Mass Medical Care with Scarce Resources: A Community Planning Guide. Chapter 8 (continued)

Pandemic Alert Period: Cases Overseas but No Confirmed Cases in U.S.

In this pandemic alert period, there have been confirmed cases of sustained human-to-human transmission of the avian H5N1 influenza virus in Asia. Asian nations request aid from the United States and take steps to protect their populations and prevent the disease from spreading further. By the end of this period in our hypothetical case study there are nearly 500 people infected with the virus and nearly 20 deaths from the disease. Planning activities to consider in this period, after laboratory-confirmed virus changes that predict sustained human-to-human transmission, are listed below.

I. Prehospital

Command Structure

• Establish an emergency operations center (EOC):
  • The EOC should include, but not be limited to, representatives of the following groups: community health centers, home health care organizations, hospitals, Public Health agencies (local, State, and Federal), Metropolitan Medical Response Systems, long-term care organizations, and other health-related groups.
  • The EOC will coordinate all EMS resources by including public, private, and volunteer representatives.
  • The EOC should encourage the use of health area operation centers. This will allow the EOC to communicate directly with a larger medical community, which could provide guidance and direction.

Communications

• Establish a comprehensive public information strategy:
  • Use mass media to provide the public information on preventive measures, home care management, and the appropriate time to seek health care services.
  • Use community health care call centers to reinforce mass messaging and to provide additional and more tailored information to individuals with questions and concerns. Review these issues for their value as potential mass media messages.
  • Use community call centers to assist with outpatient (home care) monitoring and support, thereby helping to extend the reach of public health and healthcare systems into households.
  • Use information collected by the call centers for situational awareness and disease outbreak management and control.

II. Hospital

Command Structure

• Partially activate the hospital incident command system (HICS) with the assignment of an Incident Commander (IC).
• Hold briefings for administrators and staff members.  Review talking points and discuss general action plans to be followed in the event that a flu pandemic should spread to the United States.
• Establish the hospital process for allocating scarce resources. Activate/test internal hospital committees on standards of care if necessary. Review policies and protocols.

Training

• Conduct just-in-time-training for staff members, including influenza transmission, general information, infection control information, ventilator management, and hospital plans. Training is to be conducted via E-mail, informational posters, and shift briefings.
• Conduct Personal Protection Equipment (PPE) Training.  Perform fit testing for the outpatient and inpatient staff, donning/doffing instruction, practice, and competencies. This training is to be checked by nursing unit, PPE inventory, and parameters for use per infection control.

Supplies

• Increase hospital supplies from the usual baseline of 3-day supply to 7-day supply if possible (based on an estimated 150 percent occupancy rate). Specific actions to focus on include:
  • Order, inventory, and increase par levels of IV fluids, medicines, linens, and other consumable medical goods.

Communications

• Establish lines of communication among Public Health officials, hospitals, EMS and emergency medicine to provide daily updates:
  • Identify personnel/procedures to run the Joint Information Center (JIC).
• Ensure daily communications with Public Health and EMS:
  • Designate a public relations person as the hospital Public Information Officer.
  • Reinforce the public information messaging begun in Pre-pandemic period.

Drills, Tests and Reviews

• Test the initiation process with partner facilities (e.g., durable supplies stored in a local convention center, disposables from a local Target store and partner hospitals via pre-agreement and increased par levels), drill action planning cycles, and notifications.
• Test Health Alert Network (HAN) to include off hours and notification of HAN alerts from the ED to infection control.
• Review plans for security, behavioral health, and general disaster contingencies. Review the facilities plan, including HVAC and other cohorting plans.

Monitor Outbreak; Screen Outpatients

• Establish a local Public Health point of contact.  Begin Department of Health (DOH) monitoring of influenza-like illness (outpatient and inpatient).
• Screen outpatients per CDC guidance for influenza symptoms based on fever and/or respiratory symptoms and travel history. Begin screening at the Emergency Department and outpatient clinic check-in points.
• Verify referral agreements with local hospitals in order to ensure that patients will be accepted. Clarify patient movement for infectious cases between hospitals (e.g., EMS protocol for transfer patients) and within a hospital (e.g., protocol for elevator transport of pandemic patients).
• Reinforce infection control and respiratory etiquette  for those with respiratory symptoms using posters, staff reminders, educational materials, and patient masks and tissues at triage and clinic registration points as well as near common points such as elevators and major entrances.
• Plan for Vaccine Distribution. Arrange internal distribution to staff members based on prior planning and in concert with State and regional plan criteria for essential personnel.

III. Alternative Care Sites

The following measures need to be undertaken to prepare for operation of the alternative care site (ACS):

• Perform resource assessment for standing up an ACS:
  • Include acquisition of additional necessary disposable supplies.
• Finalize policies of operation for the ACS.
• Exercise the ACS if possible:
  • As early as possible, explore the legal issues around standing up an ACS for full functional exercise with patients.
• Test communications.
• Identify and roster the ACS staff.
• Establish a process of immunization and prophylaxis of potential staff members.
• Develop a patient transport plan for movement of ACS patients to and from area hospitals.

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Pandemic Alert Period: Global Cases and First Confirmed Cases in the U.S.

In this period of our hypothetical pandemic case study scenario, the avian H5N1 flu virus begins to spread from Asia to other nations around the world. The number of people infected rises significantly as does the number of deaths. The second period ends with the first appearance of the avian flu virus in the United States. In this second period planners need to consider the following activities.

I. Prehospital

• Prepare to open community staging locations.
• Engage mutual aid partners.
• Consider home care preparations. During a pandemic, it is likely that the home will serve as a major care site. Planners may want to consider the following steps:
  • Ensure adequate stock of routine, chronic care medications is available to the community.
  • Ensure adequate stock of basic first aid supplies, including bandages, antipyretic medications (acetaminophen, ibuprofen), oral electrolyte solutions, and thermometers.
  • Ensure that backup utility support is in place should the power grid be disrupted by decreased staffing for those patients requiring electricity support for medical devices.
  • Provide advice on the establishment of a "sick room" in the home for primary management of ill household members.
  • In the event of caring for patients with advanced symptoms "too sick" for hospital care, provide symptom palliation with a home care team coordinated by local public health authorities.
  • Ensure availability of a bedside commode or bedpan.
  • Ensure availability of a bedside humidifier if possible.

II. Hospital

Command Structure

• Fully activate the HICS and open a hospital command post.

Patient Screening

• Continue to limit hospital entry to a few key entrances.
• Screen patients for symptoms of influenza (fever, respiratory symptoms) and relevant travel history (if defined enough) and with rapid diagnostic tests if available in the tent adjacent to the triage entrance.
• Mask patients with suspect symptoms and make sure that providers wear appropriate PPE until a potential influenza case is ruled out.

Anticipate Hospital Surge

• Schedule and, to the extent possible, perform all elective surgeries within the next few weeks.
• Ramp up outpatient services by increasing clinic hours and personnel to provide nonurgent services (such as annual exams, prenatal checks, and rechecks) that would be difficult to obtain during a pandemic. Extra staffing will be needed because outpatient services will be a likely place for screening of those who are concerned that they may have the flu.
• Communicate with the public about the need to get nonemergency services taken care of sooner rather than later. Use mass media to reinforce this message: "During a pandemic, you will not be seen in the clinics for nonurgent conditions."
  • Establish a hospital hotline and enable the prerecorded greeting to triage calls for information to nonclinical staff and clinical inquiries to appropriate staff at the department of health.
• Create temporary anterooms on medical surgical floors, and utilize the intensive care unit (ICU) as a cohorting area during the early phase of a pandemic.
• Prepare flat space areas in conference rooms, auditoriums, etc., for patient care (organize cots, linens, etc.).
• Open a joint information center (JIC) with the hospital association acting as liaison with all hospitals in the region. The regional coordinating hospital provides updates and solicits baseline availability of ventilators and patient beds.

III. Alternative Care Sites

• Establish incident command structure for ACS.  Planners should ensure that ACS is integrated with community, regional and State incident command systems.
• Unpack and inventory supplies at the selected site(s).
• Enable the security protection systems of the ACS to protect the supplies.

IV. Palliative Care

• Discuss goals of care. Each person who is infected with the flu has the potential of developing complications, either based on their previous health history or as a consequence of the flu itself. These complications may lead to a situation where the individual becomes too sick to survive. While the health care professional is helping this person through the various stages of their disease, it may become necessary to have a discussion regarding the goals of care and patient preferences. Establish goals of care, acknowledging that individuals may die as a result of influenza.
• Provide information on treatment options.  Patients and families need to have updated information so they may understand their condition and treatment options.
  • The decisionmaking process about the patient's care plan must be sensitive not only to changes in the patient's condition but also to the availability of community resources.
  • Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with the patient and their family throughout the continuum of care.

V. Home Care Issues

• Address the myriad challenges of providing health care services in the home setting to people with substantial disability and/or an established illness or without family or other resources to provide care. Community planners should consider the following issues related to providing care in the home setting:
  • Develop alternative ways to provide care to people in the community such as primary care vans that go into neighborhoods to provide care, answer questions, and provide resources.
  • Establish telephone hotlines to answer questions regarding the avian flu virus, such as using "Ask-A-Nurse"-type telephone support services and make use of existing hotlines.
• Consider ways to provide incentives for people to work during times of crises. Planners should be aware that health care workers may not want to leave their families to care for flu patients and should consider incentives (e.g., giving them priority status for vaccines).

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Pandemic Period: Increased and Sustained Transmission in U.S. Population

In this the final period of our hypothetical case study planning exercise, the avian flu virus has spread to communities across the U.S. Millions of individuals are infected with the virus and the death toll is increasing steadily. In this final period of the pandemic, planners need to consider the following measures.

I. Prehospital

Set Up and Utilize Casualty Treatment Areas

• Use formal triage and treatment protocols and have triage and treatment completed in nontraditional triage/treatment areas by bringing prehospital personnel to casualty treatment areas.
• Determine who can be treated on site to include those triaged with moderate (yellow) and minor (green) status.
• Determine who should be transported to area hospitals and by what means, with the sickest casualties with a reasonable chance of survival are treated and transported first.
• Bring in prehospital personnel to staff these areas.
• Prepare equipment caches containing mass casualty event (MCE)-specific supplies so they are readily deployable. Examples would include staffing and additional field-related treatment modalities for both advanced life support (drugs, airway, etc.) and basic life support (splints, oxygen, dressing, etc.) as well as easily deployable tents with portable generation.
• Consider suspension of some medical protocols (e.g., base contact for certain interventions, expansion of scope of practice, appropriate standard of care).
• Consider bringing medical care to the people triaged with moderate (yellow) and minor (green) status.
• Consider secondary triage methodologies such as one hospital triaging patients to another.

911 Dispatch Issues

• Dispatcher screening of response need.
• Provide precaution advice for scene responders.
• Limit the number of responders to the minimal necessary response.
• Provide a nonemergency information and advice line.

Maximize Utilization of Available Personnel

• Create modified shifts; expand number of providers and vehicle types.

Maximize Transport Capability

• Staff ambulances with one EMT and a non-EMT driver (firefighter, police officer, teacher, etc.).
• Expand the use of paramedic-initiated alternative transport mechanisms (e.g., buses, taxis, privately owned vehicles).
• Load ambulances with more than one patient (e.g., two critical, one critical plus one or more noncritical).
• Air transport probably will be of limited use.

Maximize Personal Protection Available to Personnel

• Distribute vaccine to personnel with the additional consideration for inclusion of family members.

Maximize Destination Choices

• Encourage home care rather than transport, if possible. Transport patients not only to hospitals but also to clinics and ACS.
• Consider other potential sites such as nursing homes, public buildings, etc.
• Consider "batching" noncritical calls in the same geographic area and transporting all patients to the closest appropriate facility, rather than the facility of the patient's choice.

II. Hospital

Planning and Information

• Institute action planning. The planning section anticipates resource needs for the next operational period and gathers situational information from within the hospital and from regional/State entities. It also works with personnel to determine staffing and availability.
• Activate the Joint Information Center opened during the pandemic alert period. The JIC is managed by the hospital association liaison for all hospitals in conjunction with Public Health and EMS. The JIC will become responsible for providing daily media messages and holding press conferences.
  • Establish daily briefing cycle for staff members and media (arranged with the JIC).

Activate Multiagency Coordination System

• Have key representatives from Public Health, Emergency Medicine, EMS, and hospital staff monitoring information on the system status from all agencies/hospitals (including liaisons from neighboring States).
• Conduct action planning at the regional level.
• Compare the "triage levels" at area facilities to assure consistency.
• Request resources (when possible) via jurisdictional Emergency Medicine.
• The Staffing Coordinator manages Public Health, Emergency Medicine, EMS, and hospital requests for staffing and allocates them based on the sources available, including the Medical Reserve Corps and ESAR VHP.
• Communicate with the State EOC or the State DOH about regional resource and policy needs.
• Ensure Public Health coordination with home care agencies and messaging, hotline and Internet support for families.

Review Staffing Plans

• Use families to provide basic patient care. The hospital should engage the patients' families (one person at a time) to provide basic patient care, such as feeding. Nurses (including Medical Reserve Corps, ESAR VHP, and retirees with appropriate mentorship by current staff nurses) provide medications and assessments and review vital signs.
  • Respiratory therapy manages ventilators only; other respiratory care services are to be provided by nurses. Floor nurses are to receive training in basic ventilator monitoring, with floor units supervised by a roving ICU nurse to monitor ventilated patients.
  • Physicians see patients on an as-needed basis, providing critical interventions and assessment for interventions, transfer, and discharge.
• Consider expanding staff capacity with changes in staff scheduling (e.g., duration of shifts, staffing ratios, changes in staff assignments), though it is important to note that longer shift duration during an infectious event may be detrimental to staff who do not adhere to PPE recommendations when fatigued.

Review Use of Hospital Space and Supplies

• Set up cohort areas of inpatient and outpatient units  for infectious patient care. These areas are to be used when volume allows (the entire facility may be a cohort during peak periods).
• Select operating room and procedure room space to be used for additional ventilated patient care.
• Use minimal documentation. Use short assessment and plan notes—medication and vital signs documentation, for example.
• Reuse disposable supplies when possible.

Clinical Care Committee

• Institute daily meetings of the clinical care committee  to examine new guidance, the situation at the hospital, and the regional situation and to determine appropriate levels of care to be offered based on staffing and other resources. The committee adapts State guidance to the hospital level and reviews any updates.
  • The Committee submits recommendations to the Planning Chief and then to the IC.
  • On approval of the IC, any changes to the previous day's triage, treatment, and diagnosis protocols are communicated to the ED, outpatient, and inpatient areas. These changes may include:
    • Guidance on laboratory and x-ray testing (both influenza case testing and clinical lab/x-ray guidance).
    • Guidance on outpatient/ED denial of service (e.g., deny care to those who will not be seen due to their injury/illness being too minor).
    • Updated information for all patients and family members presenting to the facility to be handed out by a triage nurse and reviewed with the patient's nurse or physician.
    • Inpatient care guidelines (staff responsibilities).
    • Inpatient triage/resource situation.
    • Anticipated events/trends in the next operational period.

Patient Triage

• Set up a triage team (may consist of one critical care and one infectious disease physician, among others) to review conflicting resource needs (e.g., two patients needing a single ventilator) on a case-by-case basis.
  • The team recommends assigning the resource to the patient with the better prognosis—using decision tools supplied via the State and the clinical care committee.
  • Physicians are to provide patient care when not performing triage functions.
• Identify a Bed Czar to monitor the bed and "hard" resource statuses (e.g., ventilators), make assignments based on availability, and implement triage team recommendations.
  • The bed czar receives input from clinical units about patient statuses (improving, deteriorating, etc.) on a scheduled basis.

Enable Hospital Decompression

• Establish alternative care sites in conjunction with other area hospitals as well as in conjunction with Public Health and Emergency Medicine to enable hospital decompression.
• Notify EMS, Public Health, and others of need to decompress the hospital, as needed.
• Transfer patients to and from facilities as needed based on hospital resources; critical care to be concentrated in hospitals.

Establish a Regional Home Death Management Process

• Set up regional hubs for body retrieval and processing with a review by the Medical Examiner, a registration process, and a temporary holding place awaiting definite management.
• Deploy refrigerated trucks from the hospital for body management, exchanged daily to regional processing sites.
• Arrange for Web-based death certificate processing and secure tracking to the Department Of Health.

Hospitals in Rural Areas

Some of the issues that planners need to consider that are more likely to apply to hospitals located in rural areas, include:

• The triage physician (and/or nurse) implementing decisions at the hospital/ward level.
• Promoting a regional hospital and multiagency coordination system to share staff and resources as possible and help hospitals in the region share information. Coordinate the setup of a regional ACS when needed (under the host city's jurisdictional umbrella).
  • Patient referral to regional hospitals (when possible) or supportive care provided to the extent possible at the facility.
  • Offsite care (may be a single regional facility). The ACS is the screening and care point for noncritical patients (the ACS fulfills the need for additional screening/minor treatment in a rural area, whereas in an urban area it is opened for referral transfers from hospitals only). In smaller communities, hospitals and clinics may not have the space and resources for screening that urban areas have, so bottlenecks may occur in outpatient assessment as well as inpatient care.
• Coordination of care with home care/families.
• The hospital coordinates with local public health agency  to determine the scope of care in the community and facilitate home and palliative care.
• Transfers from the hospital morgue to a regional processing point or local undertakers with the Medical Examiner as needed.

III. Alternative Care Sites

• Ensure all ACSs are fully operational.
• Investigate the need for the establishment of other functional sites for the potential purposes of supplying ambulatory care, inpatient care, quarantine, and/or palliative care.
• Establish criteria for terminating operation of the ACSs as the pandemic eventually passes.

IV. Palliative Care

Patient Triage

• Establish patient triage criteria by levels of care.
  • Classification of patients who are already chronically ill, extremely old, or in long-term care facilities (e.g., by physician prognosis).

Establish Plans for Use of Long-term Care Facilities

• Nursing homes also could provide a preventive care response to an influenza pandemic (e.g., immunizations, drug management), thereby providing relief to hospitals. Nursing homes have not only the medical expertise, but also the capability to maintain supplies that could prove useful in a pandemic.

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