The second event in a series offered in 2004, this Web conference was broadcast July 13, 2004. It was designed to help State, local, and health system policymakers explore key issues, research findings, and strategies for the use of facilities and equipment to enhance hospital surge capacity. The Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.
Cindy DiBiasi: Good afternoon. Welcome to Surge Capacity: Facilities and Equipment. This is the second event in a series of three Web conferences on surge capacity and health system preparedness. These events are designed for State and local health policymakers and health systems decisionmakers. The series is sponsored by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, often referred to by the acronym, A-H-R-Q or AHRQ. My name is Cindy DiBiasi and I will be your moderator for today's session.
The context for this series is clear and compelling. Bioterrorism continues to be a significant threat to the health and well-being of our nation. Efforts to address this threat have focused considerable attention on the need to improve and strengthen the U.S. health care and public health infrastructures to be sufficiently prepared to respond to a major public health emergency. The important aspect of bioterrorism preparedness is that of surge capacity. Surge capacity is a health care system's ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care and public health in the event of bioterrorism or other large-scale public health emergencies or disasters.
A number of important stakeholders have an essential role in ensuring that sufficient surge capacity exists within their own jurisdiction, region or delivery system. These include policymakers, planners and other decisionmakers at the Federal, State and local levels; program administrators, health system decisionmakers and providers. To be effective in their planning efforts, it is critical that they have information about the latest research, tools and models focusing on surge capacity available to them. Today's event is the second one in the 2004 series on surge capacity and health system preparedness. I will tell you more about this series later in the broadcast. Now let's turn to today's call.
We will be exploring the key issues, research findings and strategies related to enhancing surge capacity through the use of facilities and equipment and I would like to begin today by introducing today's panelists. In the studio with me I have Lt. Commander Sumner Bosler. He is a senior public health analyst in the Division of Healthcare Emergency Preparedness within the Office of Special Programs in the U.S. Public Health Service and at the Health Resources and Services Administration. Bettina Stopford, director of Public Health and Medical Emergency Preparedness within Homeland Security Support Operations at the Science Applications International Corporation. Dr. David Markinson, director of the Program for Pediatric Preparedness and deputy director of the National Center for Disaster Preparedness at Columbia University and David Gruber, assistant commissioner of the New Jersey Department of Health and Senior Services. Welcome everyone.
Before we begin our discussion, I would like to tell the audience a bit about the format of this audio conference. First we will talk with our four panelists and then open the lines to take your questions. We will give instructions on how to send questions to us later in the program. While we don't anticipate that you will experience any technical problems, I would like to give you a few tips on dealing with them just in case they come up.
Now I think we are ready to discuss today's topic. Let's begin with Sumner Bosler, who is with the National Bioterrorism Hospital Preparedness Program at the Health Resources and Services Administration, also known by the acronym H-R-S-A or HRSA, and that of course is within the U.S. Department of Health and Human Services. Sumner, for those of our listeners who might not be familiar with us, can you give us a brief overview of the HRSA National Bioterrorism Hospital Preparedness Program?
Lt. Commander Sumner Bosler: Well yes, Cindy. Our program was initiated in 2002 after the anthrax release in October. Congress authorized funding to counter bioterrorism (BT) threats and our program was started to reinforce the infrastructure and health care system of the United States. Our program initially started with $135 million in 2002 and in 2003 a continuing resolution in June 2002 allowed us to release $498 million for 2003 and that is currently what we have stayed with as of this year in 2004. We have 62 awardees, which is all 50 States, Washington, D.C., Puerto Rico, the Virgin Islands, the major metropolitan areas of Chicago, Los Angeles, and New York City, and the Pacific Territories and the freely associated nations.
Cindy DiBiasi: Now has HRSA identified any priority areas within this new program guidance?
Lt. Commander Sumner Bosler: Yes, we have six priority areas. We have administration, regional surge capacity, emergency medical services, linkages to public health departments, education preparedness training and terrorism preparedness exercises.
Cindy DiBiasi: How is an awardee's progress measured in this program?
Lt. Commander Sumner Bosler: We have a number of different ways of measuring our progress through the critical benchmarks. We have 16 critical benchmarks. They are evidence-based and they also have sentinel indicators attached to them. These are new for this year in 2004. We are looking for actually avenues of measuring preparedness and what we are looking to show through evidence-based practice and baseline sentinel indicators.
The minimal levels of readiness are developed for each benchmark. They serve, in some cases as a way of phasing in or achieving the overall benchmark. Some of the minimal levels are benchmarks themselves.
Cindy DiBiasi: Are there any critical benchmarks that are specific to surge capacity?
Lt. Commander Sumner Bosler: Yes, we have ten critical benchmarks which are critical to surge capacity. Briefly, to go over them quickly, it is beds, isolation capacity, health care personnel, advance registration, pharmaceutical caches, PPE or personal protective equipment, decontamination or behavioral, then behavioral health, and then trauma and surge capacity and communications and information technology.
Cindy DiBiasi: Can you tell us more about the surge capacity benchmarks that are related specifically to facilities and equipment?
Lt. Commander Sumner Bosler: OK. We have 2.1, which is really beds. That really speaks to people. Then we have health care personnel, which is your health care providers. Then you have personal protective equipment and decontamination. One that is not on there is 2.2, which is for isolation and I can talk about that at the end of the slides, we don't have a slide for that one.
2.1, beds, is really a population-based formula of 500 adult and pediatric victims per million, which is a ratio of about 1:2000 above the current staff/bed capacity. This allows the States to plan for a population-based formula where it is not really an arbitrary formula that somebody has been (unclear) like 500 per region.
The next is health care personnel. If you have patients or beds, you actually need to have the personnel to take care of them. Our formula or our surge capacity needs to have health care personnel attached to that. If you have ten beds, you need to have providers attached to those.
The next is PPE or personal protective equipment. When you think of biological agents or chemical agents, you tend to think about being contaminated. So what happens is you are looking at the personal protective equipment for biological agents which is considerably different than if you were talking about chemical or weapons of mass destruction hazards.
Then you have 2.7, which is decontamination. If you think about if you have someone who is contaminated with a nerve agent or a vesicant agent, which is a mustard agent that causes blisters, you are looking that you would want to be able to be decontaminated as well.
Cindy DiBiasi: We were talking a little bit earlier and you gave me what I thought was a very compelling example of the whole decontamination.
Lt. Commander Sumner Bosler: Well, if you have an incident and you have someone who has been exposed to an agent, you don't want to basically take that person and bring them into a health care facility. They are going to need to be decontaminated prior to coming in. I will use the Tokyo sarin attack. Sometimes when people are brought in, say you have a business suit on. Maybe some of the gasses or some of the agents which can be persistent are within that person who has been affected and you bring them into your hospital. You open up or start taking their clothes off. It they haven't been decontaminated, it can off-gas or some of the agent can affect the staff there and now you have affected your staff or contaminated your hospital and you don't want that to happen.
Cindy DiBiasi: So where can the audience go for more information on this program?
Lt. Commander Sumner Bosler: Well, we have a Web site, which is listed on the slide. We also have our contact numbers within the program. You also can contact your State and talk to the people within the public health departments within your State or the health care facilities related to that.
Cindy DiBiasi: OK. And we are going to be back to talk to you more to ask you some questions, but first we just want to move on to some of the other presenters. Bettina Stopford, under a grant from AHRQ, Bettina has worked on developing models and guidelines for bioterrorism preparedness focusing specifically on personnel protective equipment, decontamination, quarantine and isolation and laboratory. Bettina, why don't we start by you telling us what the goals were for this project?
Bettina Stopford: It was really quite a broad-spectrum project [unclear] we did have significant overlap categories in each of the four categories. What we are really looking for here is taking the AHRQ bioterrorism initiative, which is to capture evidence-based research and really make sure it is pertinent in an operational setting. We wanted practitioners in any of the health care arenas such as emergency medical services personnel in the field, health care providers in a hospital setting, emergency planners, whether on the State or regional level.
You really have a good snapshot of what the research shows is evidence-based best practices related to all four of these models here. We want it to be just as pertinent for practitioners and health care providers in Helena, Montana, as it is in New York City, so that was definitely a goal of ours. We realized that as we were going into this that there would be some significant research and practice gaps and shortfalls based on the fact that we in the United States have not been doing this for a very long period of time. We have not been under this level of threat for a long period of time. We reached back into a lot of different military data, looked at some other countries' models of best practices and then examined what some of our peers in health care have done as well to put this into practice. That is what we have tried to do is give us a really good overall snapshot.
We also brought in a group of stakeholders, a really nice, broad spectrum of stakeholders to augment those best practice gaps and give us some additional information that we could not necessarily find in the literature.
Cindy DiBiasi: So that is how you went about doing this and you were talking about the resources and stakeholders that were involved in the development of these models and guidelines and we see some of the specific stakeholders up there, I see. So let's talk about how you developed these models.
Bettina Stopford: What we tried to do is first do a really good solid research effort. We went back and looked at about a five-year spectrum of open source publication data, also knowing that we would have to augment a lot of that with some data in the past in key cornerstone research. We tried to take a look at it, see what was evidence-based, what was theoretical, some empirical data, put them all together in a really good research-based paper, extract the gaps and shortfalls so that we were really aware of what we need to do for the research on that, layer over the top of that stakeholder opinion and best practices that they have been doing in the United States currently and we came up with four sets of models.
What we wanted to make sure that we did is we looked at a series of questions for these four models that would show us the most broad-range applicability for these models possible. We wanted to make sure that it was pertinent for someone in not only a facility-based setting or an agency-based setting so you could do it by yourself in your facility, but also application to a regional planning effort which is extremely important as we shore up the infrastructure in the U.S. response to bioterrorism or weapons of mass destruction (WMD).
We looked at how adaptable is this. Can we save more lives with this, quite frankly. Can we take a model and make sure that we can process more patients? Can we look at surge capacity? How much will this cost in not only financial costs, but what is the burden as far as logistics and training and supplies and quite frankly as a person who has been a manager in a health care setting before, there are many priorities that you have to deal with and bioterrorism initiatives should be a high priority for planning, but I always worried how I would staff my agency and keep my people certified with CPR so we maintained regulatory compliance. We want to make sure that this stuff was not causing an undue burden but could fit into your all-hazards disaster planning approach. That is what we are going for here. Let's look at saving lives. Let's look at evidence-based practice. Let's look at identifying what was theoretical where we need to do further research and also of course of importance here is in everything we did we made sure we were compliant with what current and emerging regulations are, whether it be the Joint Commission or OSHA standards, etc. So that is the overall job on the models that we did.
Cindy DiBiasi: The report includes a section on personal protective equipment. What were your findings in that area?
Bettina Stopford: The personal protective equipment, under a bioterrorism initiative here focuses mostly on infection control and infectious disease. We felt that it would be remiss if we did not include a section on contaminated patients as well, whether that is radiological or chemical contamination. So we found that we roughly separated the two different personal protective equipment needs into either an infectious patient even or a contaminated patient event and those necessitate quite a different PPE ensemble, personal protective equipment ensemble.
We certainly advocated building upon a robust use of current Center for Disease Control and APIC (Association of Professional Infection Control) published infection control standards such as use of standard precautions. I know that is very common sense. We do that every day in health care practice but I will tell you that sometimes we are very inconsistent with our practices. For instance, we need to make sure that we are masking people appropriately that come in with respiratory signs and symptoms. It is written. It is an infection-control standard but let's be more aggressive about making sure that we do that as we have seen with emerging public health infections such as SARS.
So we looked at standard precautions with your indicate either airborne, droplet, contact precaution or infection control standards. So it was take those standards, make sure we are doing what we are supposed to be doing with those and make sure we are doing them very aggressively, we are protecting against infection control issues.
For contaminated patients, that is a whole different ball game. We wanted to make sure that we were working with OSHA because they are having some upcoming guidelines; they will be publishing that are specific for health care professionals.
What are published right now are mostly industrial standards. We wanted to work with that as well to make sure we did a cost-effective approach that was able to be achieved by health care professionals whether you are in the field doing emergency medical services or you are in a hospital or you are in a clinic and if you are dealing with a contaminated patient, and most likely the health care agency will not be able to detect exactly what that agent is, they have to go by symptomology or how that patient presents, what syndromic presentation.
We advocated that there be a minimum standard of a Level C personal protective equipment and there is a whole description in the book and it is compliant with OSHA regulations as well. We wanted to make sure that you knew that if you had your personnel that needed to go out and perform any sort of interaction or decontamination procedures, etc., with a contaminated patient, whether it is with a chemical warfare agent or an industrial incident, that you are appropriately protected so Level C with a hooded powered air purifying respirator with the appropriate filter cartridges, appropriate fabrics and that cannot stand alone; it has to be embedded within an all-hazards disaster plan with a good training program that meets your regulatory standards such as awareness levels for everyone plus an operational level for those who are going to don this personal protection equipment and we talked a lot about this comes with quite a hefty price tag for health care professionals to build up.
What is a good sort of spiral-development approach that you could start one year? Maybe this is your core elements that you could address. The following year, how could you build upon that? We wanted to make sure that health care facilities didn't work alone; they worked within the region and within their communities so they were embedded within that whole planning effort. So while it is PPE focused, it is really important that that become part of the larger picture.
Cindy DiBiasi: Some other parts of the picture are the isolation and quarantine facilities. What does the report tell us about that?
Bettina Stopford: That is such a complex issue. I tell you, we would have written an entire textbook just on isolation and quarantine and they are out there as well. Again, this is something that we have not had a lot of practice with in the modern world as far as large scale. We really went for addressing the mass casualty approach.
Now isolation, obviously very different than quarantine. The isolation piece, the surge capacity piece, for instance, in the health care facility you have certain rooms or certain areas that you can put patients in for isolation, for appropriate isolation. If we have a large scale event where a large amount of people are requiring isolation, what are some cost-effective things that we could do to reach the ultimate maybe gold standard of having retrofitted health care facilities and portable isolation capabilities, etc. Can you co-hort patients, can you retrofit? What are some things you can do to explore that in the book and some of the cost impact there?
Quarantine, a very complex planning issue that we have a whole list of sort of planning items that should be addressed in the model, not the least of which is legal authority and interaction with law enforcement. However, we felt that one of the key aspects of quarantine would be a public education program that predates any sort of an initiation of quarantine such as a community shielding model advocated by some of the research that we came up with. That was pretty important with that.
Cindy DiBiasi: Now another topic covered in your report is laboratory capacity. What were the findings in that area?
Bettina Stopford: There is actually a lot of work being done on laboratory capacity right now. One of the things we found most important was that there were some categorization of different laboratories, sentinel laboratories versus reference versus national laboratories and making sure that each of those levels of laboratories were quite defined as to what their capabilities were would be number one, initiating a very good sort of overlaying triage capability so that responders would know what samples to send to what lab and what is the best methodology for getting that lab to process a large number of samples. That is really what it comes down to.
Some of the interesting things that we found were there was a real push on the responder's side to be able to have some instant identification of agent. You can understand why, because we want to initiate the treatment protocols; however the gold standard for identifying agents still remains a culture in a lab setting which takes time. It takes time to grow a culture. So what you have here is medical professionals treating on presenting symptoms while we are sort of waiting for a culture to grow in the lab and we need to try to work towards merging the technologies that are out there that are somewhat not accurate at times versus the true accuracy of a lab. That is what we took a look at and how we can really shore up the national infrastructure. A lot of that is systems approach. Make the best use of what we have now and try to figure out where we can really shore up some of the reference labs.
Cindy DiBiasi: What about decontamination? What were your findings regarding decontamination?
Bettina Stopford: Well, it certainly sounds like it builds upon what Commander Bosler was talking about earlier with some of the decontamination findings they were having. We focused on mass-casualty decontamination and we felt the gold standard was more detailed decontamination. In other words, not just having potentially contaminated patients sort of naked in the parking lot with a fire hose on them. We really wanted them to be able to be in sort of gender-segregated, environmentally sheltered areas that they could change their clothing at the very least and then wash to take the contamination off. Obviously there is a lot of regulation involved with runoff, etc., that we were sensitive to.
So we took at a look at that and we really did our best to quantify some of that information with best practices, how our health care facilities responds to this, what does the Joint Commission say, what does OSHA say, what does the EPA say and sort of overlay a model that was cost effective so you didn't have to go and build enormous, mass-casualty decon facilities. What could you do that was effective in your area?
We quantified that in a database, in an interactive database where you can plug in data and it would help you determine what your needs were and what your current capabilities were. That is also available as part of this project.
Cindy DiBiasi: So in summary, you have four very distinct models here.
Bettina Stopford: We do and what we really tried to do was make sure that we had a solid research effort with best practice summaries. We presented it in an immediately-usable planning format and that is a model for emergency preparedness for health care professionals.
Cindy DiBiasi: And what can somebody from the audience, if they wanted more information, how could they find out more about this report?
Bettina Stopford: This report is now going to the AHRQ internal process for evaluation right now. We hope that it will be published shortly. In the interim, I can make available a draft. We can send a CD-ROM. If you E-mail me at stopfordb@saic.com and send me your address, I will be happy to send that out to you.
Cindy DiBiasi: Great. Thank you, Bettina. We will be back for questions, but first we are going to turn to Dr. David Markinson from Columbia University. Dr. Markinson has developed a set of recommendations that stem from an ARHQ-supported consensus report on the special needs of children in disaster situations. Why do we need to consider children differently? What are the special needs you are talking about?
Dr. David Markinson: There are two different ways of looking at this. We can look at this on an individual basis vs. a population basis. At the individual child level, again this applies to all children that are unique in anatomy and physiology. This very unique anatomy and physiology puts them at different risk, it requires different therapies and different types of treatments and medications and equipment. For example, they have more surface area to volume so anything that is absorbed through the skin, they get a higher dose than adults. They breathe faster and anything that is transmitted through inhalation, whether it is biologic, chemical or even radiologic, will be absorbed quicker. Their breathing is lower to the ground. Many of the nerve agents are heavier than air, concentrate at the ground, children get a higher dosage. Blood/brain barrier is immature.
Things cross and then besides just how the react differently, there is procedural difficulties. Whereas providers may be able to provide skills to an adult, providing it to a child is a difficult stretch and providing it to an adult while wearing personal protective equipment to a child may be near impossible. But that is the unique difference of the single child. We take it back and we then look at all children in our population and as we prepare for disasters or terrorism or public health emergencies affecting our population, we have to remember that at least a quarter of the U.S. population is what we call "children" and a significant amount, we are talking about 20 million as you see on the slide, are under the age of six. So if you are preparing for the population, you must prepare for children.
In addition, by ignoring children in this overall planning, your plan may fail. An example would be an evacuation plan. Say here is how we are going to evacuate everyone. We don't think about issues about kids in school and communication between the kids and the parents. Now how many parents do you know who would evacuate an area in a time of emergency without knowing about the safety of their children? I think this would take armed guards, a significant amount of force.
Even lastly, I think we can think about two types of pediatric exposure. There is a class of things, which we started to talk about, which is the population is exposed and inadvertently children who are part of the population will get affected by terrorism, disasters and public health emergencies. Unfortunately, that is not the end of the story. We also know that children can be specifically targeted. There is some very good, credible evidence there have been foiled plans stopped abroad, specifically in Singapore at the U.S. school where they were specifically targeting children. In addition, al Qaeda documents include how many children they are going to have to kill to get parity for what has been done to "the people they represent" and while this is disheartening and worrisome, it does tell us that not only do we need to think about children as part of the population, but unfortunately we may have to deal with the uniquely pediatric events.
Cindy DiBiasi: How would you describe pediatric surge capacity and do you think it is different? Is it different from adult surge capacity?
Dr. David Markinson: It is not necessarily different, but I think it follows a couple of points we just made. At the first level, there really shouldn't be anything of "adult surge capacity." If we deal with surge capacity for our population, we have to recognize that children are part of the population. So one cannot have a surge plan that does not include pediatric patients.
But that is in proportion to their normal numbers. But now as I have told you, there is also a unique threat to children and so not only do we have to have surge capacity of children as part of our population, but unfortunately we have to have unique surge plans that look at an all-child event, a school, a daycare center. There may be some adults as guardians, that's all.
The last aspect is we have to think about family units. It is hard enough to separate child and parent for therapy and treatment under ideal situations or minor emergency room or minor doctor visits. In a time of chaos and a time of terrorism or disaster, those emotions are heightened. Can you imagine having to separate a parent from their child when they are both at risk? We need to start thinking of ways to actually treat them as a family unit.
So those three elements are the three areas we have to think about in terms of children and surge.