Ventilator and Scarce Resource Triage Tabletop Exercise

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Ventilator and Scarce Resource Triage Tabletop
Exercise
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Rules of Play

• Dont fight the scenario.
• Actions must be documented.
• Use only resources you actually have or can
  acquire readily.
•  

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Assumptions

• The strain of influenza causing the atypical
  pneumonia for this event is a novel strain and
  vaccine is not available.
• The case fatality rate is 20.
• Death rates are substantially the same for all
  ages and socio-economic groups.
• The rate of attack is 30 and most public and
  private sectors are operating in a COOP
  environment.
• Patients are deteriorating to respiratory failure
  within 36-48 hours of onset and about 40 are
  requiring mechanical ventilatory support.

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Data Collection

• Please appoint a scribe to take notes. This will
  be essential for getting a good after action
  report.
• Please complete your participant evaluation forms
  before departing.

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Objectives

• Test the ability of medical staff to utilize
  triage protocols in decision-making during an
  event.
• Assure that public information policies
  /procedures are in place for events requiring
  altered standard of care decisions.
• Test the hospitals ability to accommodate a
  surge of patients requiring ventilatory support.

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Background

• November 20, 2007
• A notice appears in the Weekly Epidemiological
  Record reporting 120 cases and 21 deaths from an
  unknown acute respiratory syndrome that occurred
  between October 2, 2007 and November 15, 2007 in
  a remote province in China. The illness spread to
  household members and health care workers.
•  
• December 15, 2007
• As the epidemiological surveillance continues, it
  is noted that there has been a steep rise in the
  number of cases in Hong Kong. The U.S. is now
  reporting cases in Los Angeles, Chicago, New York
  and Houston. The CDC epidemiological
  investigation has traced the cases back to
  passengers on flights originating in Hong Kong.

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• January 1, 2007
• Hospitals in Kansas are reporting cases to their
  public health officials that are consistent with
  the case definition for the atypical pneumonia
  from the WHO and CDC. Patients are deteriorating
  to respiratory failure within 36-48 hours of
  onset and about 40 are requiring mechanical
  ventilatory support. This is putting a
  significant strain on critical care and
  ventilator capacities across the state of Kansas.
•  
• January 15, 2008
• Hospitals across the US are now bulging at the
  seams with patients who have acute respiratory
  failure. Hospitals in Kansas are at near
  capacity in most places and large hospitals are
  refusing medical referrals because they do not
  have the capacity to handle more cases. Most
  medical centers are open only to trauma cases.
  The CDC and other federal agencies have dubbed
  the event a health care crisis of epidemic
  proportions. The cause of the illness has been
  identified as a novel influenza A virus. To
  date, the only treatments appear to be supportive
  therapy. The President has declared the
  outbreak of respiratory illness a national
  crisis. The national press is focused on the
  lack of planning and information to the public
  about the pandemic. Several news programs have
  featured parents of children who were unable to
  receive the treatment they needed because of a
  lack of medical resources and personnel and the
  medical care system is described as collapsing.
  The State Emergency Operations Center is up
  and running in Topeka.

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• February 1, 2008 800am
•  At the present time your facility is at 96
  licensed occupancy and you have been unable for
  the past 3 days to get any hospital to take any
  referrals other than trauma cases. Your facility
  has only 5 of its routinely used ventilators
  unallocated. More than 50 of the patients
  currently hospitalized are atypical pneumonia
  patients. Staff is beginning to get stressed
  with the patient load. To date your facility has
  experienced 88 atypical pneumonia related deaths
  including the beloved 70 year old maintenance
  man, Henry.
•  
• Your facility has 44 staff members who are
  currently out sick with a respiratory illness
•  

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February 1, 2008 800am

• Your facility has at least 30 cases of rapidly
  progressing atypical pneumonia who are expected
  to need ventilatory support within 48 hours.
•  
• Your facility has only 5 of its routinely used
  ventilators unallocated.
•  
• Your facility also has 16 patients in the ER at
  this time. They include  Alexander Allred,
  Barry Barnett, Ned Nelson, Paul Peters, Quintana
  Qualls, Rachel Russell, James Johnson, Andrea
  Arthur, Lester Landon, Karen Kline, Wendy Waters,
  Amy Anderson, Bradley Brady, Diana Dobkins,
  Charlie Carson, Ida Iverson

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Questions 1

• What are your top three priorities?
•  
• Will these patients be admitted?
•  
• Who in the facility has the authority to make
  determinations about prioritization of available
  beds and other resources?
•  
• What accommodations, if any, will need to be made
  in available services or the physical plant to
  accommodate these patients?
•  
• What staff changes, if any, will need to be made
  to accommodate these patients?
• How will these patients be managed? Which will
  be admitted, which discharged? What level of
  care can be sustained?

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• February 2, 2008 1000am
•  
• An additional 18 ER/nursing staff members have
  called in sick. Sixteen patients on the medical
  floor have died overnight of pneumonia-related
  complications. Supplies are running low and the
  staff is exhausted.
•  
• You have patients in the ER at this time. They
  include Elaine Eastwood, Rayna Richards, Yale
  Yarborough, Gail Guthrie, Pamela Payne, Ursula
  Unrein, Hank Harper, Nathan Neff

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Questions 2

• To whom and how will you communicate your
  hospitals status and needs as related to bed
  space, available personnel, other resource needs?
•  
• What process does the hospital have for acquiring
  additional resources such as medical supplies and
  personnel?
•  
• Does the hospital have a continuity of operations
  plan that addresses this situation?
•  
• Does the hospital have plans for an alternate
  care facility? What services will this alternate
  care center offer?
•  
• How long would it take you to set up alternate
  space for care? Who would be involved in the
  process?

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• February 2, 2008 215pm
•  
• The ER has patients again.
• Gregory Gray
• Vivian Vanderwagon
• Sally Sutton
• Quinn Quackenbush
• Ollie Ogden 

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Questions 3

• How will these patients be managed? Which will
  be admitted, which discharged? What level of
  care can be sustained?
•  
• How will you decide the standard of care that
  will be provided to them? At what point will
  your facility implement any altered standard of
  care protocols or re-examine those protocols?
•  
• For how long can your facility provide that
  standard of care given existing resources?
•  
• What plans does the hospital have to make space
  available for additional patients or patients who
  require more care than can usually be provided?
•  
• Who would be responsible for implementing
  processes such as early discharge, home care or
  alternate sites?
• Who will be responsible for assuring that altered
  standards of care protocols are followed?

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• February 3, 2008 930am
•  
• Calls from local physician offices regarding new
  admissions are piling up. There are no beds
  available. Most of the patients have atypical
  pneumonia and are being described as in
  distress. The office nurses claim to have sent
  the less severe cases home. Physician offices
  are now calling multiple hospitals trying to find
  space for patients. Your facility is getting
  calls from other states regarding transfers.

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Questions 4

• What will happen to these new patients and those
  whose status has changed?
• What tools are currently available to the
  hospital to make decisions regarding
  prioritization of care and resources?
•  
• How will the ethics committee assist in making
  the decisions?
• Will legal counsel be involved in the
  decision-making process?
•  
• How will the admitting physicians and staff be
  informed of the decisions regarding
  prioritization of resources?
•  
• How will decisions about discontinuing
  in-hospital care be communicated to patients?

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• February 3, 1130 am
•  
• The local television station has contacted the
  public information office asking for an interview
  related to the pandemic and how it is affecting
  hospital operations. She has been told that the
  hospital is full and that many patients have been
  sent home to die. She says that she has heard
  that the hospital isnt able to care for patients
  like in large cities and wants to know if
  community members should be seeking medical care
  elsewhere. The reporter also shares a citizen
  hotline tip that patients who are better insured
  are receiving preferential treatment over the
  indigent. She is specifically interested in
  talking with staff members and in following a
  patient case, perhaps a child, through the
  hospitalization process.

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Questions 5

• Who is responsible for answering this request?
•  
• Please prepare a public information statement
  regarding the current situation at your facility.

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• February 3, 1030pm
•  
• The off-going nursing supervisor reports to the
  night supervisor that she had to deal with
  several breakdowns about the lack of resources
  to care for the patients. The nurses feel like
  they are letting their patients down. She
  also reports that the lab tech Suzy looks like
  shes gotten run over by a truck shes been here
  so long and shes started coughing. Everyone
  is near tears and the volunteers are now refusing
  to come to the hospital for fear of catching
  pneumonia.

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Questions 6

• What plans and procedures does the hospital have
  in place related to crisis counseling for
  employees?
•  
• Who is responsible for monitoring employees for
  signs of undue stress?
•  
• What plans and procedures does the hospital have
  in place related to mental health counseling for
  patients and their families?
•  
• Who is responsible for assisting patients in
  accessing those services?

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Hotwash

• What went well?
• What could be improved?
• What training/exercises are needed?

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Thank you for attending the exercise. Your
opinion is valuable. Please take the time to
complete your evaluation form.