HHS Pandemic Influenza Implementation Plan
CHAPTER 4: FEDERAL MEDICAL RESPONSE
Introduction
An influenza pandemic will place extraordinary demands on the health
care system requiring an integrated response by and across all local, State,
and Federal jurisdictions and partners. Efficient use of existing Federal
assets will be crucial in meeting the medical surge requirements. For medical
resources to be most efficiently utilized, effective response plans must be
developed and tested. Plans must include a command structure compatible with
the DHS National Incident Management System (NIMS) at all levels of response, a
Federal regional approach to the stockpiling and distribution of medical
materiel, and a schedule of exercises for evaluating the effectiveness of the
plans. Guidelines must be developed and disseminated by the Federal Government
to all partners and stakeholders. These guidelines must offer approaches to the
allocation of scarce resources and the altering of medical care, if needed,
such that scarce resources are distributed and applied in the most appropriate
manner. Working groups organized by the Federal Government to develop
guidelines, determine medical resource needs, and determine the response
framework should include multidisciplinary partners from Government, private,
and volunteer organizations, as well as academic medical and health training
programs.
This chapter addresses the Federal medical response only, recognizing
that State and localmedical responders are essential partners in the U.S.
effort to prepare for pandemic influenza. For preparedness guidance for State
and local partners, see the HHS Pandemic Influenza Plan (Part
2Public Health Guidance for State and local Partners Supplement 3,
Healthcare Planning: see
http://www.hhs.gov/pandemicflu/plan/sup3.html)
and Chapter 8, State, Local, and Tribal Preparedness. There are specific
HHS-sponsored programs that provide additional guidance to States regarding
their public health and medical preparations. CDC and HRSA are working closely
with States in the areas of public health and hospital preparedness, and have
entered into cooperative agreements with States to provide funding for
implementing this guidance (CDC:
http://www.bt.cdc.gov/planning/coopagreement/#fy05
and HRSA: http://www.hrsa.gov/bioterrorism).
Additionally, DHS has developed a series of National Preparedness Goals. Within
these goals are specific planning scenarios, including one that addresses
pandemic influenza (see http://www.dhs.gov).
See these resources and Web sites for further information and detail about
preparedness planning.
Surge Capacity Strategies
Federal medical support will augment, to the extent possible dictated by
availability, existing local and State infrastructure. Federal resources
include the National Disaster Medical System (NDMS), the Commissioned Corps of
the U.S. Public Health Service (USPHS), the Strategic National Stockpile (SNS),
and Federal volunteers and temporary employees. At all levels, the success of
medical response to an influenza pandemic will be determined by how medical
providers and facilities implement interventions that enable them to meet the
increased medical demands resulting from the pandemic. Strategies, developed
through Federal regional approaches, are needed for enhancing the health care
system's provider and facility surge capacity as well as the abilities to
accept, distribute equitably, and utilize the medical resources that may be
brought in from outside organizations, including Federal medical support.
Altered Standards of Care and Other Tools for
Medical Surge Capacity
Even if health care systems fully maximize their internal surge capacity
and fully utilize alternative health care sites, it is likely that under the
worst case scenario, health care systems will need to modify their standards of
care in such a way that patients can receive treatment without a significant
compromise to clinical outcomes.1 While
these difficult decisions must be based on a variety of conditions and there is
no single set of standards that addresses every situation, guidance regarding
the process of altering standards can be made using existing medical
knowledge.
States have also initiated other steps to enhance their surge capacity,
including developing alternate health care facilities and exploring the concept
of home care by lay persons, creating rosters of volunteers, enhancing hospital
bed tracking systems, and providing mutual aid compacts or agreements. A number
of models and tools have been developed and disseminated by HHS to State,
local, and tribal planners to enhance their planning for medical surge capacity
(http://www.ahrq.gov/browse/bioterbr.htm#tools).
There is a list of tools in the appendix to the HHS Pandemic
Plan (Part 2Public Health Guidance for State and Local Partners
Supplement 3 Healthcare Planning: see
http://www.hhs.gov/pandemicflu/plan/sup3.html).
Tools for hospitals include: AHRQ Altered Standards of Care in
Mass Casualty Events_4-20051.pdf and
DHHS Medical Surge
Capacity and Capability Handbook_8-2004.pdf.
Stockpiling Guidance
There are a variety of different guidelines disseminated by the Federal
Government that address the issue of stockpiled medications and supplies. SNS
has a program that is assisting States with their pharmaceutical distribution
plans. CDC offers training to States for the receipt and distribution of SNS
material (see http://www.bt.cdc.gov/stockpile/).
Recommendations From Private Sector
Partners
Private sector entities have also issued recommendations for building
State and local medical surge capacity that are applicable to all hazard
situations. For example, the American Hospital Association (AHA) has
recommended that individual hospitals have a 24-hour supply of pharmaceuticals
and that they develop a list of required medical/surgical equipment and
supplies (see AHA Hospital Resources for Disaster Readiness:
http://www.aha.org/aha_app/issues/Emergency-Readiness/index.jsp).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
recommends a 4872-hour capability of medications and supplies (JCAHO
Health Care at the Crossroads: Strategies for Creating and Sustaining
Community-wide Emergency Preparedness Systems, 2003; see
http://www.usaprepare.com/ep3-12-03.pdf).
HRSA recommends a 72-hour supply of pharmaceuticals. During an influenza
pandemic, the needs for medical surge capacity and stockpiles will be similar
to those needed during other types of hazards; however, the specific
requirements for a pandemic will also need to be addressed.
Role of HHS in Federal Medical Response
Deployment of Federal medical response assets will use the National
Response Plan (NRP) as a framework for the coordination of Federal support.
Additionally, the Federal resource inventory includes the Federal Medical
Stations (FMS). These facilities are designed to provide care to special needs
persons and others who do not require hospitalization, yet may need frequent or
continuous medical supervision.
From an incident management perspective, the NRP (Emergency Support
Function [ESF] #8) assigns HHS as the lead Federal agency responsible for
coordinating the health and medical responses to a biological event such as a
pandemic. Specifically with respect to the Federal medical response, the HHS
role is to:
- Coordinate the deployment of Federal medical resources available
through ESF#8
- Provide guidance regarding surge capacity
- Distribute stockpile medications and supplies
Specific Assumptions and Planning Considerations for HHS Federal
Medical Response
The NRP will serve as the pandemic response framework for the
Federal medical response.
The spectrum of Federal medical services can include clinical
care, immunization, patient transport, establishing augmentation facilities,
backfilling existing facilities, fatalities management, and mental health. But,
the number of Federal health care providers is limited, and it will be unlikely
that the Federal Government will be able to meet requests for personnel in the
event of a pandemic.
- The USPHS Commissioned Corps and NDMS resources will be tasked
with the primary responsibility for providing the main body of Federal
responders.
- Federal resources other than personnel will also be scarce, and
a mechanism is required for their equitable distribution.
- The Federal medical response must be sustainable for several
months during a pandemic.
- Federal responders are multidisciplinary and come from a
variety of sources, including screened volunteers and temporary Federal
employees.
- HHS will establish an interagency management system that will
be based on the HHS Incident Response Coordination Team (IRCT) and the
utilization of existing regional entities to coordinate and support the Federal
medical effort.
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HHS Actions and Expectations
Pillar One: Preparedness and Communication
Preparedness and communication are critical elements to the
implementation of successful public health interventions and medical responses.
Described below are activities that should be undertaken before a pandemic to
ensure preparedness and to communicate expectations and responsibilities to all
levels of government and society. Specifically, this section includes the
actions and steps necessary to develop the strategies for deploying Federal
resources, guidance needed for allocating scarce non-Federal health and medical
resources, and the medical materiel requirements of the SNS and stockpiles
based in States and communities. HHS has developed public communications
guidelines that are discussed in Chapter 7, Communications.
Planning for a Pandemic
- Action (HSC 6.1.2.2): HHS, DHS, DOD, and VA will develop a joint
strategy defining the objectives, conditions, and mechanisms for deployment
under which NDMS assets, USPHS Commissioned Corps, Epidemic Intelligence
Service (EIS) officers, and DOD and VA health care personnel and public health
officers would be deployed during a pandemic. (Also see chapter 2, Pillar One,
Action I [No HSC number], Step 7.)
- Timeframe: Within 9 months.
- Measure of Performance: Interagency strategy completed and tested
for the deployment of Federal medical personnel during a pandemic.
- Step 1: Convene ESF #8 working group to review ESF #8 incident
management and to define the conditions and mechanisms for equitable deployment
of Federal medical assets noted above. The NRP will be used as the framework to
coordinate the deployment of Federal resources. Review the HHS Incident
Management Team (IMT) for consideration as the pandemic influenza "Incident
Management System."
- Step 2: Identify triggers for deployment of Federal resources to
include the following:
- Declaration of a public health emergency
- Request for assistance from States
- Emergency or disaster declaration by President
- International deployment
- Step 3: Document incident management strategy and deployment
triggers and disseminate strategy to Federal partners and State, local, and
tribal health counterparts.
- Step 4: Draft results of Steps 1 and 2 into a working summary and
send out for comment to State and local public health and medical
organizations. Results will be integrated with State and local plans.
Incorporate revisions as appropriate and establish documents as Standard
Operating Procedures.
- Step 5: Conduct a facilitated discussion with ESF #8 partners to
test the Federal public health and medical response strategy.
- Step 6: Revise plans, strategies, and materiel, based on
exercises and partner feedback.
- Action (HSC 6.1.2.4): HHS, in coordination with DHS, DOD, and VA, and
in collaboration with medical professional and specialty societies, within
their domains of expertise, will develop guidance for allocating scarce health
and medical resources during a pandemic. (Also see chapter 8, Pillar One,
Action CC [HSC 6.1.13.6].)
- Timeframe: Within 6 months.
- Measure of Performance: Guidance developed and disseminated.
- Step 1: Convene ESF #8 partners and private collaborators (AHA,
AMA, ACEP, JCAHO, NGOs, IDSA, SHEA, and APIC) to discuss options for scarce
resource allocation. AHRQ with the Office of Public Health Emergency
Preparedness (OPHEP) guidance convened this working group on June 1-2, 2006, to
develop a Community Based Planning Guide for State, local, and tribal health
planners who are responsible for developing medical response plans. The guide
will be released in late summer 2006 and be disseminated to local and State
jurisdictions.
- Step 2: Define scarce resources for local, State, and Federal:
- Personnelwhich specialties and
disciplineshospital, prehospital, and other local health care
providers
- Equipmentventilators, monitoring equipment, PPE, and
masks
- Suppliespharmaceuticals
- Servicesintensive care, respiratory care, laboratory,
diagnostics
- Step 3: The working group will review existing guidance for
allocation of scarce resources and recommend options for maximizing resource
utilization such as:
- Developing clinical algorithms
- Using clinical "extenders"
- Using alternate health care facilities
- Step 4: Develop consensus document on allocation of scarce
resources.
- Step 5: Disseminate new guidance to Federal, State, and local
partners.
- Step 6: Revise plans, strategies, and materiel, based on
exercises, evaluations, and partner feedback.
- Action (HSC 6.3.4.8): All hospitals should be prepared to treat
patients with pandemic influenza (i.e., equipped and ready to care for: (1) a
limited number of patients infected with a pandemic influenza virus, or other
novel strain of influenza, as part of normal operations; and (2) a large number
of patients in the event of escalating transmission of pandemic influenza).
- Timeframe: 24 months.
- Measure of Performance: Hospital pandemic influenza plans
completed and tested.
- Step 1: Ensure that HHS-supported hospitals and clinics are
prepared to treat patients with pandemic influenza by reviewing their disaster
plans and identifying resources necessary to enhance surge capacity.
Producing and Stockpiling Countermeasures and
Medical Materiel
- Action (HSC 6.1.6.2): HHS, in coordination with DOD, VA, and State,
local, and tribal partners, will define critical medical material requirements
for stockpiling by the SNS and States to respond to the diversity of needs
presented by a pandemic.
- Timeframe: Within 9 months.
- Measure of Performance: Requirements defined and guidance
provided on stockpiling.
- Step 1: Convene meeting between the HRSA Bioterrorism Hospital
Preparedness Program and CDC to build a medical requirements list for pandemic
influenza to include the following:
- Identify critical medical materiel requirements based on
population
- Identify what State stockpiles exist and list contents
- Review SNS and State stockpiles to determine gap between the
HHS Essential Materials List (EML) and stockpiles
- Step 2: Develop a budget for procurement of additional
material.
- Step 3: Disseminate these materials to Federal, State, and local
partners, as materiel becomes available from manufacturers.
- Step 4: Revise plans, strategies, and materiel, based on
exercises, evaluations, and partner feedback.
- Action (HSC 6.3.4.10): All health care systems, individually or
collaborating with other facilities to develop local or regional stockpiles
maintained under vendor managed inventory systems, should consider stockpiling
consumable critical medical materiel (including but not limited to food, fuel,
water, N95 respirators, surgical and/or procedural masks, gowns, and
ethyl-alcohol based gels) sufficient for the peak period of a pandemic wave
(2-3 weeks).
- Timeframe: 24 months.
- Measure of Performance: Stockpiling plans completed.
- Step 1: Ensure that HHS-supported health care systems consider
stockpiling consumable critical medical materiel, either on an individual or
regional basis.
Establishing Distribution Plans
- Action (HSC 6.1.13.7): HHS, in coordination with DHS, DOT, DOD, and
VA, will work with State, local, and tribal governments and private sector
partners to develop and test plans to allocate and distribute critical medical
materiel (e.g., ventilators with accessories, resuscitator bags, gloves, face
masks, gowns) in a health emergency. (Also see chapter 8, Pillar One, Action DD
[HSC 6.1.13.7].)
- Timeframe: Within 6 months.
- Measure of Performance: Plans developed, tested, and incorporated
into department plan, and disseminated to States and tribes for incorporation
into department plan, and disseminated to States and tribes for incorporation
into their pandemic response plans.
- Step 1: Convene meeting with Federal, State, and local partners
to develop regional distribution plans for medical materiel:
- Review the appropriateness of distribution plans developed by
the States
- Modify distribution plans as appropriate
- Step 2: Work with States and local partners to develop
coordinated regional distribution exercises. Utilize existing Federal, State,
local, and tribal exercises whenever possible and appropriate.
- Step 3: Conduct exercises with evaluations of plans.
- Step 4: Revise plans, strategies, and materiel, based on
exercises, evaluations, and partner feedback.
Pillar Two: Surveillance and Detection
Federal medical response actions and steps are carried out either in the
pre-pandemic preparedness or pandemic response periods. Surveillance and
detection actions that identify the beginning of a pandemic or trigger
deployment of Federal medical resources are covered elsewhere in this document.
(See Chapter 2, Domestic Surveillance and Chapter 8, State, Local, and Tribal
Preparedness.)
Pillar Three: Response and Containment
HHS supports a layered strategy of influenza pandemic response and
containment. In the event of sustained and efficient human-to-human
transmission of an influenza virus with pandemic potential, HHS will first
leverage available resources and interventions to contain the pandemic at its
source and to delay its introduction into the United States. If such efforts
fail, HHS resources and recommended interventions will be redirected to
limiting or otherwise delaying the spread of the pandemic within the United
States, minimizing suffering and death, sustaining critical infrastructure and
a constitutional form of government, and reducing the economic and social
effects of the pandemic. This section covers the deployment of Federal medical
resources and the review of clinical care algorithms.
Containing Outbreaks
- Action (HSC 6.3.2.6): HHS health care facilities will develop test
and be prepared to implement infection control campaigns for pandemic
influenza.
- Timeframe: 6 months.
- Measure of Performance: HHS will have initiated infection control
campaigns on pandemic influenza in its health care facilities.
- Step 1: Review existing infection control strategies within HHS
health care facilities.
- Step 2: Develop infection control campaigns for pandemic
influenza for HHS health care facilities based on the findings of Step 1.
- Step 3: Beta test the infection control campaigns.
- Step 4: Implement the infection control campaigns for pandemic
influenza.
Leveraging National Medical and Public Health
Surge Capacity
- Action (HSC 6.3.4.1): HHS will work in collaboration with DHS, DOD,
and VA to assist major medical societies and organizations in developing and
disseminating protocols for changing clinical care algorithms in settings of
severe medical surge. (Also see chapter 8, Pillar Two, Action B [HSC 6.2.2.8];
and chapter 7, Pillar Three, Actions D, E, and H [HSC 6.3.2.6, 6.3.2.7, and
6.3.3.1].)
- Timeframe: Ongoing.
- Measure of Performance: Evidence-based protocols developed to
optimize care that can be provided in conditions of severe medical surge.
- See Pillar One, Action B [HSC 6.1.2.4] for steps.
- Action (HSC 6.3.4.2): HHS will develop, in coordination with DHS,
DOD, and VA, and in collaboration with States, localities, tribal entities, and
private sector healthcare facilities, strategies and protocols for expanding
hospital and home healthcare delivery capacity in order to provide care as
effectively and equitably as possible. (Also see chapter 8, Pillar Three,
Action A [HSC 6.3.4.2], and Actions in chapter 2, Pillar Three.)
- Timeframe: Within 6 months.
- Measure of Performance: Guidance and protocols developed and
disseminated.
- Step 1: Review medical literature for best practices regarding
evidence-based clinical care algorithms for medical practice, including mental
health, in mass casualty incidents.
- Step 2: Convene Federal, State, and private partners to develop
options based on review of literature in Step 1, above. The workgroup will
develop guidance for consensus.
- Step 3: Disseminate options to Federal medical responders and
private partners through Federal agency Web sites and teleconferencing.
- Action (HSC 6.3.4.4): HHS assets, such as the USPHS Commissioned
Corps and FMS's, along with DHS assets, such as NDMS medical materiel and
mobile medical units, will be deployed in a manner consistent with pre-defined
strategic considerations.
- Timeframe: Within 6 months.
- Measure of Performance: Development of strategic principles for
deployment of Federal medical assets in a pandemic; consistency of deployments
during a pandemic with these principles.
- Step 1: HHS-convened working group of ESF #8 partners will
develop strategic principles for the deployment of the HHS assets in a
pandemic.
- Step 2: Strategic principles are shared with State and local
partners.
- Action (HSC 6.3.4.6): HHS will deploy the USPHS Commissioned Corps
and FMS's, if available and in combination or separately as circumstances
warrant, to augment efforts of State/local governments as part of the Federal
response.
- Timeframe: Within 9 months.
- Measure of Performance: USPHS Commissioned Corps personnel
trained on FMS; Commissioned Corps personnel and FMS's deployed within 72 hours
of order to mobilize during a pandemic.
- Step 1: Work with OPHEP, USPHS Office of Force Readiness and
Deployment (OFRD), CDC, and MRC to identify USPHS Commissioned Corps deployable
resourceswith this chapter's planning assumptions in mind.
- Step 2: Develop concept of operations for FMS.
- Step 3: Determine challenges/barriers to deployment of FMS, if
any, and enhance logistic support for FMS deployment.
- Step 4: Develop optimal configuration (staffing and material) for
FMS to respond to pandemic influenza. Procure any material deficiencies. Adjust
staffing as necessary.
Sustaining Infrastructure, Essential
Services, and the Economy
- Action (HSC 6.3.7.1): HHS, in coordination with DHS, DOD, VA, and
DOT, and as the lead for ESF #8 (Public Health and Medical Services, see
http://www.dhs.gov/xlibrary/assets/NRP_FullText.pdf),
will identify public health and medical capabilities required to support a
pandemic response and work with other supporting agencies to identify and
deploy or otherwise deliver the available capability or asset, if available.
- Timeframe: Within 6 months.
- Measure of Performance: Inventory of public health and medical
capabilities; available public health or medical capabilities or assets
deployed or delivered during a pandemic.
- Step 1: Convene partners to develop medical/public health
capabilities requirements list for the following areas:
- Personnel
- Equipment
- Supplies
- Facilities
- Services
- Step 2: ESF #8 partners identify their respective public health
and medical capabilities available to respond to pandemic.
- Step 3: Review by ESF #8 partners of how capabilities will be
deployed through ESF #8 IMT infrastructure.
- Step 4: Develop and conduct an exercise to evaluate the 72-hour
deployment capabilities to respond to a pandemic.
- Step 5: Revise plans, strategies, and materiel, based on
exercises, evaluations, and partner feedback.
Footnote
1 Initial work on altering
standards of care has been published, including a white paper from AHRQ
(Altered Standards of Care in Mass Casualty Events, May 2005,
http://ahrq.gov/research/altstand/altstand.pdf).
JCAHO has also begun to address the issue (see
http://www.jointcommission.org).
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