Health Care Delivery Model for Pandemic Influenza

1
Health Care Delivery Modelfor Pandemic Influenza

• Island County Health Departments Approach
• Presented by
• Roger S Case, MD
• October 2007
• Thanks to Charron Plumer and staff of
  Tacoma-Pierce County Health Dept for making this
  presentation possible.

2
GOAL

• Increase Health Care capacity in Island County
  during a medical catastrophe
• Minimize morbidity mortality

3
Island County Flu Impact

• A WORST CASE SCENARIO
• 24,000 patients seek care (30 attack rate)
• Up to 5,200 will be hospitalized (22 of those
  ill)
• Up to 720 will require ICU care (3 of
  hospitalized)
• Up to 950 will die (4 of those seeking care)
• Beds and staff exceeded quickly 25 beds
  currently staffed

4
Pandemic Severity IndexCDC 2/07
Projected Number of Deaths in Island County
Case Fatality Ratio
gt 2
gt 480
Category 5
Category 4
1 - lt 2
240 - lt 480
Category 3
120 - lt 240
0.5 - lt 1
Category 2
0.1 - lt 0.5
24 - lt 120
lt 24
lt 0.1
Category 1
Based on a population estimate of 80,000 with
30 ill
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Work Group Objectives

• Engage community health care partners in
  developing model
• Design and implement a coordinated system to
  deliver medical care during a medical catastrophe
• Develop triage protocols to guide allocation of
  scarce resources, e.g. equipment, staff, supplies

6
Initial Work Group Planning Organization

• Triage and
• Treatment
• Protocols
• Pre-Tier 1, Tier 1
• Tier 2

• Community
• Medical
• Coordination

Facilities Logistics Operations
Started early in 2005
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Concept of Operations

• Care delivered outside of hospitals
• Home
• Alternate care facilities divert pts away from
  ERS
• Hospitals acute/critical care
• Care site based on severity of illness resources

8
Concept of Operations

• Altered Standards of Care
• Insured/non-insured seen
• Relax insurance limitations
• Discussion elevated to state level
• Legal consultant
• Staff 24/7 with community medical providers and
  Medical Reserve Corps

9
Ethical Considerations

• To guide our Planning, we rely on the following
  principles
• To the greatest extent possible, everyone in
  Island County who becomes ill should be given the
  best care we can provide at that time, regardless
  of that persons social worth.
• To maximize our ability to implement this model,
  caregivers who work directly with patients and
  essential healthcare support workers should be
  considered a priority group for all preventive
  healthcare resources.
• If resources become so scarce that we cannot
  provide all patients with the care they need,
  care should be given to the patients likely to
  receive the most benefit from those resources.
• If it should become necessary to restrict
  individual liberties for the sake of the public
  health, the least restrictive interventions
  likely to be effective should be employed.

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Four Tiered System

• Pre-Tier 1 EMS (including 911) and Health Care
  Information lines
• Tier 2 Neighborhood Emergency Help Centers
• Triage, Outpatient Treatment and Referral
  function
• Tier 3 Alternate Care Facilities
• Expanded bed capacity with limited care
• Tier 4 Hospitals
• Higher acuity, lower census
• Adapted Based on Modular Emergency Medical
  System Developed for mass casualty bioterrorism
  events US Army Soldier and Biological Chemical
  Command 6/1/02

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Facilities

• ?? NEHC Tier 1 sites identified
• ?? ACFS Tier 2 sites identified
• Memoranda of Agreements
• Facilities will be standardized

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Pre-Tier 1

• EMS - 911 medical dispatching protocols developed
• Not all calls will get an ambulance
• EMS empowered to triage patients to appropriate
  levels
• Including care and comfort at home
• Nurse Triage Lines
• Similar protocols to 911
• Can refer patients to Tier 1 or send EMS

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Pre-Hospital Straw PersonPre-Tier 1/Phone Triage
Tx to Tier 3
Y
Y
EMS sent
Hypoxic, Hypertensive
Require Transport?
Y
Tx to Tier 2
Call to 911 or other public safety answer point
Unstable?
N
N
Evaluated by Nurse line
N
Refer to Tier 1 NEHC
Call to Nurse line
Y
Arrange for AVM
Needs in-person evaluation?
Y
Consideration special access phone for high
priority personnel to access nurse line
AVM eligible
Refer patients to Tier 1 location to p/u AVM
N
N
Info only
Create mechanism for nurse to communicate with
Tier 1 nurse phone order AVM
Nurse lines are run by multiple health care
organizations, will require standardization
between organizations and agencies. May also
require standardization across counties. Antivir
al medicationsNeighborhood Emergency Help
Center
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Tier 1 - Triage Neighborhood Emergency Help
Center (NEHC)

• Triage and basic evaluation
• dispense antiviral medications
• Patient receiving area separate pts by severity
  of illness
• Flu kits and home care information
• Holding areas - Pts waiting on transport to
  higher tier

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Tier 2

• For patients referred from Tier 1, or step down
  from Tier 3
• Persons not sick enough for hospital, need care
  that cannot be provided in home, or palliative
  care
• Short stay (I.e. dehydrated)
• Limited testing capability
• O2 saturations, Chemistry/glucose
• Oxygen, IV fluids
• Antiviral medications, abx for secondary
  bacterial pneumonia

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Tier 3 Alternate Care Facilities

• Pre-id sites for surge capacity medical care
• Mostly high schools
• Geographically located around Island County
• Facility set up in 50 bed units
• Continue to expand until full capacity

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Tier 3 (continued)

• Rest area for family care givers
• Palliative care area
• Occupational Health office
• Functioning cafeteria 24/7
• Staff break and sleeping area
• Chapel morgue
• Children under 3 y/o receive care at Tier 3
  eliminates need for cribs
• Posters, videos w/ care instructions infection
  control

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Patient Tracking Systems

• Tracking system Iris
• Bar coded wrist band
• Tracks from first physical contact until
  disposition
• Can be used to track staff as well

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Joint Information Center Risk Messaging

• Switch to alternate care system
• Home health care information
• How to contact health information line
• When to enter the system and go to Tier 1
• How to get to nearest Tier 1 Site
• What to bring clean linens/pillow, personal
  hygiene products, routine meds, one family
  caregiver

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Staffing

• Medical Coordination and Recruiting
• Medical Reserve Corps
• Registration
• JITT - Safety training, Triage and treatment
  protocols, Job Action Sheets, Infection Control,
  PPE

21
Medical Reserve Corps

• A group of community based medical volunteers
  called upon to serve in large-scale emergency,
  natural disaster, or public health incident

22
Liability Concerns

• Liability concerns permeate the discussion
• Pandemic or mass casualty event creates
  uncertainty and unpredictability as to how courts
  will interpret the legal standards in medical
  malpractice actions

23
Liability

• WA State assumes considerable liability for
  damage to property, injury or death that might
  occur during an emergency or medical disaster for
  registered worker
• Generally, Emergency workers, including state and
  local employees are indemnified by the State
  state will pay judgment for public employee who
  is found liable (if not due to gross negligence
  or willful misconduct)
• Covered (Registered) Volunteer emergency workers
  are immune from liability

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Liability

• In order for an emergency worker to be protected,
  emergency management must have assigned a mission
  number to approved missions and other emergency
  activities
• Citizens who are commandeered into service are
  entitled to the same privileges, benefits and
  immunities
• Covered volunteer emergency workers are granted
  immunity only when engaged in a covered activity
  and acting within the scope of his/her duties,
  under the direction of a local emergency
  management or law enforcement

25
Worker Registration

• Critical to register emergency workers
• Registered workers receive training on medical
  disaster system
• Statewide medical disaster system standard of
  care is implemented (proposed)

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Emergency Workers vs. Covered Volunteer Emergency
Worker

• Emergency Worker Any person who is registered
  with a local emergency management organization or
  the state military dept
• Holds an ID card issued by the above for the
  purpose of engaging in authorized emergency
  management activities
• Or is an employee of WA State or any political
  subdivision called upon to perform emergency
  management activities

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Covered Volunteer Emergency Worker

• An Emergency Worker, such as an MRC volunteer,
  not receiving compensation as an emergency worker
  from the state or local government.
• Is not a state or local government employee
• Registration critical

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Altered Standards of Care

• Community clinical decision makers will be
  identified who will assess the evolution of the
  illness and coordinate existing and changing
  standards of care within PC and the State

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Altered Standards of Care Principles

• Goal of an organized and coordinated response to
  a mass casualty event should be to maximize the
  number of lives saved
• Rather than doing everything possible to save
  every life, it will be necessary to allocate
  scarce resources in a different manner to save as
  many lives as possible
• Process must be fair and clinically sound,
  transparent and judged by public to be fair
• Triage protocols need to be flexible as event
  grows

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Statewide Standards

• Suggested that WA approach the issue of Altered
  Standards of Care in a Statewide manner
• Seek approval of proposed altered standards by
  professional organizations
• Submit to accreditation organizations for review
• Adoption of statewide standard of care would give
  medical providers increased guidance and
  increased likelihood of liability protection

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Tier 3 Work Group Goals

• Increase hospital capacity to care for acutely
  ill during a pandemic flu
• Identify patient type categories to facilitate
  triage during a pandemic flu
• Develop triage guidelines to guide allocation of
  scare hospital/ICU resources
• Develop Response Matrix outlining triage
  guidelines

Hospitals PH, EMS Military DEM
Participants
Work started early January 2007
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Assumptions

• Pandemic severity index, WHO Phases and Federal
  Response Stages will be the triggers guiding
  response and implementing the tiered triage
  protocols
• Standards of Care will be altered as incident
  progresses and emergency declared
• Focus on keeping health care systems functioning

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Patient Types
A matrix has been developed that outlines and
defines patient types. Four types have been
identified RED, YELLOW, GREEN, and BLUE
RED very poor prognosis, expected to die within
2-3 days

• Massive respiratory failure overwhelming entry
  of inflammatory cells (Cytokine storm)
• Rapid onset of SOB, cyanosis, tachypnea
• This type of response likely to occur in the
  younger, healthier persons 15-40 years old
• If treated in ICU/ventilators survival rate
  50
• Ref Grattan Woodson, M.D. 2/13/07

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Patient Types
YELLOW Very ill, survival past 3 days

• Pulmonary and/or cardiovascular complications
• Elderly, very young, adults with chronic medical
  condition
• Significant co-morbidities, e.g. diabetes, heart
  disease, HTN, asthma
• Pregnant women at high risk
• Survival rate is 85 if treated with IV abx, ICU
  and ventilator when needed
• 50 mortality rate if left at home
• Ref Grattan Woodson, M.D. 2/13/07

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Patient Types
GREEN greatest chance of survival

• Majority of those ill with pan flu
• Dependent upon others (household members) to care
  for them
• Fever, cough, malaise
• No cyanosis, hypoxia, or hemorrhage
• Co-morbidities under control
• Survival rate 99 if admitted to hospital when
  needed 95 if treated at home
• Death primarily due to dehydration
• Ref Grattan Woods, M.D. 2/13/07

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Patient Types
BLUE near death

• May be unconscious
• Will receive palliative care

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TIER 3 (HOSPITAL) PATIENT TRIAGE DURING PANDEMIC
INFLUENZA  
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Triggers Phases and Stages of a Pandemic

• Fed Govt Response Stages
• Stage 3 Widespread
• human outbreak in multiple locations overseas
• Stage 4 First human case
• in N. America
• Stage 5 Spread throughout U.S.
• Stage 6 Recovery prep for
• subsequent waves

• WHO (World) Phases
• Phase 6 Pandemic Phase increased and sustained
  transmission in general population

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Response Guidelines

• Triggers
• Fed Govt Stage 4
• First human cases in
• North America
• 1-2 ICU cases in Is. Co.
• Full hospital resources
• Category 1 Usual Standards of Care

• Actions
• Alert and Standby Tiers 1 2
• Conduct JITT of staff
• Admit all patient types
• Refer Green patients for
• home health monitoring
• Normal Critical care admission
• Elective procedures continue

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Response Guidelines

• Triggers
• Fed Govt Stage 5
• Spread throughout U.S.
• Pan Flu in W. WA
• Up to 10 ICU cases in IC
• Diminished Hospital
• capacity
• Emergency Declaration
• Category II Altered Standards of Care

• Actions
• Triage ED patients to Tier 1, as appropriate
• Refer GREEN patients to Tier 1
• Admit to CC based on ventilator, homodynamic
  support needs
• Admit YELLOW and RED when ICU beds available
• Once ICU beds filled, YELLOW patients receive
  priority

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Response GuidelinesCategory II Actions
(continued)

• Lift EMTALA by decree of Declaration of Emergency
• Activate surge capacity and emergency response
  plans
• ACFS operational
• Hospital Command Centers communicate on patient
  triage and movement
• Elective procedures decreased
• Implement early discharge protocols

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Response Guidelines Category III Altered
Standards of Care

• Triggers
• Fed Govt Stage 5
• Community Spread
• ICU cases greater than 10
• Hospital resources are nearly or completely
  diminished
• Category III Altered Standards of Care

• Actions
• Implement criteria for inclusion or exclusion to
  CC
• Admit YELLOW patients with greater chance of
  survivability
• Assess RED patients case by case (if ICU bed is
  available and no YELLOW patient is waiting, admit
  RED)
• Refer RED patients to hospice, Home Health, Tier
  2 Palliative care
• Exclude elective surgeries
• Emergency surgeries traumas, appendectomies
  will be continued

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Response GuidelinesCategory III Actions
(continued)

• Activate resource conservation, conversion
• Convert surgical suites, day surgery, recovery
  suites in CC beds
• Shift human resources from OR and Recovery to CC
• Cancel elective procedures
• Hospital Command Center coordinates movement of
  patients between hospitals

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Response GuidelinesCategory III Critical Care
Inclusion/Exclusion Guidelines

• Critical Care Inclusion
• Requires ventilator support
• Requires homodynamic support

• Critical Care Exclusion
• Severe trauma, severe burns, cardiac arrest
• Severe baseline cognitive impairment
• Advanced untreatable neuromuscular disease
• Metastatic malignant disease
• Advanced immunocompromised
• Advanced/irreversible neurologic event
• End-stage organ failure
• Elective palliative surgery

Ref CMAJ 11/21/06 Development of a triage
protocol for critical care during an influenza
pandemic
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Tier 3 Triage Admission Guidelines

• Tier 3 Response Matrix

46
Tier 3 Response Matrix
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Pediatric Triage TreatmentCurrent workgroup

• Expand Tier 1 and Tier 2 protocols
• Incorporate pediatric protocols into Tier 3
  matrix
• Pediatric modifiers for Patient Type descriptions
• Admission Guidelines of pediatric patients to
  adult hospitals

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Pediatric ModifiersPatient Types

• Little available in literature re clinical
  presentation or historical models of peds during
  pan flu
• Additional complexity family treatment modality
  makes social distancing more difficult

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Pediatric Patient Types

• Red (very poor prognosis, expected to die within
  2-3 days)
• Peds robust immune system, primary flu,
  suspected high inflammatory response, young
  adults in good health

• lt 15 y.o not likely to be categorized as Red Type
• gt15 y.o likely to have higher immune system
  response, therefore thought to be at higher risk

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Pediatric Patient Types

• Yellow (very ill, survival past 3 days)
• Peds Main risk is secondary infection creating
  compromised health
• Green (greatest chance of survival)
• Peds Very ill and symptomatic, but with a high
  survival rate
• Blue (near death) very ill, routed to holding
  area

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Concept of Operations

• Altered Standard of Care for peds minimize risk
  for providers, I.e. delay of pediatric elective
  surgery
• Use of step-down beds and reallocation of ICU
  resources
• Develop standing orders and guidelines for
  non-pediatric hospitals to take lower acuity peds
  if main pediatric hospital is full

52
Pediatrics

• Demarcation for adult care physiologically is not
  very different for typical child gt 15 y.o.
• Concern is the social familial support needs
  for child
• gt 18 y.o independent admission
• lt 18 y.o. need family present

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Pediatrics - Notes

• Categories I-III most children lt 15 y.o.
  manageable by non-pediatricians
• lt 40 kg. Cannot use adult vents
• Ped patient gt3 y.o. triaged as a Green patient
  can be managed at Tier 2 site following
  standardized protocols accompanied by legal
  guardian
• Skill set for starting IV same in child gt 3 y.o.
  as in adult

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Pediatrics - Notes

• Peds already admitted to hospital at time of
  emergency declaration would not have care removed
• Need to reserve vents in NICU might use
  survivability of pre-term neonates as a threshold
• Under elevated category conditions, NICU vents
  can be used for babies lt 12 months old.

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Pediatrics - Critical Care Exclusion

• Severe trauma, severe burns, cardiac arrest
• Severe cognitive impairment totally dependent
  for all ADLs
• Advanced untreatable neuromuscular disease
• malignant disease with poor survivability
• Advanced, irreversible immunocompromised

• End-stage organ failure
• lt 28 weeks gestational age
• Elective palliative surgery
• Major congenital anomaly with decreased
  survivability
• End-stage pulmonary disease
• Heart transplant patients
• Unrepaired cyanotic heart disease patients

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Current Work Groups

• Respiratory Therapy
• Pediatrics
• Just-in-time Training
• MRC system designed beginning implementation
  and recruitment

57
Parking Lot

• Surveillance Tool Its coming projections,
  number of cases, severity
• Tool to Activate Tiers 1 2 phased approach,
  number and locations
• Tool to assess function effectiveness of Tiers
  1 2
• Pregnancy Care
• Palliative Care protocols
• Criteria for phasing out elective surgeries
• Criteria for withdrawal of support

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Summary

• A work in progress
• Attempt at a needs-based response to a situation
  with scarce resources
• Attempts to maximize resource utilization by
  applying county-wide triage protocol
• Standardizes care across county
• Addresses application of limited resources

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For more information
Roger S Case, MD _at_ 360 914-0840 Larry Wall _at_
360-661-2924