AHRQ Master Slide Template - Global Health Care

Mass Medical Care with Scarce Resources: Community Planning National Emergency Management Summit March 4-6 New Orleans, LA Sally Phillips, RN, PhD Moderator Co Editor Director, Public Health Emergency Preparedness Providing Mass Medical Care with Scarce Resources: A Community Planning Guide Collaboration between AHRQ and ASPR

Ethical Considerations in Community Disaster Planning Assessing the Legal Environment Prehospital Care Hospital/Acute Care Alternative Care Sites Palliative Care Influenza Pandemic Case Study Editors: Sally J. Phillips- AHRQ Ann Knebel- HHS/ASPR

Lead Authors: Marc Roberts, PhD Harvard University James C. Hodge, Jr.- Georgetown and Johns Hopkins University Edward J. Gabriel- Walt Disney Corp. John L. Hick- Hennepin County Medical Center, University of Minnesota

Stephen Cantrill- Denver Health Medical Center Anne Wilkerson- RAND Corp Marianne Matzo- University of Oklahoma Ethical Principles Greatest good for greatest number Utilitarian perspective important to consider Other principles important to consider Respecting the norms and values of the community Respecting all human beings Determining what is right and fair

Ethical Principles Ethical process requires Openness Explicit decisions Transparent reporting Political accountability Difficult choices will have to be made; the better we plan the more ethically sound the choices will be Legal Issues

Can the local community declare a disaster? Advance planning and issue identification are essential, but not sufficient Legal Triage planners should partner with legal community for planning and during disasters Prehospital Care

Edward Gabriel, M.P.A., AEMT-P Edward Gabriel, Director of Crisis Management for Walt Disney Corporation; Past Deputy Commissioner for Planning and Preparedness NYC Office of Emergency Management PREHOSPITAL CARE The Main Issue For Planners In the event of a Catastrophic MCE, the emergency medical services (EMS) systems will be called on to provide first-responder rescue, assessment, care, and transportation and access to the emergency

medical health care system. The bulk of EMS in this country is provided through a complex system of highly variable organizational structures. RECOMMENDATIONS: EMS PLANNERS Plan and implement strategies to maximize to the extent possible: Use and availability of EMS personnel Transport capacity Role of dispatch and Public Safety Answering Points

RECOMMENDATIONS: EMS PLANNERS Mutual aid agreements or interstate compacts to: Address licensure and indemnification matters regarding responders Address memoranda of understandings (MOUs) among public, volunteer, and private ambulance services Coordinate response to potential MCEs RECOMMENDATIONS:

EMS PLANNERS Use natural opportunities to exercise disaster planning Develop strategies to identify large numbers of young children who may be separated from parents Develop strategies to identify and respond to vulnerable populations v RECOMMENDATIONS:

EMS PLANNERS Develop partnerships with Federal, State, and local stakeholders to clarify roles, resources, and responses to potential MCEs Improve communication and coordination strategies and backup plans Exercise, evaluate, modify, and refine MCE plans FORGING PARTNERSHIPS AT ALL LEVELS

Emergency management is really about building relationships, whether you are in the public or private sector. And in building those relationships, it is important to remember not to tell, but to talk. Hospital Care John L. Hick, M.D. Emergency Physician Hennepin County Medical Center Chair, Metropolitan Hospital Compact

Hospital Care Planning Assumptions Overwhelming demand Greatest good Resources lacking

No temporary solution Federal level may provide guidance Operational implementation is State/local State emergency health powers Provider liability protection

Coordinated Mass Casualty Care Effective incident management critical Fully integrated Conduct action planning cycles Anticipate resource needs Make timely requests and allocate Coordinated Mass Casualty Care Increased system capacity (surge

capacity) Decisionmaking process for resource allocation Shift from reactive to proactive strategies Administrative vs. clinical changes Incremental changes to standard of care Usual patient care provided Austere patient care provided

Low impact administration changes High-impact clinical changes Administrative Changes to usual care Clinical Changes to usual care Triage set up in

lobby area Significant reduction in documentation Vital signs checked less regularly Re-allocate ventilators due to shortage Meals served by nonclinical staff

Significant changes in nurse/patient ratios Deny care to those presenting to ED with minor symptoms Significantly raise threshold for admission (chest pain with normal ECG goes home, etc.)

Nurse educators pulled to clinical duties Use of non-healthcare workers to provide basic patient cares (bathing, assistance, feeding) Stable ventilator patients managed on step-down beds Use of non-healthcare

workers to provide basic patient cares (bathing, assistance, feeding) Disaster documentation forms used Cancel most/all outpatient appointments and procedures Minimal lab and x-ray testing

Allocate limited antivirals to select patients Need increasingly exceeds resources State-level Responsibilities Recognize Provide supportive policy and decision resource shortfall

tools Request additional Provide liability resources or relief facilitate transfer Manage the scarce of resources in an patients/alternativ equitable framework e care site

Hospital Responsibilities Plan for administrative adaptations (roles and responsibilities) Optimize surge capacity planning Practice incident management and work with regional stakeholders Decisionmaking process for scarce resource situations Scarce Clinical Resources Process for planning vs. process for

response Response concept of operations: IMS recognizes situation Clinical care committee Triage plan Decision implementation Clinical Care Committee Multiple institutional stakeholders decide, based on resources and demand:

Administrative decisions primary, secondary, tertiary triage Ethical basis AMA principles, etc. Decision tool(s) to be used Triage Plan Assign triage staff Review resources and demand Use decision tools and clinical judgment to determine which patients will benefit most Advise bed czar or other

implementing staff Implementing Decisions Bed Czar or other designated staff Transition of care support (as needed) Behavioral health issues Security issues Administrative issues Palliative care issues Alternative Care Sites

Stephen V. Cantrill, M.D., FACEP Associate Director Department of Emergency Medicine Denver Health Medical Center Alternative Care Sites Concept of an Alternative Care Site Nontraditional location for the provision of health care

Wide range of potential levels of care: Traditional inpatient care Chronic care Palliative care Home care Potential Uses of an ACS Primary triage of victims Offloaded hospital ward patients Primary victim care Nursing home replacement Ambulatory chronic care/shelter Quarantine

Palliative care Vaccine/drug distribution center Potential Alternative Care Sites Buildings of opportunity Advantage of preexisting infrastructure support Convention centers, hotels, schools, sameday surgery centers, shuttered hospitals, etc. Portable or temporary shelters Flexible but may be costly Sites best identified in advance

Factors in Selecting an ACS Basic environmental support HVAC, plumbing, lighting, sanitary facilities, etc Adequate spaces Patient care, family areas, pharmacy, food prep, mortuary, etc Ease in establishing security Access: patients/supplies/EMS Site Selection Tool: www.ahrq.gov/downloads/pub/biotertools/alttool.xls Potential Non-Hospital Site Analysis

Matrix Ability to lock down facility Adequate building security personnel Adequate Lighting Air Conditioning Area for equipment storage Biohazard & other waste disposal Communications (# phones, Local/Long Distance, Intercom) Door sizes adequate for gurneys/beds Electrical Power (Backup) Family Areas

Floor & Walls Food supply/food prep areas (size) Heating Lab/specimen handling area Laundry Loading Dock Mortuary holding area Oxygen delivery capability Parking for staff/visitors Patient decontamination areas Pharmacy Area Proximity to main hospital Roof

Space for Auxillary Services (Rx, counselors, chapel) Staff Areas Toilet Facilities/Showers (#) Two-way radio capability to main facility Water Wired for IT and Internet Access Total Rating/Ranking (Largest # Indicates Best Site) 0 0

0 0 0 0 0 0

0 0 0 0 0 0 0

0 0 Some Issues and Decision Points Who is responsible for the advance planning? Ownership and command and control of the site Decision to open an alternative care site Supplies/equipment Staffing Emergency System for Advanced Registration

of Volunteer Health Professionals: ESARVHP? Medical Reserve Corps? Some Issues and Decision Points Documentation of care Communications Rules/policies for operation Exit strategy Exercises Katrina/Rita: ACS Issues

Importance of regional planning Importance of security Advantages of manpower proximity Segregating special needs populations Organized facility layout Importance of incident command system Katrina/Rita: ACS Issues The need for House Rules Importance of public health issues Safe food Clean water Latrine resources

Sanitation supplies Palliative Care Issues Marianne Matzo, Ph.D., APRN, BC, FAAN Professor, Palliative Care Nursing University of Oklahoma College of Nursing Palliative care is care provided by an interdisciplinary team Focused on the relief of suffering Support for the best possible quality of

life Catastrophic Mass Casualty Palliative Care Palliative Care is: Evidence-based medical treatment Vigorous care of pain and symptoms throughout illness Care that patients want

Palliative Care is not: Abandonment The same as hospice Euthanasia Hastening death Good palliative care occurs wherever the patient is. The community should be prepared about the principles of palliative care in a disaster situation.

The minimum goal: die pain and symptom free. Effective pain and symptom management is a basic minimum of service. Adequate and aggressive palliative care services should be available to everyone. Palliative care under circumstances of a

mass casualty event is aggressive symptom management. Catastrophic MCE Triage + 1st response The too well Prevailing circumstances Receiving disease

modifying treatment The optimal for treatment Existing hospice and PC patients The too sick to survive Catastrophic MCE and Large Volume

The too sick to survive * Then: Initially left in place Transport Other than active treatment site *

1. Those exposed who will die over the course of weeks 2. Already existing palliative care population 3. Vulnerable population who become palliative care due to scarcity Clinical Services After Triage Resources: Personnel Coordination Supplies Clinical Process Issues Symptom management, including sedation

near death Spirituality/meaningfulness Family and provider support mental health Family and provider grief and bereavement Event-driven protocols and clinical pathways Preparation For The Future

Many of us discussed the need to evaluate what happened and learn how to be better prepared for the future. Youre expected to know how to do mass casualty. You must

train for the worst and hope for the best. Application of Concepts to a Pandemic Case Study Ann Knebel, R.N., D.N.Sc., FAAN Captain U.S. Public Health Service ASPR Co Editor The Next Pandemic What Can We Expect?

Estimates of Impact of 1918-like Event Illness 90 million (30%) Outpatient 45 million medical care (50%) Hospitalization 9, 900,000 ICU care

1,485,000 Mechanical 745,500 ventilation Deaths 1,903,000 Containment Strategies Community-based Interventions 1. Delay outbreak peak 2. Decompress peak burden on hospitals/infrastructure

3. Diminish overall cases and health impacts #1 Pandemic outbreak: No intervention #2 Daily Cases Pandemic outbreak: With intervention

#3 Days Since First Case Seasonal Flu vs. Pandemic Flu Seasonal Predictable patterns Some immunity Healthy adults not at serious risk Health systems

adequate to meet needs Pandemic Occurs rarely Little or no immunity Health people may be at increased risk Health systems may be overwhelmed

Role of the Primary Care Provider Emergency Hospital during influenza epidemic, Camp Funston, Kansas. Shows head to foot bed arrangement. National Museum of Health and Medicine, Armed Forces Institute of Pathology, NCP 1603. Role of Home Care Significant role for primary care providers Family members will play a significant role Planning should consider Daily Deaths, Ohio, 1918

Brodrick OL. Influenza and pneumonia deaths in Ohio in October and November, 1918. Ohio Public Health Journal. 1919;10:7072. Take Home Messages Community-level planning should be going on now, including the broad range of stakeholders Regional planning and coalition building serve as force multipliers Engage the community in a

transparent planning process and communication strategy More Information [email protected] Visit the AHRQ Web site: http://ahrq.gov/browse/bioterbr.htm Community Planning guide: http://www.ahrq.gov/research/mce

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