Florida Hurricanes 2004

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Florida Hurricanes 2004Models of Integration
Between FL-1 DMAT and Local Hospitals

• David GC McCann MD
• Chief Medical Officer
• FL-1 DMAT
• Fort Walton Beach, Florida

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Objectives

• To understand methods of integrating a DMAT with
  local EDs during disaster response
• To appreciate the differing challenges facing
  DMATs attempting to integrate with local EDs
• 1. When the DMAT is first out
• 2. When the DMAT is relieving another team
  already on-site

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Objectives

• To appreciate the advantages and disadvantages of
  various integration scenarios
• To make recommendations for integration in future
  disaster deployments

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Florida Hurricanes 2004

• Four major hurricanes hit Florida in 2004
• Charley
• Frances
• Ivan
• Jeanne
• A record number of landfalls and tremendous damage

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Florida Changes Its State Slogan
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Florida Hurricanes 2004

• Hurricane Charley
• Landfall Friday, August 13 at Charlotte Harbor in
  SW Florida at 345 PM EDT
• Wind speed150 mph (Cat 4)
• Damage to insured property14 billion
• Direct Fatalities 10
• Hurricane Frances
• Landfall Sunday, Sept 5 at Sewalls Point, Stuart
  in South Florida at 1 AM EDT
• Wind speed105 mph (Cat 2)
• Damage to insured property8.9 billion
• Direct Fatalities 23

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Hurricane Charley
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Florida Hurricanes 2004

• Hurricane Ivan
• Landfall Thursday, September 16 at Gulf Shores,
  AL at 3 AM EDT
• Wind speed130 mph (Cat 3)
• Damage to insured property13 billion
• Direct Fatalities 25 in Florida
  
• Hurricane Jeanne
• Landfall Saturday, Sept 25 at North Hutchison
  Island, Stuart in South Florida at 1150 PM EDT
• Wind speed 120 mph (Cat 3)
• Damage to insured property6.5 billion
• Direct Fatalities 12

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Hurricane Ivan Signals Offshore
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Jeanne Hits Stuart, FL
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Disaster Response Principles

• Better too much than too little
• Push resources toward affected area prior to
  event?when safe!
• A quick, overwhelming response is better than a
  slow, well-planned response
• If you wait until you have all the facts, it will
  be harder to change the outcome.

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Starting Pitcher vs. Ace Reliever DMAT Roles
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Starter versus Reliever?

• There are advantages and disadvantages to being
  first out versus relieving another team already
  on-site
• Knowing the upside and downside of each scenario
  helps you prepare to meet challenges

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First Out Team?Pros

• Set up physical plant the way you want?do it so
  patient flow is under your control and optimized
• Initial contact with local hospital? get off on
  the right foot?communication!
• All team members psyched?disaster has just
  occurred?Lets roll

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Hurricane Charley
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Hurricane Jeanne
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First Out Team?Cons

• No pharmacy cache available until some time after
  set up on-site (usually)
• Possibly difficult getting to deployment site due
  to downed trees, power lines etc.
• Rapid Needs Assessment (RAN) still
  ongoing?mission may not be completely elucidated
  when you deploy?waiting game

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Relieving Team?Pros

• RAN is complete?mission is certain and needs well
  determined
• Pharmacy cache, air-conditioned tents on-site
• Properly done handover allows continuity of
  care?no need to reinvent the wheel

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Relieving Team?Cons

• Set up of physical plant is pre-determined? if
  problems, now yours!
• Any communication or interpersonal problems
  between previous team and local hospital? you
  have to smooth over
• Can be problem disengaging? we like having a
  DMAT, you cant leave!

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DMAT Triage

• Set up physical plant so patient flow controlled
  by DMAT
• At Hurricane Charley we did this? set up right in
  ED entrance? worked very well
• At Hurricane Jeanne, set up was across roadway?
  inefficient and decreased numbers seen by DMAT as
  ED did triage and kept more patients.

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Disaster Principle

• In a study of 29 major disasters, only 10-15 of
  casualties were injured seriously enough to
  require overnight admission to hospital only 6
  of affected hospitals suffered supply shortages,
  and only 2 had personnel shortages.

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So What Do Disaster Victims Need in Healthcare?

• Custodial care (e.g. if Nursing Homes
  damaged/destroyed)
• Basic medical care
• Mental Health care
• Prescription medications/refills
• Treatment for chronic illnesses (e.g. diabetes,
  asthma/COPD, CAD, etc.)
• Oxygen for people on chronic oxygen

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Healthcare Visits to DMATs

• Study by Nufer Wilson-Ramirez (2004) looked at
  NM-1 DMAT experience
• Commonest Chief Complaints to DMAT
• Wounds
• Musculoskeletal Pain
• Med refill
• URI
• Rash/Cellulitis
• Abdominal complaints (pain, vomiting/diarrhea)

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Nufer Wilson-Ramirez

• Commonest Treatments Provided
• Tetanus vaccination
• Wound care
• Antibiotics
• Pain reliever
• Medication refills

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Nufer Wilson-Ramirez

• Triage Categories
• Green 80
• Yellow 16
• Red 4
• Patient Disposition
• Home 91
• Hospital 6
• Left AMA 3

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Prescriptions Refills

• We found sending a letter by fax to all local
  pharmacies with doctors DEA numbers and FEMA
  credentials decreased call backs for verification
• Do this as soon as DMAT set up
• Obtain list daily of open pharmacies and local
  doctors offices to communicate to patientstry
  to arrange follow-up with their own physician if
  possible

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Prescriptions Refills

• DMATs need pharm cache sufficient to at least
  partially fill majority of scripts
• Pre-printed prescription pads with doctors DEA
  and FEMA informationor at least a stamp with
  this info
• Narcotic abuse is rampant?dont write drugs of
  abuse?send into ED where regulars well-known

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CA-MRSA

• Community-acquired MRSA is now a fact of life
• Spider-bites and abscesses may be
  CA-MRSA?culture then treat
• We used Clindamycin as outpatient treatment of
  skin infectionsrecent reports also found TMP-SMX
  works on CA-MRSA
• BUT, clindamycin-inducible CA-MRSA resistance
  common?there is a test for this through lab

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Breaking Up Is Hard To Do

• Disengagementwork closely with emergency
  managers and hospital admin
• Implement demobilization incrementally
• Chart call volume, peak times and duration? watch
  trends especially in relation to expected
  post-disaster historical trends
• Systematically reduce local dependence on DMAT

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Things Not to Say

• Were from FEMAwe are federalizing this ED and
  taking over.
• Well stay as long as you feel we are needed.
  (That might be a long time)
• Telling patients Everything is free, you wont
  have to pay for anything!

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Disaster Research
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NIMS and Disaster Research

• According to FEMA IS-700 course on NIMS
• The NIMS Integration Center will also develop a
  national database for incident reports
• Excellent idea? to do it we need a system of
  uniform data entry/capture across all incident
  types and missions

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Disaster Research Data Capture

• We need uniform capture of data across all
  DMAT/IMSURT Missions
• Design an MS Access/Excel Program which all
  patient encounters would use for registration
  (mandatory field entry)
• Print out Patient Encounter forms with entered
  data
• Field codes to be saved in Access database

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Disaster Uniform Data Entry System (DUDES)

• Ideal program would log following fields
• Age
• Sex
• Race
• Ethnicity
• Disaster Category
• Classification (patient)

• Disaster Related Activity
• Chief Complaint
• Co morbidities
• Diagnosis
• ICD-9 Code
• Disposition
• Triage Category

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Disaster Research Data Capture

• DUDES data should be kept in central server
  repository (NIMS Integration Center)? make
  available for disaster researchers with
  appropriate clearance
• Disasters occur infrequently? lets not miss
  opportunity to collect and store data!
• Use Utstein template to internationally
  rationalize Disaster Research

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Disaster Response Permutations
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Disaster Response Permutations

• After a disaster? either there is a hospital to
  serve the injured/sick or not
• Depending on the situation, either DMATs, IMSURTs
  or other portable medical assets may need
  deployment
• Let us look at the possible permutations

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Maintaining Local Infrastructure

• After hurricanes, hospitals, clinics doctors
  offices may be damaged or destroyed
• How can we (FEMA/DMATs) help prevent further loss
  of infrastructure due to economic impact?
• Dont want local docs and surgeons packing up
  leaving for good

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Competing Interests

• Damaged hospitals need to get up running ASAP
  to decrease lost revenue which threatens
  long-term viability
• DMATs must use proper hospital order forms so
  tests run will be reimbursed
• DMAT Triage vs Hospital ED triage?pros and cons
  both ways

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Portable Hospital Assets
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Portable Hospital Assets

• Federal Medical Contingency Station (FMCS)part
  of Strategic National Stockpile
• HHS developing 20 mobile medical facilities?no
  OR, no ICU, no isolation but otherwise
  operational hospital
• 250 beds each with enough supplies for 3 days
• 170,000-300,000 apiece

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Portable Hospital Assets

• HHS also plans 2 more sophisticated units
• Everything for a full-fledged hospital
• 5 million each
• HHS 2006 budget?money set aside to create
  voluntary national database of doctors, nurses,
  and emergency personnel who could be called upon
  in event of national disaster

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Portable Hospital Assets

• Future Medical Shelter System (FMSS)
• Developed at Y-12 Oak Ridge Labs and now
  delivered to Ft Detrick (military)
• With 24 volt battery and push of green button?box
  morphs into 8x8x20 OR with protection from
  biological chemical weapons

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Recommendations

• DMAT should always do triage but send in business
  to keep hospital viable? this worked well after
  Hurricane Charley
• FEMA should have portable buildings available to
  move in post-disaster so docs can begin seeing
  patients even if their offices are damaged
• IMSURT may have to be sent in if OR
  damaged/destroyed

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Recommendations

• Deploy longer term OR/hospital assets that could
  be left on-site for up to a year post-disaster (a
  portable replacement hospital such as FMCS
  FMSS)
• Need to allow local docs to work in DMAT tents
  until portable buildings available
• Let local surgeons work in IMSURTs until
  longer-term OR set up

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Recommendations

• Forward deploying DMATs toward area of expected
  hurricane cuts response time? e.g. send FL-1 to
  Ocala (when safe) and then can get anywhere in S
  Florida quickly
• You are being watched? attend to sterile
  technique, HIPAA confidentiality, no off color
  humor?Be professional at all times
• Know your limits? send to ED anything which might
  be beyond your abilities

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Things We Wish We Had

• Single Phase Air-conditioned tents
• temperatures in Florida in August/September
  90-100 F
• Pharmacy cache going out the door
• Always arrives late and we need meds en route to
  treat team members if necessary? not to mention
  patients once set up

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Things We Wish We Had

• A standardized patient encounter form for all
  DMATs
• Standardized data entry software for patient
  encounters in MS Access/Excel format with
  permanent database
• Properly labeled cache/equipment by all DMATs so
  mixing of resources doesnt cause inadvertent
  misdirection of resources

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Summary

• Good communication essential
• Pharmacy cache should deploy with team
• DMAT setup in front of ED if possible
• DMAT should do all triage
• Treat wounds as if CA-MRSA present
• Allow local docs and surgeons to use our tent
  facilities if necessary

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Summary

• IMSURT may need deployment as bridge if OR
  damaged and no other hospital nearby
• FEMA should provide portable buildings and have
  portable hospital available to prevent loss of
  infrastructure post-disaster

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Summary

• Disengagement incremental in close consultation
  with local admin
• Need Database Program with Disaster Uniform Data
  Entry System (DUDES)
• Keep DUDES in central data server for research?
  NIMS Integration Center

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The Hand of God
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QUESTIONS?