered Standard