Third in a series of Web conferences on surge capacity, this event was broadcast October 26, 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.
Penny Daniels: Good afternoon and welcome to "Addressing Surge Capacity in a Mass Casualty Event." This is the third 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. This series is sponsored by the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, which is often referred to by the acronym AHRQ or 'ARK'. My name is Penny Daniels, and I will be your moderator for today's session.
The reason 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 our health care systems; and in particular our public health infrastructure. We must be prepared to respond in the event of a major public health emergency; and a critically important aspect of bioterrorism preparedness is surge capacity.
Surge capacity is defined as a "health care systems' 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." Many important stakeholders have essential roles in this process. Policymakers, planners and other decisionmakers at the Federal, State and local level; program administrators, health system decisionmakers and providers each have an essential role to make sure there is sufficient surge capacity within their own jurisdiction, region or delivery system. And to be most effective in planning, they or you, need information about the latest research tools and models on surge capacity.
Today's event is the third one in the 2004 series that is specifically designed to provide you with that information; work for important issues, research findings, tools and strategies to help stakeholders plan and provide surge capacity during an event involving mass casualties, which is thousands if not tens of thousands, of victims.
I'll begin by introducing our panelists today. In the studio with me I have Dr. Robert Claypool, who is the Deputy Chief Medical Officer, Office of the Assistant Secretary for Public Health and Emergency Preparedness within the U.S. Department of Health and Human Services. Thank you for joining us Dr. Claypool.
Dr. Robert Claypool: My pleasure.
Penny Daniels: Dr. Nathaniel Hupert, Assistant Professor of Public Health and Medicine, Department of Public Health and Medicine, Weill Medical College of Cornell University. Dr. Hupert, thanks for joining us.
Dr. Nathaniel Hupert: Thanks for having me.
Penny Daniels: Dr. Michael Shannon, Director of the Center for Biopreparedness and Chief of the Hospital's Emergency Medicine Division, Childrens' Hospital in Boston. Dr. Shannon, thanks.
Dr. Michael Shannon: Good afternoon, Penny, thank you.
Penny Daniels: Dr. Gregory Bogdan, Research Director and Medical Toxicology Coordinator, Rocky Mountain Poison and Drug Center, Denver Health. Dr. Bogdan, thanks for coming.
Dr. Gregory Bogdan: Hello, thank you Penny for having me.
Penny Daniels: Okay, and welcome everyone. Before we begin our discussion I am going to explain the format of this Web conference. First, we will talk with our four panelists, and then we will open up the lines to take your questions.
We begin with Dr. Claypool who once again is the Deputy Chief Medical Officer in the Office of the Assistant Secretary for Public Health Emergency Preparedness within the U.S. Department of Health and Human Services, HHS.
Dr. Claypool, as you heard I gave a very brief definition of surge capacity earlier. Can you begin your presentation by telling us what is meant by surge when specifically addressing medical response to a disaster?
Dr. Robert Claypool: Sure Penny, I'll give it a try. But before I address that specific question, I would like to re-emphasize in your definition of surge that it addresses not only the volume, but also time as a function of the volume, as well as that, the complexity of the cases involved. And on my first slide, I think if you look in the lower left-hand side, surge is a very daily occurrence in many of our health care institutions, and we deal with it every time a hospital goes on bypass or has to send patients to other places.
So surge actually represents a way that we live on a normal day-to-day basis. And even in certain kinds of disasters surge is something that we deal very well with, and are able to handle it without any degradation in care. However, as we look at the right-hand side in the upper corner, dealing with weapons of mass destruction, we wind up perhaps having a problem where surge then is so severely stressed, and our system becomes so inelastic that at least two things happen. Number one is access to care, or being having care rendered becomes compromised. And secondly is we have to look at whether or not the quality or the standards would have to change in order to meet the greatest maximum good.
And finally, I would like to mention the fact that even at the lower left-hand side, surge doesn't necessarily have to do with large volumes of patients. I think the case in point has to do with the SARS epidemic that recently occurred in this country. Not, I'm sorry not in this country, but in the world in the sense that there were not great numbers of SARS patients, but particularly up in Canada the relatively few numbers of patients severely challenged the health care delivery capability within that city. And we'll talk a little bit more about burns; burns represented another example of how relatively few numbers of burn cases can severely stress our surge capability.
Penny Daniels: That's very interesting. Okay, now in the next slide, Dr. Claypool, you're going to talk about the National Response Plan, so let's take a look at that. Chris, our Director, is changing the slides for us today; thanks Chris. Tell us a little bit, describe this National Response Plan and the emergency support functions within it to us, with specific attention, if you will, to the role of HHS in meeting these surge requirements?
Dr. Robert Claypool: Right Penny. If I can back up for a bit, the National Response Plan, which is at the top in the title of the slide, is currently in evolution. It's pretty close to being signed by the federal government, and will become our National Response Plan. Right now we're living with something known as the INRP, or the Initial National Response Plan which represents an interim step that combines the pre-existing Federal Response Plan along with other response plans such as; The Federal Emergency Radiologic Response Plan. But that's perhaps more detail than we need, but what it is it—the point I'm trying to make is that we as a nation are moving towards an overarching, a [bell] organization to respond to this, known as the National Response Plan.
Penny Daniels: This is a good thing?
Dr. Robert Claypool: Right. Now within the National Response Plan one of the elements has to do with emergency support functions. And these emergency support functions, which actually currently number 12, and they will increase to 15 when the National Response Plan is published, the emergency support functions define how the federal government responds on various different scenarios to support State and local or jurisdictional kinds of needs. And for example, I think it goes without saying, that issues that involve transportation would be led by the Department of Transportation; issues that involve food by the U.S. Department of Agriculture and so forth.
Within Health and Medical Services, Health and Human Services, HHS, has the lead for ESFP and this is the emergency support function that deals with health and medical issues. The block on the left-hand side has a number of letters, of course, that refer to the various support agencies. And you can see Health and Medical is an equal opportunity employer; it cuts across the entire gamut of the federal government, and many of our agencies such as; Department of Justice, and Transportation and the Postal Service, they all support Health and Human Services as we deliver this important emergency support function.
Two specific things in addition to mention are the fact that Homeland Security Presidential Directive-10, if I can back up for a minute, you know the Homeland Security Act formed The Homeland Security Council, and so we have National Security Presidential Directives and those are then, in the past, that are developed by the National Security Council. And The Homeland Security Council then works on Homeland Security Presidential Directives. Homeland Security Presidential Directive-10 deals with the response to, particularly bioterrorism, but other weapons of mass destruction defense, and it identifies Health and Human Services as the lead for the consequence and management aspects for those things that happen as a result of a terrorist or national disaster event.
And lastly, The Homeland Security Council, as you may recall Top-Off 2 was a federally level tabletop exercise that occurred last, late spring, and it dealt with a simultaneous event both in Seattle and in Chicago with the plague episode in Chicago, and a radiological dispersion device in Seattle. And part of the product that came out of that was the realization that as a nation we really needed to address surge in a more holistic fashion. So the Homeland Security Council charged HSS with pulling together, in an agency group, to look at how we would handle surge.
Penny Daniels: Well this is quite a broad and complex challenge Dr. Claypool. So how is the Department addressing the entire spectrum of surge?
Dr. Robert Claypool: Can I have the next slide please? As well as we can. As you said, Penny, this is a very complicated area and this slide is equally complicated to match that statement. But I think the point that I would like to make is, is that surge, you know, very often if we think of surge at least to me, I get a visual metaphor of a tsunami or some big tidal wave coming. But surge really has a number of moving parts to it, a number of elements, and it really represents a contingency of different things that all are—that all compose the entire picture of surge. And so we have another agency group that includes a lot of the agencies that have been mentioned in the previous slide, that are dealing with all these various different aspects. And for instance, one of the things for instance that we think is very important has to do with risk and crisis communication, and that's particularly is a way to mitigate the effect of weapons of mass destruction, and surge, if we can get better public messages out that's really an important aspect to the whole problem of surge.
For the purposes of this discussion I would like to point out the fact that, you know, expanded health care system and the capacity to provide health care is perhaps the Achilles heel, or the most vulnerable part of this because it represents the most resource-intensive component of it. And so it's one of the ones that we have been paying particularly more attention to.
Penny Daniels: Can you tell us what steps HHS is taking to increase hospital bed capacity as one component of surge?
Dr. Robert Claypool: Right, as I mentioned that is and perhaps the Achilles heel, and the one that's demanding a great deal of our time, and at the top of this page I would like to underscore the fact that this really represents particularly a collaborative effective of four different agencies, and for those of you who don't recognize the logos; they include Health and Human Services, Department of Homeland Security, Department of Defense, and Department of Veteran's Affairs.
And first of all I would like to state that I think all of you are aware of the fact that with the right-sizing of health, and American health care industry and I think all of you know that we continue to lose hospitals almost on a daily basis across the country as we right-size our goals to deliver health care. So with that loss of infrastructure; and if you couple with that the fact that the federal government who include the VAD or the HHS, really don't have that much in the way of dead, hospital-fixed resource to support health care. You can see that we are really out behind the eight ball in terms of existent, extant hospital bed capacity.
And so there are a couple of initiatives that we are doing, and a number of the HHS agencies do include ARHQ, Health Resources and Services Administration, CDC, are all looking at different ways through grant and cooperative agreement programs to increase bed capacity in our country, and a number of these initiatives are going across the country at the present time.
I think it might be interesting to step back a bit, and look in the past. And for those of you who are old enough to remember back in the Civil Defense era's, particularly back in the 1960's, under the Civil Defense System we had something known as Packaged Disaster Hospitals and this was in the era when in the United States, we feared a—what was the doctrine, Mutual Assured Destruction, where we and the Soviet Union would be able to pummel ourselves into near annihilation. And so with the concept of having our health care infrastructures destroyed, the U.S. government went ahead and developed a number of deployable hospitals that could be constituted to support care in the event of such an attack. And at the peak of the Packaged Disaster Hospital era there were 2,000 of these that were stationed across the country, and each one of them provided 200 to 250 beds.
With that as sort of progenitor we began to think of the fact that well we really in the past have shown the ability to assemble, and get facilities that we could deploy, we realized we don't have enough capacity in the extant health care infrastructure to provide for a WMD, or mass casualty event, we thought we needed to look for a way to go ahead and be able to project health care forward.
And so for that reason, building on the platform and the success of the Strategic National Stockpile, and their logistics and acquisition capability, we are developing a program known as the Public Health Service Contingency Stations.
Penny Daniels: Tell us a little bit more about the capabilities of the Public Health Service Contingency Stations.
Dr. Robert Claypool: Right, let me be a little bit; let me be—.
Penny Daniels: The acronym is, just so I don't have to say it again? The acronym is VHSCS, yes.
Dr. Robert Claypool: A word back on that, first of all the Public Health Service, of course, has a long historic and a proud tradition, and a career and it's linked to a statute as long as—is as the term contingency stations. And we are concerned, at least at this point, to call these hospitals because although they do have hospital-care capability, they really are not hospitals in the sense that most of us think about them.
Let me state that this is really a very modest beginning that we've started so far, and in 2004 we've used dollars from 2004 to purchase four of these contingency stations and each one of these, as you can see on the left, each one of these is a 250-bed module and the 250-bed module—I think probably the easiest way to think about it, for those of you who are familiar with hospitals, is that it represents the capability of a general medical surgical ward. It has that kind of medical material, and the ability to support it.
The facility does not have an operating room; it does not have an ICU; it does not have an ER, this initial one doesn't have a triage area. So, we are building four of these. Now, each of these is packaged in 50-bed increments, and so they can be deployed in 50-bed increments up to, as I say, 250 beds for each one, and we will have four of them this year.
In addition, to the actual beds and so forth that support the facility, there is a medical material piece that includes the bandages, dressings and the normal things that you find in med/surg ward as well as a pharmaceutical package. And in terms of the staying power of this, if we deployed all 250 beds it comes with its own generators and so forth—we'd have to really depend upon—if used as a shelter of opportunity it would go into a facility such as a high school or gymnasium or an armory, and if all 250 beds deploy, there is enough medical material to support 250 patients for about 3 days; if we deployed a 50-bed increment we could go for 15 days before re-supplying.
Penny Daniels: Briefly, what will be some of the future capabilities, Dr. Claypool?
Dr. Robert Claypool: Yes, what we're looking at is a build out, I think on the next slide, I'll focus on two areas. There are two areas that we're really concerned about and that is, number one is burns. I think as you know in the United States we only have severe capability to provide burn care and the recent Rhode Island nightclub disaster stressed hospitals in the East Coast in terms of providing care for what amounts to a relatively few number of patients.
And in the U.S. there are really only 2,000 licensed ABA-certified beds, American Burn Association certified beds, and so—and that's 2,000 total with about 800 or so empty at any one time. So our surge capacity to provide this kind of level of care is limited. So one of the things we're looking at is trying to find a mobile way to be able to provide burn, burn care in the event that a burn event occurred. And remember that, you know, under certain events like with the vesicant kinds of chemical agents, that kind of a lesion mimics a burn. So that it's not inconceivable that there could be some sort of an event where we have great numbers of burn patients.
The second thing that we're looking at is developing an isolation module. And that is, if there is a communicable disease that involves a number of patients, you know, we're concerned that perhaps taking individuals and putting them in a Holiday Inn may not be the best way to either take care of the patients or to provide confidence in this on the part of our community because as we know, like with the anthrax episode decontaminating a building that is a public or a private venture is a significant enterprise, and so it may be better having a deployable federal facility that will do that.
So we're looking at trying to expand out this capability. Now these, if we develop, or when we develop these will be self-contained, would have their own floors and walls and tents and that sort of thing.
Penny Daniels: What about the shortage of health care personnel during a mass casualty incident, that could be a severe problem. What are you looking at in terms of that?
Dr. Robert Claypool: Right, one of the things that we're looking at is trying to think differently. You know, rather than necessarily going and beating the bushes and finding more providers, we're trying to find ways to look at making better use of our providers. For instance, in terms of critical-care intervention one of the things that is most important is our ventilators. And ventilators, of course, are very resource intensive in terms of finding people to support them. So on the one hand we have a number of ventilators around in The Strategic Stockpile, but the question we have is, do we have enough people? Enough respiratory therapists and others who can put people on ventilators, and take care of them, and monitor them?
So what we're doing under an AHRQ project is to try to find a way to develop a model to cross-train individuals, and then take a model out of that and test it and see whether it's sufficient. And what we're trying to do is back in the days, in the crisising era when I was in training, anybody, you know, they would grab you and "hey you" and you'd be able to—to bag a patient or even put, I put people on ventilators, I even used to that. But I think we realize that, of course, not good quality medicine. So if we could take individuals and cross-train them, then maybe we'll be able to go ahead and provide quality ventilatory care when it's needed.
And we're going to try to do this, say we could add the doctrine of daily use so that the cross-training winds up having a daily use. And I, without going to a different example, yesterday we we're learning for instance that one of the problems that came in Florida had to do with dialysis. And so one of the things we're going to look at is, you know, do we need to have some kind of surge capability for dialysis in the country? And if we did that, you know, would we look at finding more dialysis technicians; that may be a rate-limiting step. Well maybe we'd look at, you know, someone like cardio-pulmonary thoracic technicians, because they're used to dealing with people with tubes and IV's and things. Maybe there's a way to cross-train them, and let them help support dialysis care. I don't know, that's just an idea. But I mean I think what we're trying to do is to think creatively to be able to use our professional people in different kinds of modes.
Penny Daniels: Thank you Dr. Claypool; very interesting information. I know we'll have a lot of questions from our audience in a few moments. But right now I would like to turn to Dr. Nathaniel Hupert. Dr. Hupert, once again is Assistant Professor of Public Health and Medicine in the Department of Public Health and Medicine at the Wiell Medical College of Cornell.
As you know, to help increase surge capacity AHRQ has sponsored the development of a variety of models, and guides on hospital preparedness, and an example of this Dr. Hupert, is your community-based mass prophylactic planning guide for public health preparedness. And you're also modeling surge capacity. Can you explain to us what's the value of doing these models?
Dr. Nathaniel Hupert: Sure, Penny. I can answer that with two thoughts. One is that modeling really helps us question our common assumptions about what it would take to respond to a large mass casualty incident. And it helps in the reassessment of those assumptions by making us specify, very explicitly, what those are.
Secondly though, I can actually reference something that Dr. Claypool just mentioned, which is this notion of the content of surge capacity. He mentioned that it's—there's a time component, there's a number component and there are a number of moving parts. One of the things that modeling helps you do is actually analyze those different moving parts in a quantitative manner so that you can actually generate some concrete numbers to use in planning.
Penny Daniels: It sounds like strategy; it sounds like good strategy to me. So when you develop this model for a mass casualty event, what are some of the things that you would specifically need to think about.
Dr. Nathaniel Hupert: Well, what we've done at Wiell Cornell in the work that's been funded by AHRQ, is we've tried to break down what the determinants of surge capacity are. And really there are three things that you can focus on. The first is patient arrivals at the hospital, and that can really be seen as two separate events. The first obviously, is exposure of patients to whatever event occurs, either a biological event or a chemical event. However, those patients don't just come straight to the hospital. They actually might be treated outside the hospital, and you can see on the slide that that's the diamond that says pre-hospital management.
In the event of a biological attack or an outbreak of an infectious disease that might include, for example, the dispensing of antibiotics, or the dispensing of vaccines. And it's the combination of the number of people who've been exposed or involved in an event and the pre-hospital management that leads to the surge on the hospital.
Once you get into the hospital there are really two things that we focus on. The first is the supply-side, that's staff, medical supplies, and the circulation of beds, so that we can see what we have to treat patients with. On the other hand, and this is something that we saw in our own hospital in New York City on September 11th and the following day, there is a notion of surge discharge and this is something that a colleague of mine at New York City Office of Emergency Management, Sam Benson, first brought to my attention, which is that there are only a certain number of places to which patients can go when an event happens.
At our hospital, New York Presbyterian Hospital, we were able to discharge about 20% of the patients that were in the Hospital on 9/11, and so that gives an example of the fact that this might actually involve a lot of patients. And so you free up space inside the hospital to admit those surge arrivals, and then you can either treat these people or perhaps transfer them somewhere else.
Penny Daniels: And just a point of clarification, SNF, stands for?
Dr. Nathaniel Hupert: Skilled Nursing Facility, so I've listed on this slide, three examples of places that patients can go if they are ready for discharge from the hospital. They can go home, perhaps with skilled nursing at home to an out-of-region facility, or to a special skilled nursing facility.
Penny Daniels: Okay. Now, one of the things that we think about in terms of bioterrorism or an attack is how soon patients should be given treatment. Using anthrax, the whole anthrax incident as an example, what can you tell us about this?
Dr. Nathaniel Hupert: It's a very interesting and surprisingly tricky question. We have used anthrax in a lot of our modeling, and intuitively everyone knows that the quicker you get people treatment, the better they'll do. But the trick for creating a usable and useful model is to break that down into its components, so that we can actually design our response to address specific issues. So for example, on the slide that's displayed you can see that we have broken down the response time where you get more protection, and hopefully you'll become treated within the proper amount of time into the delay in the reaction of the community, and this could be sensors, this could be clinical cases, and the time needed to protect the entire community.
The other way to think about this is the time to the first pill dispensed, which is the delay, and the time to the last pill dispensed, which is the time needed for the entire campaign. What we can do with our model that was again funded fully by AHRQ, and will be available on the AHRQ Web site, is we've been able to actually take this concept and turn it into numbers. So, for example, you can see that if we use the consensus estimates of how inhalational anthrax might act if there were an outdoor release with anthrax spores, you can see that there's actually a fairly restricted spectrum of times for delay in response time, and time to community antibiotic coverage, that give you really good outcomes.
Again, I want to caution people that this is just a model. There are a lot of assumptions that go into the model, and we can perhaps talk about those later. But you can see that these percentages are—the percentage of exposed individuals who actually don't get sick because they've been given their prophylactic antibiotics, for example, for Anthrax ciprofloxacin or doxycycline or ampocillan, in time. And the smaller the number, the greater the delay, the more the hospital surge that you'll find.
Penny Daniels: Now are these people that can be treated outside the hospital?
Dr. Nathaniel Hupert: Right, the idea is that this is what you would wind up with after pre-hospital treatment. The hope would be that not all of these people would swamp the hospital initially, but that treatment sites would be set up outside of the hospital so that people could get their necessary antibiotics.
Penny Daniels: Okay and you're going to show us who will need to be—how you use this model to figure out who will need to be hospitalized?
Dr. Nathaniel Hupert: Right, so again getting back to Dr. Claypool's breakdown of time and number, these percentages play out in very interesting ways when you model specific attack scenarios. So, for example, here's a slide that shows what happens if 100,000 people were exposed to anthrax. Now obviously that's a very, very large hypothetical exposure, but not inconceivable given the studies that have been done over the last several decades. If your community could get antibiotics to all 100,000 of those people in 2 days, after only a 1-day delay, which of course is very quick, imagine an announced attack.
Penny Daniels: Yes it is, yes.
Dr. Nathaniel Hupert: Then the graph shows the hypothetical number or the estimated number of people who would actually become sick before getting their antibiotics. And you can see that it's a very low number in the first 24-hours, and then about 500 people, and then another 5—a little bit more than 500 people.
In contrast, if the response were to be changed just a little bit, so instead of a one-day delay to recognition of the attack, if you model out a two-day delay so this perhaps would be more a clinical recognition where people found sick cases in the emergency room within the first 24-hours, and made the link that something large was happening, the number of people estimated to become sick rises dramatically to about 4,000, and the key thing is that in the first and the second 24-hours it looks almost exactly alike.
And the point here is that modeling out the different scenarios gives you a sense of when the maximum surge will occur. So here you can see that it's actually during the third day that you will have up to 2,000 people needing hospital-based care in this scenario. So it's not just the overall number, but rather the overall number played out over time to help you prepare for the actual response to the patient loads, and of course, you can imagine that this would be a much lower number if the number of people exposed were lower.
Penny Daniels: And of course this ties directly into what Dr. Claypool was saying earlier, so you're really drawing us a picture of what we need to do. Can you summarize now for us briefly, the advantages of being able to model both pre-hospital and hospital-based surge capacity?
Dr. Nathaniel Hupert: Sure we are, as a country, approaching bioterrorism response and other mass casualty incidents from, I think, a very reasonable perspective which is to create a number of scenarios that the entire country can wrestle with in terms of imaging what our response could be. And one interesting feature of this modeling is that you can take one exposure scenario and play it out, even outside the hospital, in a number of different ways, and wind up with extremely different total and daily casualty loads, depending upon how the community has been organized, and how successful the community if to responding to that event.
So the point that we're trying to address in some of this modeling is to show all of the linkages between the pre-hospital response and the hospital surge capacity, in part to encourage people who spend most of their time in the hospital setting, to work with the folks in the out-patient community, and thankfully we've seen a lot more of that collaboration over the last three years here.
Penny Daniels: Yes, really important. Are there limitations to this type of modeling?
Dr. Nathaniel Hupert: There are, and I definitely want to address those. One is that we made a number of simplifying assumptions for this model, and so I would caution people not to use those percentages that they saw in one of the slides, quite so literally. For example, we made assumptions about the percentage of people who will be compliant with their medications. We made assumptions about the fact that the anthrax exposure would actually be susceptible to treatment with the antibiotics that would be, for example, in the Strategic National Stockpile.
A lot of these assumptions err on the side of caution, but they also err on the side of making the numbers look good. So, future versions of the model and certainly community-wide discussions of the results of these models, we need to take those into account.
Penny Daniels: Okay, so how do people get more information on this?
Dr. Nathaniel Hupert: Well, again, thanks to AHRQ we've been able to actually post a planning guide that we wrote over the last year-and-a-half that references some of these models on the AHRQ Web site. This is actually available now on the CDC Web site, under both the Anthrax and the Smallpox headings. So I would as a first blush, encourage people to go; take a look at that, it's a very brief report, but it covers a lot of the information that we've talked about today.
Penny Daniels: Okay, Dr. Hupert, thank you so much.
Dr. Nathaniel Hupert: You're welcome.