Assessing Level of Care: Special Needs Category Assignments during Evacuation and Residence at FMS C

1
Assessing Level of Care Special Needs Category
Assignments during Evacuation and Residence at
FMS College Station

• CAPT Ellen Lazarus, MD, USPHS
• CDR Catherine Vieweg, USPHS
• CAPT(P) Michelle Leff, MD, USPHS
• CAPT Steven Hirschfeld, MD, PHD, USPHS

2
Federal Medical Station (FMS) College Station

• A FMS is comprised of four tractor-trailers of
  supplies that require a shelter of opportunity
• PHS1 Rapid Deployment Force (RDF), tier 2 mental
  health and tier 3 officers were deployed to set
  up and operate a FMS in the Reed Arena of the
  Texas AM University on September 10, 2008 to
  receive special needs patients evacuated in
  advance of Hurricane Ike making landfall

3
FMS Capability

• Medical special needs sheltering for displaced
  persons with chronic diseases, limited mobility,
  or behavioral health requirements
• Inpatient care that is sub-acute, non-traumatic,
  non-surgical for areas where hospital bed
  capacity has been exceeded
• Support to quarantine missions (e.g. assist CDC
  Quarantine Stations)

4
Pre-staging a golden opportunity

• Training in FMS capability
• EMR
• Call-down
• Personnel accountability and tracking
• Lessons learned from teams deployed during
  Hurricane Gustav
• Integration of staff from the 3 tiers into a
  coherent FMS team

5
Patient Transport
By airplane
and ambulance
6
What it looked like
7
FMS College Station, TX
8
Shelter Profile

• Approximately 333 residents with a single day
  peak of 302
• Ratio of patient to accompanying caregiver was
  approximately 5 to 1
• 32 of caregivers who accompanied a patient
  became patients themselves
• Age range of shelter residents 1-101 years
• Mean age 65.5 years Median age 65.0 years

9
Origin of Shelter Residents

• Origin Per Cent
• Own home or apartment 68
• Nursing home 16
• Other/Unknown 12
• Facility other than nursing
• home (e.g., group home) 3.5
• Hospital 0.5

10
Diagnostic Categories
Data from first 6 days. Patients may have one
more than one diagnosis.
11
Assessing Acuity/Care Needs

• Several standards - Military/Rescue Service
  Triage, Texas/CMS scale, FMS special needs scale
• Selection of most relevant metric for local
  resources - Texas state authorities applied the
  Texas/CMS scale level (0-5) assigned to each
  evacuee prior to transport
• The levels were indicated on patient evacuation
  flight manifests faxed to the admin staff at the
  FMS shortly before the patients were received

12
Texas State Special Needs Patient Category Scale
(Texas SNC)

• Level 0 - No medical needs, but require
  transportation assistance for evacuation
• Level 1 - People who rely on others to provide
  their daily, routine care such as a child under
  18 without adult supervision
• Level 2 - People who are blind, hearing impaired,
  or have an amputation
• Level 3 - Need medical assistance incl. nursing
  care and help taking medicine dependent on
  equipment or have mental health disorders

13
Texas SNC - continued

• Level 4 - Not in a hospital, long-term
  care/assisted living facility or state school but
  require important medical assistance (i.e., IV
  chemotherapy, ventilator, dialysis, life support
  equipment, hospital bed, total care, or morbidly
  obese)
• Level 5 - People in settings such as a hospital,
  long-term care/assisted living facility, or a
  state school

14
Medical acuity and complexity on evacuation

• Texas state authorities appropriately screened
  for medical acuity and complexity
• Few, if any, patients evacuated to the College
  Station FMS were beyond the capability of the FMS
  due to medical complexity
• DMAT co-located within the FMS
• The Texas SNC scale does not clearly
  differentiate medical acuity and complexity from
  level of care requirements

15
Role of level of care assessment

• Medical condition acuity is important for triage
  where, when, and how should the evacuees be
  transported
• Level of care is important for determining
  resources at evacuation site
• Number and type of staff
• Supplies and equipment, contract services,
  nutritional support
• Low medical acuity does not necessarily mean low
  level of care

16
Patient assessment and tracking tools available
in the FMS

• The FMS uses the NDMS Electronic Medical Record
  (EMR) which currently does not include level of
  care as a data element
• Requires entry of triage category on admission
• Triage category remains with resident through
  discharge
• Resident/patient tracking capability of EMR
  limited
• There is currently no tool adopted for use at a
  FMS to assess residents level of care

17
FMS CS rapid assessment for level of care

• It became immediately and strikingly apparent
  that the evacuation manifest and triage
  categories did not correlate with the level of
  care
• A rapid evaluation method was developed to
  determine resident care needs
• Focused on 3 specific questions that would
  include or exclude patients from each of the
  Texas Special Needs Categories
• Validated by multiple users serial assessments
  performed

18
Question 1 Are you able to give yourself your
own medicine?
19
Levels 3, 4 and 5 were assigned to 66 of all
residents and 75 of main arena residents
20
Profile of Level of Care by Texas SNC Scale-
Serial Formal Assessments started on 10/15/08
Higher higher level of care
21
Patient Special Needs Category -Flight Manifests
vs. Post-admission Assessment

• Almost 2/3 of patients and caregivers were listed
  as category 2 on the manifests remainder listed
  as 3A
• Subsequently, formal SNC assessments were
  performed for the patients at the FMS 33 were
  assessed as categories 0-3, 50 category 3 or 4,
  and 15 category 5

22
Challenges associated with greater than expected
level of care

• Supplies and FMS layout not initially optimal for
  patients with high level of care requirements
  needed to rapidly requisition hospital-type
  supplies and services
• Staffing and shift configurations staff
  exhaustion, physical stress
• Resident and staff nutritional needs
• FMS capacity (number of beds filled, number of
  staff) was not exceeded before resources were
  exhausted

23
Conclusions

• Medical Special Needs Categories assigned at the
  point of evacuation may not accurately predict
  level of care
• Assessment scales may not be linear and are not
  designed to categorize evacuees based on level of
  care
• Tracking patient and caregiver SNC over the
  course of the FMS deployment aids in
• Allocating personnel and equipment resources
• Prioritizing residents for discharge
• Due to lack of alternatives, restriction of FMS
  capacity based on level of care may not be
  possible

24
Recommendations

• Planners should recognize the uncertainty of the
  level of care when directing evacuees to the FMS
  
• Additional staff/supplies may be merited when
  level of care is high
• FMS staff should be trained and prepared to
  accommodate residents with a high level of care
  requirement

25
Recommendations

• If level of care data are considered valuable for
  effective and efficient allocation of resources,
  a rapid, simple assessment tool should be
  developed for use with a scale specific to this
  purpose
• The Electronic Medical Record should include this
  data element for use during admission and patient
  tracking

26
Acknowledgements
FMS CS Commanders CAPT Bill Hess CAPT Dean
Coppola CAPT Jon Perez
FMS CS Operations CAPT Jeffrey Kopp Preventive
Medicine Section Staff
FMS CS Administration Section Patient Tracking
Staff CDR Diedre Presley LCDR Michelle
Everett LCDR Monique Howard LTJG David
Schwab LT Terrence Lew