Mass Medical Care with Scarce Resources: A Community Planning Guide (continued)

Chapter 5. Hospital/Acute Care

By John L. Hick, M.D., Lead Author,^a Gabor Kelen, M.D.,^b Daniel O'Laughlin, M.D.,^c Lewis Rubinson, M.D., Ph.D.,^d Richard Waldhorn, M.D.,^e Dennis P. Whalen^f

^a Assistant Professor, Emergency Department, Hennepin County Medical Center
^b Director, Office of Critical Event Preparedness and Response, Johns Hopkins University
^c Assistant Professor of Emergency Medicine, University of Minnesota/Abbott Northwestern Hospital
^d Health Officer, Deschutes County Health Department/Bend Memorial Clinic
^e Distinguished Scholar, Center for Biosecurity, University of Pittsburgh Medical Center
^f Executive Deputy Commissioner, New York State Department of Health

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Hospital and Acute Care in the Context of a Catastrophic MCE

The overall goal of hospital and acute care response in an MCE is to meet the reasonable care needs of as many patients as possible while also meeting at least minimal obligations for comfort to each patient.⁶³

In the case of a catastrophic MCE, however, hospitals will not have access to many needed resources (e.g., manual resuscitation bags to provide ventilation in response to a pandemic influenza, supply of antitoxin in the case of mass botulism poisoning). Thus, difficult decisions will have to be made regarding the allocation of available resources.

During an MCE, Federal and State agencies might be able to offer policy guidance, nationally sanctioned decision tools, and event-specific relief of certain regulatory obligations. However, the operational decisions regarding limited resource allocation (and the liability related to such policies) will be the responsibility of individual hospitals, communities, and regions. Thus, it will be incumbent on these localities and entities before an event occurs to establish and test plans for operational incident management systems that can be applied to respond to an MCE.

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Challenges for MCE Planning

Much of the hospital-based response to an MCE will rely on planning, protocols, and actions that should be put into place and tested well ahead of time. In order to address those planning needs, however, planners must take into account the critical challenges that hospitals will face in responding to catastrophic events.⁶⁴ Those challenges include the following:

Surge Capacity Issues. A recent report on hospital-based emergency care from the Institute of Medicine2 reveals that many hospital emergency and trauma services are already at or near full capacity and thus not equipped to respond to the increased demand and decreased resources that would occur in an MCE. Interhospital agreements have the potential to alleviate overcrowding by transferring existing inpatients to other facilities, for example, but evidence from a Centers for Disease Control and Prevention study indicates that only 46 percent of hospitals have agreements of this type. ⁶⁵

Inadequate Supplies. Lack of sufficient supplies, particularly of specialized equipment such as personal protective equipment, ventilators, and negative pressure rooms, will be a challenge for most hospitals.

Need for Coordination, Cooperation, and Consistency Between Health Care Systems That Are in Competition With One Another. Public health and State government may have certain authorities to make decisions during an emergency, but the scope of their powers often does not extend into health care facilities. Thought should be given to approaches to facilitating or enhancing cooperation between diverse, and potentially competing, entities.

Communication Barriers. In order to respond at a level appropriate to the incident, critical information must be shared and processed across systems to give an overview of the event, guide the mobilization of necessary resources, and inform the development of strategies and tactics at the hospital and community levels. The fragmented nature of emergency care systems leads to incompatibilities in communications and data systems between EMS systems, hospitals, trauma centers, public safety services and public health agencies.

Lack of Specialists and Other Essential Staff Members. Even in the current emergency and trauma care system, the supply of on-call specialists and other essential staff members (e.g., nurses) is not great enough to meet demand—a gap that will be greatly exacerbated in an MCE.

Need for Security Presence and Protection. Hospital staff members, supplies, and assets will need to be protected in the case of an MCE, which naturally will result in scarcities and the potential for fear, theft, or violence.

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Recommendations Related to Advance Planning

In the event of a catastrophic MCE, decisions and policies regarding resource allocation within hospitals will have to occur at multiple levels, ranging from the State down to local communities and institutions. Ideally, these decisions and policies should be crafted in advance of the event and should reflect nationally sanctioned guidance.

Hospital administrators and local and State elected officials must work to ensure that the framework for such decisionmaking is in place and that a public conversation is held that ensures understanding of the resources and limitations of the health care system.

They must be prepared to defend this planning to State agencies and government and help them to understand the implications of resource allocations. Local and regional legal issues must be raised and defined, and solutions must be determined.

Ideally, hospitals should be able to follow guidance and decision support tools to make resource allocation decisions (e.g., who should receive mechanical ventilation) that are sanctioned and approved at the Federal level and are distributed by the State. Even with the support of these tools or policies, however, it is the hospital that will have to take on the role of implementing them.

To plan for addressing the hospital and acute care needs following an MCE prior to an event, hospitals and their partners should do the following:

Develop an Integrated Incident Management System. In order to respond to the demands and scarcity of resources that would be brought on by an MCE, hospitals must have in place a system of coordination with other local hospitals, public health departments, incident commanders, public safety, and EMS systems to provide care.

Thus, integrated incident management is critical to preparing for an MCE and must be developed prior to any catastrophic event.⁶⁶

The Institute of Medicine report on hospital-based emergency care recommends that coordination and incident management require the following components:⁶⁷

• The establishment of hospital coalitions, compacts, and mutual aid agreements to create a common platform for planning and response. This may be facilitated by the use of an existing program, such as the former Hospital Emergency Incident Command System, which has been revised and renamed the Hospital Incident Command System (HICS). HICS is a well-instituted and nationally recognized approach to disaster management.
• The establishment of a jurisdictional Emergency Operations Center. Each hospital should be familiar with its local office of emergency preparedness and know how it is represented there, whether through assignment of direct liaison, the public health department, a hospital association, the EMS system, or another mechanism.
• The designation of a particular hospital or local public health agency as a "trusted source" to serve as the hospital's resource and policy gateway within the region during a major multijurisdictional event.

Develop a Planning Framework for Allocating Scarce Resources. This framework should be transparent and shared with key stakeholders in the health department, attorney general's office, and governor's office as well as with the community, both in advance of and during an MCE. The framework should establish ways to do the following:

• Define or project the resource shortfalls and the impact on clinical care.
• Identify the facilities and area to be affected.
• Request additional resources, facilitate the transfer of patients out of the affected area, or facilitate alternative strategies for patient care (e.g., offsite care, home care).
• Develop and disseminate supportive policy and clinical guidance (e.g., triage and treatment recommendations, decision tools)—ideally ones that have been nationally sanctioned or federally approved and disseminated. Sources of expertise may include the academic, private, or public medical care system. Clinical guidance or decision aids should reflect any available Federal guidance and ideally be flexible enough to allow hospital and clinician discretion in making resource allocation decisions, as deemed medically justified.
• Provide guidance for liability relief for providers in good-faith compliance with such policies and guidance.
• Include guidance on the equitable management and allocation of scarce resources. For example, prior to an MCE both government and private institutions should know the extent to which they can commandeer equipment or information about remaining supplies and to allocate resources.
• Articulate the integration of response strategies and tactics across facilities and agencies at the local and regional levels (go to Figure 5.1). Use a tiered approach, ranging from the smallest unit, the individual health care facility (HCF) or group of providers (Tier 1); through health care coalitions (Tier 2) and jurisdictional incident management systems (Tier 3); to broader State, interstate, and Federal response levels (Tiers 4-6). Resource coordination needs that overwhelm the lower tiers spill over onto the higher tiers either to meet the resource needs or to make policy decisions to cope with the lack of resources.

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Coordinating Community and Regional Planning of Hospital/Acute Care MCE Responses

Regional Planning

The State health department has the overall responsibility for projecting health resource needs in the event of a major health-related emergency and for allocating scarce resources to meet those needs. Some States have intrastate regional coalitions (clearinghouse hospitals, regional coordinating hospitals), which can assist the State health department in managing resource allocation within their area. This arrangement establishes a more effective span of control for the State, with only a few regions rather than multiple individual facilities, reporting data and resource needs. It also allows for plans to consolidate inventories of supplies, epidemiological data, medical response, communications, and command and control. These intrastate regional coalitions, where they exist, should be incorporated into regional Multi- Agency Coordination (MAC) planning and response (go to Figure 5.2). Planners should expect that there will be issues with communication, coordination, and overlapping responsibilities, and thus it is important to practice all elements of the State, regional, or local interface in advance. Such advance practice would enable planners to find ways to account for and adapt to the variability in relationships among local emergency operations centers, hospitals, regional MACs, and the State.

Interstate regional coordination is another means of managing allocation of scarce resources.  Interstate agreements and cooperation help promote sharing of assets across State lines. These types of agreements also help ensure consistency of response (e.g., National Capital Region) where inconsistencies between State plans could prove problematic. This level of interstate cooperation is difficult to achieve but is one of the most important ways to maximize resource allocation. The development of national-level clinical decision tools to address commonly limited resources (e.g., dialysis, mechanical ventilation) would be very valuable in helping to facilitate greater interstate cooperation.

Coordination and Communication

The State, rather than local jurisdictions, should take responsibility for overall risk communication management. This includes information provided to hospitals and health care systems, as well as the provision of public information releases and information for providers or members of the public that are posted through telephone, the Internet, the media, and other access points. A JIC should be established as well as other ways to link communications at the local, jurisdictional, and State levels to establish mechanisms for media message development.

Communications strategies must be established and practiced ahead of time to ensure that messages will come from accurate sources in a timely and consistent manner. These strategies should include the use of risk communication, regular media releases, and press conferences.

Using Expert Panels or Planning Groups

At this time, no current predictive model is sufficient to serve as a decision framework for determining the allocation of critical care resources (e.g., ventilators, intensive care therapies). One valuable strategy for examining the allocation of scarce resources, however, is to convene a balanced expert panel that can bring in multiple viewpoints and establish decisionmaking guidelines. The panel must be inclusive of relevant stakeholders who reflect the jurisdictional area and its demographics, in addition to recognizing border issues with adjoining States. The composition, functions, and operational role of these groups must be carefully considered.

Issues of resource allocation ideally would be addressed by expert panels or groups as part of MCE planning. An ad hoc expert panel may be called on to address an unexpected event to determine which factors will be used for decisionmaking based on a particular situation and the specific resource in short supply. The community member panels that allocated scarce hemodialysis resources in the city of Seattle during the 1960s can serve as an historic example of this process.

Some questions that States should consider when developing an expert panel include:

• Is the group considered an advisory body or a policy development body for the health department? If it is advisory, what internal process within the department is followed to develop and approve the policy?
• What is the liability of the members of the group (if any) for their decisions?
• What is the expectation of the group during an event? How often will they meet? What will be their sources of information? Is there enough redundancy in the group in case of illness or absence?
• Would the composition of the group need to be modified based on the type of MCE? If so, who would decide?
• How does the group convene, develop consensus and recommendations, and modify them as needed?

The recommendations of the expert panel should be vetted and shared with larger, more diverse groups to allow feedback and further modifications. Those groups might include physicians or other health care professionals, palliative care providers, ethicists, State health officers, representatives from the Office of Emergency Preparedness, community leaders, and others. Any guidelines or decisionmaking framework developed should be circulated between facilities and jurisdictions prior to an event.

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Increasing System Capacity During an MCE

During an MCE, the capacity of the health care system should be expanded according to an incident management system-directed mobilization of physical space, personnel, and material resources—sometimes referred to as "space, staff, and stuff." For example, in advance of an MCE, hospitals should establish a preference list of supplemental providers to expand staff capacity. These providers might include local hospital staff, clinic staff, and health professional volunteers who have registered with and had their credentials verified by one of the State Emergency Systems for Advance Registration of Volunteer Healthcare Professionals (ESAR-VHP), Medical Reserve Corps, National Disaster Medical System teams, trainees, patient family members, military members, Community Emergency Response Teams, and lay volunteers. Policies should be in place in advance to credential staff members and manage deployment of nonhospital personnel at community and hospital levels, and there should be a plan for managing spontaneous volunteers.

Another critical component of increasing system capacity during an MCE is informing the public. It is important to provide the public with information on two fronts: information about ongoing events and how to care for themselves, as well as information that will enable them to make appropriate decisions about their own personal health care situation. This information process will help limit or slow the spread of disease while engaging the public in the allocation of scarce resources.

The goal of informing the public can be achieved through a two-pronged approach: the use of effective media campaigns to educate and inform most of the public, supported by enlisting the assistance of established community health call centers (poison centers, nurse advice lines, public health hotlines) to help address the public's additional concerns and questions. This approach should enable most people to care for themselves, and at the same time, will help to lessen demands on the healthcare system.

Short-term Strategies

Short-term strategies may be applied to increase healthcare facility capacity in cases where resource shortages can be expected to be resolved relatively quickly (within hours or days). These strategies usually do not require a systematic assessment of the standard of care being provided. They may include the following:

Increase space capacity with:

• Rapid discharge of emergency department (ED) and other outpatients who can continue their care at home safely.
• Rapid discharge of inpatients who can safely continue their care at home (or at alternate facilities if they are available).
• Cancellation of elective surgeries and procedures, with reassignment of surgical staff members and space.
• Reduction of the usual use of imaging, laboratory testing, and other ancillary services.
• Expansion of critical care capacity by placing select ventilated patients on monitored or step-down beds; using pulse oximetry (with high/low rate alarms) in lieu of cardiac monitors; or relying on ventilator alarms (which should alert for disconnect, high pressure, and apnea) for ventilated patients, with spot oximetry checks.
• Conversion of single rooms to double rooms or double rooms to triple rooms if possible.
• Designation of wards or areas of the facility that can be converted to negative pressure or isolated from the rest of the ventilation system for cohorting contagious patients; or use of these areas to cohort those health care providers caring for contagious patients to minimize disease transmission to uninfected patients.
• Use of cots and beds in flat space areas (e.g., classrooms, gymnasiums, lobbies) within the hospital for noncritical patient care.
• Transfer of patients to other institutions in the State, interstate region, or nationally.
• Facilitation of home-based care for patients in cooperation with public health and home care agencies.
• Establishment of mobile or temporary evaluation and treatment facilities in the community to supplement usual clinic locations. These locations also may be used to screen those with mild symptoms when medications are available and must be taken early in the course of illness to be effective.

Expand staff capacity with:

• Call-in of appropriate staff members.
• Changes in staff scheduling (e.g., duration of shifts, staffing ratios, changes in staff assignments).
• Requests for supplemental staff members from partner hospitals through the use of Emergency Systems for Advance Registration of Volunteer Health Professionals (ESAR VHP), clinics, the Medical Reserve Corps (MRC), the local American Red Cross, public health, public works, schools, or other agencies and State and Federal sources as applicable.
• Promotion of home care and discouragement of the "worried well" from seeking hospital evaluation and care through the use of media campaigns and access to community health call centers.
• Establishment of guidelines and public messaging describing how to evaluate symptoms, what treatment can be safely delayed, and how to care for themselves at home
• Sharing of small numbers of specialized staff members (e.g., burn nurses, pediatric critical care staff members) with hospitals in need
• Activation of memoranda of understanding (MOUs) with regional and distant hospitals, health systems, or State disaster medical assistance teams.

Increase access to supplies by:

• Activation of MOUs with commercial companies for supply chain continuity.

If these strategies are not sufficient to meet the demands of the incident and no immediate relief is available, then a systematic evaluation of the level of care being provided must be conducted. These surge strategies should be reviewed and revised based on the available resources.

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