The State of Texas Disaster Medical System

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The State of Texas Disaster Medical System An
Overview of TDMS and ESF-8 Coordination

• Bruce Clements, MPH
• Director, Community Preparedness Section
• Texas Dept of State Health Services
• Rick Bays
• Director, Response and Recovery Unit
• Texas Department of State Health Services
• Emily Kidd, MD
• Assistant Professor, UT Health Science Center San
  Antonio
• Project Director Texas Disaster Medical System

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TDMS Update
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Emergency Support Function 8, Public-Private
Partnership
ESF-8 Capacity
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National Preparedness Strategies

• Public health and healthcare preparedness is part
  of a national preparedness strategy
• Presidential Policy Directive 8 National
  Preparedness
• aimed at strengthening the security and
  resilience of the United States through
  systematic preparation for the threats that pose
  the greatest risk to the security of the Nation,
  including acts of terrorism, cyber attacks,
  pandemics, and catastrophic natural disasters.
• aimed at facilitating an integrated,
  all-of-Nation, capabilities-based approach to
  preparedness.

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Vision and Strategy Alignment
Homeland Security Presidential Directives
Pandemic and All-Hazards Preparedness Act (PAHPA)
OPHPR Strategic Plan
National Health Security Strategy (NHSS)
National Preparedness GoalCore Capability List
Public Health and Healthcare Preparedness
Capability Development
Trust for Americas Health Ready or Not
Conceptualizing and Defining Public
Health Emergency Preparedness
Health Preparedness Capability Prioritization
Project
Project Public Health Ready
Note Partner documents are not an exhaustive
list, shown for representation purposes only
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Public Health and Healthcare Preparedness
Capabilities
TDMS
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TDMS Intersects The Critical Three
Public Health Emergency Preparedness Hospital Preparedness Program Department of Homeland Security
Emphasis on strengthening community resilience v v v
All-of-Nation All-of-State / whole community approach v v v
Capabilities-based approach v v v
Identification of gaps v v v
Requirement for risk assessment v v v
Need for demonstration of ROI v v v
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NDMS and TDMS

• HHS may activate the NDMS to provide aid to
  victims of a public health emergency or to be
  present at locations at risk of a public health
  emergency.
• HHS is the lead federal agency for Emergency
  Support Function 8 (ESF8) Public Health and
  Medical Services. 

• DSHS may activate TDMS to provide aid to victims
  of a public health emergency or to be present at
  locations at risk of a public health emergency.
• DSHS is the lead state agency for Emergency
  Support Function 8 (ESF8) Public Health and
  Medical Services. 

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Healthcare and Public Health Capabilities

• Public Health Emergency Preparedness (PHEP)
  awardees address 15 public health preparedness
  capabilities
• Hospital Preparedness Program (HPP) awardees
  address 8 healthcare preparedness capabilities

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Capabilities Overview

• Fifteen (15) public health and eight (8)
  healthcare preparedness capabilities
• Numerical designations cross PHEP and HPP
• Based on NHSS, PPD-8, NRF, NIMS and CPG101
• Intent
• Continuity of essential public health and
  healthcare services to the community
  post-disaster
• Effective management ESF-8 challenges
• Ensure ESF-8 priorities and resource needs are
  addressed during response and recovery

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Capabilities Overview
Public Health Preparedness Capabilities Public Health Preparedness Capabilities Healthcare Preparedness Capabilities Healthcare Preparedness Capabilities
1 Community Preparedness 1 Healthcare System Preparedness
2 Community Recovery 2 Healthcare System Recovery
3 Emergency Operations Coordination 3 Emergency Operations Coordination
4 Emergency Public Information and Warning 4
5 Fatality Management 5 Fatality Management
6 Information Sharing 6 Information Sharing
7 Mass Care 7
8 Medical Countermeasure Dispensing 8
9 Medical Materiel Management and Distribution 9
10 Medical Surge 10 Medical Surge
11 Non-Pharmaceutical Interventions 11
12 Public Health Laboratory Testing 12
13 Public Health Surveillance and Epidemiological Investigation 13
14 Responder Safety and Health 14 Responder Safety and Health
15 Volunteer Management 15 Volunteer Management
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Public Health and Healthcare Preparedness
Capabilities

• Consistent with national preparedness strategies
• Capabilities-based planning and implementation
• Provides national guidance with a whole of
  community and all of nation approach
• Serve as the foundation for the 2012 HPP-PHEP
  cooperative agreements

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Illustrating and Communicating ESF-8 Complexity

• Acute Healthcare and Public Health
• Two sets of distinct functions that strongly
  influence each other
• They can stand alone but are much stronger
  together
• Cant be too close
• Complete integration is not possible (placing
  acute care in public health or vice versa)
• Cant be too far apart
• They strongly influence each other

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ESF-8 Coordination The Keystone
Collaboration of public health and acute medical
care preparedness
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Resources

• Spectrum of Resources
• Equipment (e.g. AMBUS)
• Equipment with Crew (e.g. Mobile Medical Unit)
• Teams with Equipment (e.g. Ambulance Strike
  Teams)
• Persons with Skills (e.g. Physicians,
  Epidemiologists)

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TDMS Resource Typing and Credentialing

• RESOURCE TYPE
• External attributes that are obvious
• Measurable
• Countable
• Things
• Unlikely to change
• Quantitative - Descriptive Definition
• Equipment or Teams

• CREDENTIAL
• Internal attributes that are not obvious
• Skills
• Knowledge
• Ability
• Can to be transitory
• Vetted Identity
• Badge to combine Identity and Attributes
• Persons

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TDMS Process

• Collaborative planning
• Response hierarchy coordination
• Role and responsibility clarification
• Sequencing response actions
• Focusing resources on risks
• Defining resources and support
• Improvement processes

The TDMS process is a forum for collaborative
planning for healthcare and public health
stakeholders to refine preparedness and response
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TDMS Texas Disaster Medical System
Courtesy TDEM Website

• The Texas Disaster Medical System is the
  collaboration of all public health and acute
  medical care preparedness initiatives within the
  State of Texas relating to the mitigation of,
  response to, and recovery from natural and
  manmade disasters and other significant events
  within any region in Texas, with respect to
  Emergency Service Function (ESF)-8 functions.

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Where does TDMS get its authority?

• The Texas Disaster Medical System (TDMS)
  Steering Committee was established under the
  direction of the Texas Department of State Health
  Services (DSHS) in 2010. DSHS is the lead agency
  for Emergency Support Function (EDF)-8 (Public
  Health Medical Services) per the state of Texas
  Emergency Management plan, Annex H, Texas
  Government Code 418.042, 418.043(13), and
  418.173(a).

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TDMS Steering Committee
TDMS Steering Committee
Public Health
Acute Care
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Who is represented on the TDMS Steering Committee?

• Local Public Health Authorities
• Local Health Departments
• Regional Public Health Authorities
• Regional Health Departments (HSRs)
• Texas Department of State Health Services
• Trauma Service Areas / Regional Advisory Councils
• Hospitals and the Texas Hospital Association
• Hospital Emergency Management
• Academic Medicine
• EMS Agencies Rural, Urban, Fire-based
• Texas Division of Emergency Management

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Issues / gaps identified (so far.)

• Need for standardized training curricula and
  schedules for almost every response / resource
  group
• Overlap of emergency response personnel on
  multiple team rosters
• Coordination with Texas Military Forces resources
• Funding responsibilities
• Liability coverage of medical response personnel
• Continuation of funding of teams/assets
• Our role in medical component of mass-care
  sheltering
• FNSS integration into plans and operations
• Integration with federal response systems
  (timing, resource typing, availability, etc.)
• Mass Fatality planning

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Issues / gaps identified (so far.)

• Patient tracking issues
• Standardized patient records
• Patient records management
• HIPAA compliance during a disaster
• Use of MRCs / VOADs / volunteers
• Integration of Medical Operations Centers into
  TDEM organizational chart
• Medical Operations Centers functions and purpose
• Integration of MOCs across the State

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TDMS Overview Document

• Strategic framework and resource guide for P.H.
  and medical response and recovery
• Guidelines, protocols, concepts, tasks,
  responsibilities, resource management information
• Proposes MOC structure for ESF-8 coordination
• Not intended to supplant local plans

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TDMS Goals

• Ensure highest level of readiness to respond
• Ensure coordination, communication and
  collaboration among partners
• Ensure understanding of roles and
  responsibilities of partners
• Maintain updated list of ESF-8 resources

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Planning and Coordination

• Bring together all partners from public health
  and acute care
• Reveals gaps and overlaps
• Facilitates better understanding of roles and
  responsibilities
• Provides for continuous improvement
• Partner workgroups at local jurisdiction,
  regional/multijurisdictional and state

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Planning and Coordination Functions

• Access all current plans de-conflict and
  coordinate
• Compile list of available resources, assess gaps
  and overlaps
• Establish mutual aid agreements
• Develop organizational model for MOC and assign
  participants
• Develop communications plan among partners

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Planning and Coordination Functions (cont)

• Determine how local and regional plans integrate
  with state plans
• Develop written documents for plans and resources
• Disseminate plans to all partners
• Communicate gaps and capabilities to DSHS and
  TDMS Steering Committee

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The MOC(Medical Operations Center)

• During response and recovery both acute care and
  public health must come together quickly
• Single organization for ESF-8 coordination
• MOC is not stand alone but is integrated into
  incident command
• Flexible and scalable based upon the incident

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MOC Structure
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MOC Development Partners

• Single Jurisdiction
• Local public health
• EMS
• Local EM
• Local health authority
• Hospitals/nursing homes
• ME/JP
• DME providers
• Medical staffing agencies
• Mental Health Centers
• Disability community

• Multi-jurisdictional
• DDC/Regional coordinators
• RAC
• DADS
• DARS
• Community mental health centers
• Disability community
• ME/JP

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ESF 8 CoordinationPrimary Functions

• Assessment of Health Medical Needs
• - P. H. infrastructure
• - Mental Health services
• - hospital dialysis and LTC
• facilities Capacity
• - EMS
• - home bound population
• Health Surveillance
• - general and medical shelters
• - hospitals, dialysis and LTC facilities
• - illness, injury, deaths
• Medical Care Personnel
• - coordinate and manage deployed staff and teams
• - facilitate resources
• - medical volunteer management

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ESF 8 CoordinationPrimary Functions

• Health and Medical Supplies and Equipment
• - general and medical shelters
• - facilities
• - EMS
• - Pharmacy and Oxygen
• Evacuation
• - coordinate medical ground and
• air assets
• - coordinate staging
• - coordinate facility evacuations and
  destinations
• - coordinate embarkation/reception
  triage/shelter
• placement
• Patient Care
• - facilitate management of medical surge
• - hospital census and bed availability

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ESF 8 CoordinationPrimary Functions

• Food Safety and Security
• - food safety in shelters
• - food safety during recovery
• - food borne illness outbreak
• Mental Health Services
• - Disaster behavioral health
• - Substance abuse services
• Mortuary Services
• - assist in Family Assistance Centers
• - coordinate mortuary services/cemetery

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ESF 8 CoordinationPrimary Functions

• Public Health / Medical information
• - risk messaging to public
• - public health policy and guidance
• Recovery
• - re-entry of evacuees
• - infrastructure
• - vector

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Incident Scenarios

• Hurricane
• Flooding
• Wildfire
• Catastrophic disease
• (including pandemic)
• Drought / Water Loss
• Tornado
• Radiologic Emergency
• Food Contamination Attack /
• Food Borne Illness

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Incident Scenarios
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Incident Scenarios

• Awareness of injury risks
• Medical care for sheltered individuals
• Evacuation
• Stress Reactions
• Preventing disease in congregate care settings
• Mass Fatalities
• Medical Surge
• ESF-8 Coordination and Management
• To name a few..

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Incident Scenarios
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TDMS Training Levels

• Basic knowledge related to an integrated TDMS
  emergency response and its key components
• The target audience is all existing or potential
  participants of the TDMS

• Core knowledge and skills that are common to
  most of the TDMS technical teams or activities
• The target audience is individual TDMS members

• Advanced TDMS team training
• The target audience is individuals or entire
  units assigned to specialized TDMS teams (e.g.,
  MMU, MIST, RAT, CAT, BHAT)

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Pilot Courses

• Not Throwing Caution to the Wind 4/3 230 Deploy
  ment Safety
• Exec. Overview of WebEOC in Texas 4/4 1000
• ESF8 Resource Roundup 1 4/4 230
• ESF8 Resource Roundup 2 4/4 400
• Going Down Range Deployment Basics 4/5 1000

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Emergency Medical Task Force
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Emergency Medical Task Force Leadership Team Emergency Medical Task Force Leadership Team Emergency Medical Task Force Leadership Team Emergency Medical Task Force Leadership Team
Command/General Staff (from EMS agencies/hospitals in local jurisdictions) ICS 100, 200, 300, 400, and AHIMT certs, with position specific certs as well Must have EMS/ER/IMT management experience Full comms package to communicate with all group and Local EOC/DDC/MACC/DSHS/TDEM-SOC Logistics package to support all groups Command/General Staff (from EMS agencies/hospitals in local jurisdictions) ICS 100, 200, 300, 400, and AHIMT certs, with position specific certs as well Must have EMS/ER/IMT management experience Full comms package to communicate with all group and Local EOC/DDC/MACC/DSHS/TDEM-SOC Logistics package to support all groups Command/General Staff (from EMS agencies/hospitals in local jurisdictions) ICS 100, 200, 300, 400, and AHIMT certs, with position specific certs as well Must have EMS/ER/IMT management experience Full comms package to communicate with all group and Local EOC/DDC/MACC/DSHS/TDEM-SOC Logistics package to support all groups Command/General Staff (from EMS agencies/hospitals in local jurisdictions) ICS 100, 200, 300, 400, and AHIMT certs, with position specific certs as well Must have EMS/ER/IMT management experience Full comms package to communicate with all group and Local EOC/DDC/MACC/DSHS/TDEM-SOC Logistics package to support all groups
5 Ambulance Strike Teams 5 RN Strike Teams 2 Ambuses Mobile Medical Unit
5 Ambulances in each Strike Team (25 total ambulances) Each Strike Team has pre-assigned Strike Team Leader Teams are Pre-rostered 10 min launch time for lt12 hr deployment 4 hour launch time for minimum for 72 hr deployment with additional gear as needed. 5 RNs in each Strike Team (25 total RNs) Each Team has pre-assigned Strike Team Leader 3 ER Strike Teams 1 ICU Strike Team 1 Specialty area (Burn, OB, Pedi, NICU, etc) 6 hour launch time for minimum of 72 hr deployment Ambuses are capable of transporting up to 20 litter patients at one time Pre-plumbed for O2, medical gases, etc Assigned to EMS agencies that will deploy 4-6 paramedics 10 min launch time for 12 hour deployment 4 hour launch time for 72 hour deployment 16-32 bed capacity Able to provide emergency stabilizing care (23 hrs only) Fully staffed with EM physicians, ER nurses, techs, logistics, clerical and other support 6-12 hour launch time for 72 hr deployment Further typing for MMT integration is in progress
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Ambulance Strike Teams

• 5 Ambulances/AST (25 total)
• Pre-identified teams
• No-notice regional deployment
• Statewide tasked missions
• Common communications

• Currently 32 ASTs engaged, 150 units

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Mobile Medical Units

• 16-32 bed capacity
• Provide emergency stabilizing care and transfer
• Staffed with physicians, nurses, techs,
  logistics, clerical, etc
• 6-12 hr launch time for 72-96 hr deployment
• Standardized cache of supplies, pharmaceuticals,
  and capabilities

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AMBUS Project

• MPV Multi-Patient Vehicle
• Transport gt12 litter patient at a time
• Pre-plumbed for O2 and medical gases
• No-notice regional and statewide taskings
• 4-6 paramedics/AMBUS

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EMTF 2 North Central Texas
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RN Strike Teams

• Nurses deployed into a like environment
  standardized training
• Must be qualified nurses with critical thinking
  skills during disaster situations
• Understand NIMS and disaster response
• Statewide tasking missions
• Still being developed

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ESF-8 Coordination in Action

• TDMS Components active during wildfire response
• State medical operations center
• DDC medical operations center
• Ambulance Bus
• CAT Team
• Ambulance Strike Teams
• Mobile Medical Team (MMT/MMU)
• Pharmacy services
• Disaster behavioral health

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ESF-8 Coordination in Action

• TDMS Components active during wildfire response,
  cont
• Medical support in general shelters
• DME/ Medical supplies
• Public Health
• Shelter surveillance
• Public health messaging
• Epi surveillance
• Infection control
• Assessment

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Questions and Discussion