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Iowa Healthcare Preparedness Coalition DevelopmentHigh Consequence Pathogen Management
The State of the State’s Preparedness
M. Hartley, NRP, CHECEmergency Manager
Operations Manager – Special Isolation Unit
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The World We Live In…
• The United States has endured significant “disasters” in the past decade and a half: 9/11; Hurricanes Katrina, Sandy, Harvey, Irma; Joplin Tornado; H1N1 Pandemic; Boston Bombing; Regional Floods; Wildfires;Mass Shootings; Emerging Diseases (Ebola, MERS, etc.).
• Healthcare systems have been compelled to enhance their ability to sustain operations under all types of adverse conditions.
• The Federal government wants us all to work together to ensure resiliency and capacity…plan…prepare…respond…recover.
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Be Prepared…”All Hazards”
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WWII / Cold War Era – Civil Defense
• Civil Defense – organized non‐military effort to prepare America for a military attack on our soil.
• Formal Origins: Office of Civilian Defense (OCD) within the Office of Emergency Planning (OEP) in the Executive Office of the President on May 20, 1941.
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Emergency Management
• “The discipline and the profession of applying science, technology, planning, and management to deal with extreme events that can injure or kill large numbers of people, do extensive damage to property, damage critical infrastructure, disrupt commerce and disrupt community life”.
• “Process of ensuring that an organization is in a state of readiness to contain the effects of a disastrous event and has the capability and resources to continue to sustain its essential functions without being overwhelmed by the demand placed on them”.
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National Level
• U.S. Dept. of Homeland Security – Cabinet Level– FEMA, Coast Guard, Customs/Boarder Protection, Secret Service, TSA,
Immigrations/Customs Enforcement, Domestic Nuclear Detection Office, Fed. Law Enforcement Training Centers
• FEMA – Regions I‐X (Region XII Office is in Kansas City).
• U.S. Dept. of Health and Human Services – Cabinet Level– Assist. Secretary for Preparedness and Response (ASPR)
– Center for Disease Control and Prevention (CDC)• Healthcare Preparedness Grant Programs
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State Level
• Iowa Dept. of Homeland Security and Emergency Management
• Iowa Dept. of Public Health
• “Center for Disaster Operations and Response” – CDOR
• State Emergency Operations Center – SEOC: located in Johnston, IA, near Des Moines.
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Federal and State Response Support
State Plan & Epidemiologist; Regional Epi’s IDPH Duty Officer‐24/7 Reporting
CDC ‐ Division of Strategic National Stockpile (DSNS)
Antibiotics, chemical antidotes, antitoxins, vaccines, antiviral drugs and other life‐saving medical materiel.
12‐hour “push packs”; 24‐36 hrs. Managed Inventory (MI).
CHEMPACK Program: nerve agent/chemical antidotes and medicines for use in radiation events have been forward deployed in each state.
EMS – 454, Hospital – 1000 casualties
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County/Local Level
• Each county has an Emergency Management Agency (EMA) instead of a Civil Defense Office.
• Preparedness planning, training, grant funding and interagency cooperation…”All Hazards Approach”.
• Actual disaster response/recovery centrally coordinated from a local “Emergency Operations Center (EOC)”.
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Homeland Security/Original HC Preparedness Regions
HSGP – Homeland Security Grant Program (Funder by USDHS)EMPG – Emergency Management Performance GrantHPP – Hospital Preparedness Program (Funded by ASPR)PHEP – Public Health Emergency Preparedness (Funded by CDC)
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Healthcare System Preparedness Coalitions
• HPP and PHEP grant programs aligned in July 2012• Defined a set of 15 Healthcare Preparedness Capabilities for Public
Health, 8 of which applied to hospitals. • Key elements:
– Build Surge Capacity to handle mass casualties– Build robust interoperable communications capabilities to share
information, patient records, situation reports, etc. – Build mass fatality management capability– Build capacity to recover and maintain healthcare services by alternative
means– Build ability to utilize volunteers– Build stockpiles of PPE to protect healthcare workers.
– Mandate: Develop Healthcare Preparedness Coalitions in each state that join multiple public safety/public health partners for the common goal of making communities safer, healthier, robust and resilient .
• Hospitals, public health agencies, EMAs, EMS, Fire/First Responders, mental health agencies, long term care facilities, law enforcement agencies…
• Support their communities before, during and after disasters/healthcare crises.
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Healthcare Preparedness Coalitions
Iowa Population ‐ 3.1 million(0. 9% of total U.S. population)
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HCCs by FY’16 End
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Iowa HCCs Starting July 1, 2017
• Established 7 “Service Areas” –are subdivided initially to simplify start‐up. • Sweeping multi‐system changes in one stroke:
• Hospital Preparedness Program• Public Health Preparedness Program• EMS System Development – currently >900 EMS services of all types• Time‐Critical Conditions Focus: Trauma, Stroke, AMI• Highly Infectious Disease Management System
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Speaking of Infectious Diseases…
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2014
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BellevueHospital
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State and Hospital Preparedness
The final CDC REP Team Readiness Site Visit Was to Iowa – February, 2015
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A New National Treatment Network
• Management of: “Ebola and other high‐consequence/special pathogens”
• 10 Regional Biocontainment Units
• >55‐State designated/CDC‐verified treatment centers
HHS RegionRegional Biocontainment UnitsState‐Designated Tx CentersBCUs (not included by ASPR)
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A New National Training/Support Infrastructure
The National Ebola Training and Education Center is comprised of faculty and staff from Emory University, the University of Nebraska Medical Center/Nebraska Medicine and the New York Health and Hospitals Corporation, Bellevue Hospital Center.
Mission: To increase the capability of United States public health and health care systems to safely and effectively manage individuals with suspected and confirmed special pathogens
www.netec.org
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What “Special Pathogens” Need Care in a BCU?
[High Level Isolation Unit]
• High Morbidity/Mortality• High Chance of Secondary
Cases (Person to Person)• No vaccine/prophylaxis or Tx• Clinical/public concern/panic
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What’s Next? “Highly Pathogenic Resp. Virus”
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Iowa Concept of Operations
• Public Health Surveillance System
• Tiered Medical Care System:
– Tier 1 – Regional Biocontainment Units (UNMC – Region 7)
– Tier 2 – State‐designated Ebola/HCP Treatment Center: UIHC
– Tier 3 – Ebola/HCP Assessment Centers: Mercy Medical Center, Iowa Methodist Medical Center – Des Moines
– Tier 4 – All other hospitals, medical facilities/clinics (screen, isolate, transfer)
• State Hygienic Laboratory – testing
• EMS Transport Services – 5 services trained & equipped 24
Iowa’s Assessment Hospitals and EMS Agencies
• Assessment centers – initial care of a person under investigation for a special pathogen (PUI) for up to 5 days.
– Mercy Medical Center, Des Moines
– Unity Point Methodist Medical Center, Des Moines
• Iowa Designated Transport Agencies
– West Des Moines EMS
– Mercy EMS Des Moines
– AMR Iowa Falls
– Area Ambulance Cedar Rapids
– Medic EMS Davenport
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UIHC – Iowa’s Treatment Center
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• - Disinfectant/Wipes/Glove Station• - Biohazard Waste Hamper (Red bag)• - Doffing Mat (Disposable)• - Clean Traffic Flow• - Sink• - Min. Unit PPE Required (Warm Zone)• - Full PPE Required (Hot Zone)• - Non-treated Biohazard Waste• Rolling Container • Autoclave-treated Waste Box
Autoclave
Biosafety Cabinet
Lab Tab
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IT
Shoe RackPAPR Cart
PPE Cart
Work Table
Work Table
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Port X‐ray
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Nurses Station
Clean Supply PPE Cart
MM IT
‐Multi‐media IT Work Station (Vidyo® Telemedicine Consultation)
‐ Charting Work Station (wall or countertop)
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Waste Staging / Dirty Equip StoragePoint of Care Lab
MM IT
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A ‐ Flush Hopper
Special Isolation Unit – Maximum Containment
MM IT
MM IT
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Security
• Unit activation = Lockdown• Armed UIPD officer at main SNICU
desk (PRN)• Restricted I.D. card access only• Unit door screening by S& S officer• Documentation of all persons
entering/exiting SIU.• Door bell w/telephone and security
video access screening.• Multi‐camera video security system
can be monitored at nurses’ station and in Safety and Security Ops.
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Enhanced PPE / Training / Doffing & Donning
Main Hallway – Positive Pressure
Maximum Negative Pressure
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Enhanced Negative Pressure Isolation System
• Stand‐alone air handling system serves the SIU.
• Designed to assure that no airborne pathogens escape from the unit into the building.
• “Gasketed” O.R. – type ceilings for enhanced infection control.
• Zones of increasing negative pressure airflow progressing from the hallway, the anterooms, to the patient rooms/autoclave room (dirty side).
• Patient room air is exhausted from above the patient, double HEPA‐
filtered and vented out to the hospital rooftop 25 ft. from all structures.
Main Hallway – Positive Pressure
Maximum Negative Pressure
Increasing Negative Pressure
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Unit‐Based Infectious Waste Processing• 26x26x67” Primus pass-through biocontainment autoclave (sterilizer). • All infectious waste is treated/neutralized in the unit before being safely removed.• Dirty side (neg. air pressure) – untreated waste loaded under strict isolation conditions.• Clean side (pos. air pressure) – treated waste unloaded and boxed for shipment.
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Communications/E‐Consultation
• Telemedicine technology • Vidyo© – encrypted healthcare video conferencing platform• HD quality, low‐latency multipoint video conferencing to any end point,
any device over any IP network. • Consultants may talk with patient and healthcare workers in the
patient’s room from a remote location or from within unit clean zone. • Patients and family members can communicate via iPads.
• Hands‐free intercom system• Each patient room has its own
hands‐free intercom for staff to communicate in/out
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Remote Care Consultation by Specialists
• Thinklabs Digital Stethoscopes• In‐room use: single‐use disposable ear buds
• Worn under PPE by provider• Outside room:
• Blue‐tooth transmitter + blue‐tooth headset or speaker
• Consulting clinician remains in unit “clean zone” 30ft. from patient’s room.
30 feet
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Laboratory Testing / Enhanced Bio‐Safety
• Point‐of‐Care testing in SIU or in BSL‐3 micro lab in Boyd Tower
• Protocols for specimen collection and transport
• Core lab staff have had PPE/Cat. A sample transport training
• All waste, samples, etc. processed through unit autoclave
SIU Patient Room Converted to Lab w/Neg. Pressure, Anteroom, etc.
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Environmental Infection Control
• Primary Disinfectant: 10% Bleach
• Alternative Detergent/Disinfectant – Micro‐Chem Plus®
• Terminal Disinfection ‐ Ultraviolet Germicidal Irradiation (UVGI)
• Lumacept™ UV‐C Reflective Wall Coating Throughout Unit
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A Volunteer Core Team With Specialized Training
Primary Core Patient Care Team (16)Primary Core Patient Care Team (16)
•Nurses / LIPs / Clin Techs
• First Tier Care Providers: RNs, MDs (Critical Care), autoclave techs
•Assist with JIT training & prepare unit upon activation
•Training:
• Initial 4‐hour Hands On
•Online ICON Training | 2x year
• 4‐Hour Hands On Skills/Workflow Class | 2x year
•Annual Exercise
Secondary Core Patient Care Team (20+)Secondary Core Patient Care Team (20+)
•Nurses | LIPs
• Second Tier Care Providers and Subspecialties – Peds, OB/GYN, Neonatal
•Training:
• Initial 4‐hour Hands On
•Online Training | 2x year
• 4‐Hour Hands On Skills Class | 1x year
•Upon activation: Just In Time Skills Refresher Training (72 hr. notice)
Support Staff Support Staff •Monitors
•Respiratory Therapists
•Radiology
•Decedent Care Center
•Lab/Pathology Personnel‐Autoclave Techs
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April Unit Comps
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Physician Central Line Insertion/Airway Training
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System Activation for Special Pathogens
• Examples of Special Pathogens: Viral Hemorrhagic Fever (Ebola, Marburg, Lassa, etc.); MERS; Avian/novel Influenza or other highly pathogenic variant; XDR‐TB; SARS…
• PUI presents somewhere within the State of Iowa and Iowa Dept. of Public Health is contacted.
• Working with CDC, patient disposition is determined: transport to Assessment Center or Treatment Center.
• If Assessment Center testing via SHL is positive, patient is transported to Regional Center (UNMC) or State Center (UIHC)
• UIHC SIU will be placed on standby by DHHS Region 7 if the region’s primary biocontainment unit (UNMC) receives an admission.
• The SIU is expected to be active and Core Team just‐in‐time training completed within 72 hrs. of receiving notice from the region.
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Our Mentors – Univ. of NE BCU Leadership
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“Failing in preparation is preparing to fail.”‐Benjamin Franklin
(1706‐1790)
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Thank you!