Overcrowding: Should your Disaster Plan be Activated?

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Overcrowding Should your Disaster Plan be
Activated?

• Andrew I. Bern, MD, FACEP
• Founder and Chair,
• Section of Disaster Medicine
• American College of Emergency Physicians

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Should your Disaster Plan be activated for
overcrowding?
What are the benefits? What are the downside
risks? What is the ROI (return on
Investment? What are the costs?

• Thinking outside the box!

3
Overview

• Identify a common link between hospital and
  Emergency Department overcrowding and Medical
  Disasters
• Define the cascade effect and how it applies to
  crowding and disasters
• Identify the role of the hospital in outcomes and
  solutions

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Overview (continued)

• Review the impact of changes in JCAHO Standards
• Change in Attitude is reflected in standards
• Six measurable changes at the hospital
• Review those Ten Troubling Cs
• Discuss the question Should you activate your
  Disaster Plan--for Overcrowding?

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Crowding and Disaster are linked by similar event
definitions

• At the root is the issue of
• resources or capacity

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Responding to Emergency Department Crowding A
Guidebook for Chapters

• Emergency Department Crowding A situation in
  which the identified need for emergency services
  outstrips available resources in the ED.
• A Report of the Crowding Resources Task Force
• August 2002

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Disaster Medical Services ACEP Policy Compendium

• A medical disaster occurs when the destructive
  effects of natural or man-made forces overwhelm
  the ability of a given area or community to meet
  the demand for health care.
• Approved 1985 Reaffirmed 1997 Revised 2000

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Different Natural Disasters have different time
courses

• Tornadoes in the Mid-West
• Significant Damage-- focal area
• Time Course little advanced warning

9
Acts of Terrorism can occur without warning and
strike without the ability to prepare.

• Rocket launched missiles such as stingers have a
  range of 3-5 miles

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Transportation Terrorism Air Travel

• Clear shot from 39th floor of building in
  downtown Boston to Logan Airport

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Bioterrorism

• Unlike explosions, the time course impacting the
  population affected by a BT event is dependent on
  the agent used.
• Other important unique considerations include
  contagion and the need for isolation.
• Key tool is surveillance and integration with
  public health

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Hurricanes Time Course Preparation time up to
72 hours
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Time Course describes the Cascade Effects in the
hospital and the community

• In Hospital the cascade moves from the ED
  through ancillary services to critical care and
  general hospital bed capacity.
• In Disasters the cascade moves from the zone of
  impact through secondary collection points,
  triage, transportation, and then to definitive
  care.
• The hospital itself can be the zone of impact!

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Cascade Effects (continued)

• In Hospitals the effect gradually builds to a
  saturation plateau which can create a domino
  system failure of ancillary services and an
  inability to place additional patients in
  critical care or hospital beds.
• This leads to ED boarding and back up.

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Without intervention by the hospital the Cascade
Effect Leads to

• Inpatient hospital saturation .
• ED capacitance is reached due to boarding of
  inpatients
• Inability to decompress or provide areas of
  treatment for new patients
• Resulting in DIVERSION !!!

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Cascade Effect Into the Community

• With the EDs and Hospitals capacity maximized
• With Diversion activated
• EMS must shift patient care to other facilities
• Each facility potentially can contribute to a
  system wide capacitance plateau

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Cascade Effect Into the Community (continued)

• If each facility has reached full capacity and is
  on diversion, the health care of the community is
  at risk.
• Introduce a Chemical /Bioterrorism event into
  this community and you could see system-wide
  failure!

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The Day that changed everything
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Testimony of Dennis OLeary, MD, President,
JCAH0-10/10/01 before Congress

• Some people believe that the health care
  delivery system- if faced with a bioterrorism
  effect- will somehow be able to accommodate the
  thousands of ill, injured, and worried well who
  will seek health care in that situation. The
  unfortunate truth is that we have much to do
  before such a belief can be fulfilled.

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In both Crowding and Disasters-- Solutions
Directed

• In a time phased response model (The Time
  Course)
• At personnel
• At resources
• At capacity
• At the Ten C problem areas

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Hospitals and EDs play pivotal roles

• In Crowding without intervention--diversion and
  increased LOS
• Impact affects communitys ability to respond
• In Disasters without coordination and
  preplanning
• Danger of overwhelming resources at any given
  facility
• Transferring the disaster ----convergence

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Emergency Management can change OUTCOMES !

• Mitigation (Prevention)
• Threat assessment
• Risk assessment
• HVA (hazards vulnerability assessment)
• Emergency Planning and Community Right to Know
  Act (EPCRA)
• LEPC/SERC

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Identification of Risks Floods

• Mitigation prevention
• Do you know your risks?
• Are you plugged into Community Risk and Threat
  Assessments?
• Example--The Houston Floods--hospitals evacuated.

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Identification of Risks BT

• Importance of Community Integration
• Local-State-Federal Coordination and Leadership

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Outcomes affected by (continued)

• Preparedness (all hazards approach)
• Includes unique events such as
• Terrorism nuclear, biologic, chemical
• Natural events storm, fire, earthquake, etc
• Man-made events transportation accidents, war
• Requires integration into an overall emergency
  management philosophy

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JCAHO Standards--A change of Attitude (effective
2001)

• Six areas of significant change
• 1. Emergency Preparedness to Emergency
  Management
• 2. All Hazards Vulnerability Analysis (HVA)
  approach
• 3. HEICS Command and Control
• 4. Community-wide practice drill
• 5. Off site capacity / treatment- evaluation
• 6. Integration with public health

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(1) Shift from Emergency Preparedness to
Management

• Adopting common terms and language
• Management addresses four phases
• 1. Mitigation prevention
• 2. Preparedness
• 3. Response
• 4. Recovery (returning to normal operation prior
  to the event)
• Involves the community

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Preparedness Need for Self Help

• Community Preparedness
• CERT program
• FEMA directed programs at families and children

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Disaster Response
How many? How many critical? How many requiring
unique resources? How many by EMS? How many by
Convergence? What of the worried well?
What of the media?
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(2) All Hazards Vulnerability Analysis (HVA)
approach

• Includes BT (Bioterrorism)
• Includes WMD (NBCEI)
• Includes integrating analysis from local, state,
  and federal authorities (LREC, SERC)
• Includes Natural Disasters
• Includes Man-Made / Industrial Disasters

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(3) HEICSHospital Emergency Incident Command
System

• Hospital application of the widely adopted
  Incident Command System (ICS) by uniform
  services--EMS, fire, law enforcement
• Improves Interoperability between organizations
  using common system
• Introduces concept of command and control

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(4) Community-Wide Practice Drill--Evaluate

• Interoperability of response structure
• Communication
• Coordination
• Command and Control

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(5) Off Site capacity / Treatments

• Casualty Collection Points (CCPs)
• Decontamination of Patients
• Isolation and treatment of contagious patients
• Treatment provided in home and alternative sites
  to increase capacity

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(6) Integration of Public Health and Medical Care

• Coordination of Effort
• Surveillance
• Bi-directional communications between hospitals
  and Public Health agencies
• Reporting
• Vaccination and treatment programs

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Hospital Emergency Management Outcome Goals

• 1. Integrated system of response
• 2. Scalable
• 3. Interoperability
• 4. Hazard Vulnerability Analysis
• 5. GAP analysis- supplies, personnel,
  vulnerabilities
• 6. Surveillance systems
• Automated
• Community Management

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Chaos--A tale of two cities
9.
First responders EMS and Law Enforcement
Community Mutual Aid --Activation of County EOC

MMRS
Impact
MRT
CERT
Emergency Management
Convergence Volunteers
EMAC
National Guard
Needing additional Resources--Multi-County Mutual
Aid
Needing additional resources--State involvement
Dept of Health Bureau EMS/ Trauma Services
Following State Assessment and Governors Request
to President--Federally Declared Disaster
NDMS
FEMA RESOURCES
USR
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Those troubling Cs (TEN)

• 1. Charge (Who is in Charge?---Operational
  Control)
• Who has the authority to activate and deactivate
  plan?
• 2. Command and Control (Chain of Command)
• 3. Communication
• 4. Coordination
• 5. Convergence

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Those troubling Cs (TEN) continued

• 6. Contamination
• 7. Capacity
• 8. Cooperation
• 9. Chaos
• 10. Critical Stress Debriefing

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Critical Incident Stress Debriefing (CISD)

• Recovery is a community wide process of
  returning to pre-event life and functioning.
• Mourning and debriefing of first responders and
  family members are important in their healing

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Should you activate your Disaster Plan?

• This depends on
• how you developed your plan
• what contingencies were planned for
• If the plan is well rehearsed
• If the plan can tap into community resources

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How you develop your plan

• What tools or resources do you use to develop
  your plan?
• JCAHO standards?
• OSHA requirements?
• State regulations?
• Planning Guides
• Community Risk/ Vulnerability Assessments?

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Should you activate your Disaster Plan?

• Practice makes Perfect!
• The more frequently the plan is rehearsed and
  used---
• The greater the chance that the plan can be used
  to solve facility problems.
• People forget and skills diminish if you only
  practice twice a year.

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Should you activate your Disaster Plan? What
would that solve? (continued)

• Access to personnel
• Phased and targeted response
• Activation of discharge planning or strategies to
  increase bed capacity

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Should you activate your Disaster Plan? What
would that solve? (continued)

• Activation of mutual aid agreements between
  hospital and community resources
• Use of surveillance tools
• Access to local assets--MRT (Medical Response
  Teams), MMRS (Metropolitan Medical Response Team)

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Should your Disaster Plan be activated for
overcrowding?
What are the benefits? What are the downside
risks? What is the ROI (return on
Investment? What are the costs?

• Thinking outside the box!

46
What are the benefits?

• Intra and Inter-Institutional support to
• Increase personnel
• Increase supplies and equipment
• Increase bed capacity
• Practice a community response
• Practice community surveillance
• Coordination to spread the load and minimize the
  risk of community wide system failure

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What are the downside risks?

• Making the tough decision!
• Rambo-like attitude of we can handle anything
• Appearance that to activate is a failure of
  administrative leadership
• Budget busting cost of mobilizing personnel.
• Historic lack of inter-institutional cooperation.
• Willingness to share real time capacity
  information openly with community surveillance.

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What is the ROI (return on Investment)?

• Preparation and intervention strategies might
  prevent diversion.
• Improved community cooperation.
• The ability to identify and create surge capacity.

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What are the costs?

• Time is money
• Cost for carrying out disaster drills can be
  significant--
• Committee meetings--personnel time
• Supplies and Equipment
• The actual drill
• EMS participation--units out of service
• The entire effort has not historically been
  reimbursed

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What are the costs? (continued)

• Recent exercise coordinated by the University of
  Maryland Medical System called Free State
  Response
• Cost 200-300,000
• Unfunded mandate for exercises
• 1984 study --coordinating hospital cost
  80-100,000 participating hospital cost 50-60k

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Some monies are available
Additional monies from CDC and HRSA State
Block Grants Homeland Sec.Act
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A New Season Is Beginning--Prevention-Preparation-
Response- Recovery