National Hospital Available Beds for Emergencies and Disasters (HAvBED) System

V. Results

A.  Review of Current Relevant Bed Availability Reporting Systems

Denver Health Medical Center

Denver Health Medical Center (DHMC) administrates all emergency medical service (EMS) 911 activity in the City and County of Denver, Colorado. To facilitate orderly transport of patients from the field to area hospitals, DHMC EMS dispatch must be aware of real-time hospital resource availability. A computer-based system to log and distribute this information has been in place since 1986. These data have also been available on a Web-based system since 2002. Denver area hospitals have an interest in reporting to this system since it provides an ability to regulate hospital emergency department (ED) arrivals.  Denver area paramedics are key users of this system and have the capability of accessing this system on laptop computers located in the ambulances. These data are summarized by hospital. Each hospital has access to its own data summary.

National Disaster Medical System (NDMS)

The NDMS is a section within the U.S. Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA), Response Division, Operations Branch, and has the responsibility for managing and coordinating the Federal medical response to major emergencies and Federally declared disasters including:¹

• Natural Disasters.
• Technological Disasters.
• Major Transportation Accidents.
• Acts of Terrorism including Weapons of Mass Destruction (WMD) Events.

Working in partnership with the Departments of Health and Human Services (HHS), Defense (DoD), and Veterans Affairs (VA), the NDMS Section serves as the lead Federal agency for medical response under the National Response Plan (NRP). The three primary objectives of NDMS are:²

• To provide health, medical and related social service response to a disaster area in the form of medical response units or teams and medical supplies and equipment.
• To evacuate patients who cannot be cared for in the affected area to designated locations elsewhere in the Nation.
• To provide hospitalization in Federal hospitals and a voluntary network of non-Federal acute care hospitals that have agreed to accept patients in the event of a national emergency.

There are currently 1,656 NDMS participating hospitals, which represent about one third of all U.S. acute care hospitals providing a potential capacity of 100,000 beds.³ NDMS hospital bed availability is currently reported using the following six categories:

1. Medical/Surgical.
2. Critical Care-Pediatrics.
3. Critical Care-Adult.
4. Pediatrics.
5. Psychiatric.
6. Burn.

Participating NDMS hospitals report the current number of available beds (within 12 hours) and the maximum number of beds, by category, that could be made available within 24 and 48 hours.  When NDMS is activated, these data are requested by NDMS federal coordinating centers (FCCs) as frequently as once per week.  Reporting is via phone, fax or area-wide computerized bed availability systems.  Figure 2 depicts the location of the NDMS FCCs throughout the U.S.

HHS OASPHEP

The OASPHEP was established to direct preparation for, protect against, respond to, and recover from all acts of bioterrorism and other public health emergencies that affect the civilian population.⁴ OASPHEP serves as the focal point within HHS for these activities, and directs and coordinates the implementation of a comprehensive HHS strategy. A major component of OASPHEP is the Office of Emergency Response (OER), transferred from the Office of Public Health and Science (OPHS), and formerly named the Office of Emergency Preparedness. OER is the primary OASPHEP component for emergency response operations. In carrying out this responsibility, OER utilizes the resources of the NDMS.  The OASPHEP has also engaged in the longest continual activation of the NDMS in its history, beginning on September 11, 2001, through the end of August 2002.⁵

OASPHEP has established and operated the Secretary's Command Center (SCC) to serve as a single point of emergency contact for HHS. The SCC has responded to over 8,000 communications and along with HHS emergency operations centers have monitored nearly 600 cases potentially related to terrorism. The OASPHEP SCC has also established the Hospital Asset Reporting System.

State of New York Department of Health/Greater NY Hospital Association

New York's Hospital Emergency Response Data System (HERDS) combines geographic information systems (GIS) technology and a comprehensive, interactive database to provide health officials with online, real time data describing available hospital beds, medical supplies, personnel, numbers, status and immediate care needs of ill or injured persons, along with other urgent information to facilitate a rapid and effective emergency response.

At the direction of Governor Pataki, HERDS was developed by the State Health Department, in conjunction with the Greater New York Hospital Association, following the World Trade Center attacks. The system, which includes highly sophisticated features to ensure its security, is capable of responding to simultaneous emergencies, whether they occur in the same city or many different locations.

Should a health emergency occur, the State Health Department could use HERDS to generate a computer map of the affected area and identify and "activate" nearby hospitals. Once activated, hospitals participate in an online dialogue with health officials to provide real-time data about available beds, medications, equipment, staff and other essential information to address immediate needs and ensure that ill or injured persons are directed to hospitals best able to provide necessary care. This system is not used for daily, non-mass casualty operation.

The system also facilitates transport of patients to hospitals and transfer of assets among hospitals, so that resources can be directed where they are needed most. HERDS also includes a "patient locator" function since in an emergency people often flood hospitals with calls, trying to locate their loved ones who are missing and may require medical care. This function allows authorized persons to conduct searches for specific individuals by name, gender, age range and/or patient type (e.g., civilian, military, etc.).  This comprises a patient locator function as opposed to a strict patient tracking function.

EMSystem®

Headquartered in Milwaukee, Wisconsin, EMSystem® was founded in 1998 as a division of Infinity HealthCare, Inc., a multi-hospital emergency medicine physician practice. The company's founders initially designed EMSystem® to assist communities with addressing over-capacity in hospital emergency rooms. The purpose of this system is similar to the Denver Health Web-accessible divert system described above.

EMSystem® is an internet based application that tracks the status of various resources within the emergency medical environment. According to the President of EMSystem®, Dr. Christopher Felton, this system is currently being used by nearly 20 percent of the hospitals in the U.S., including Colorado.  Missouri, New Mexico, Arizona, Oklahoma, Nevada, Kentucky and Hawaii have already or are in the process of deploying EMSystem® Statewide. EMSystem® lists the resources within a geographic region providing real-time resource status to system users. In providing real-time communications and resource management solutions, preparedness and response to medical emergencies, mass casualty incidents, and public health incidents, including terrorist events are enhanced. All EMSystem® applications are created with State-of-the-art technology consistent with emerging national data standards and are hosted in secure and redundant data centers to ensure continuous availability of the services and robust data security. Components of the data centers include multiple redundant application and database servers, redundant internet communication services and multiple back-up power sources. Even though EMSystem® is currently focused on relaying hospital ambulance divert status information, the system is expected to easily support the reporting of hospital bed availability. In addition, a patient tracking function has recently been introduced.

ReddiNet®

ReddiNet® (Rapid Emergency Digital Data Information Network) is the product of a unique collaborative process that involved a range of healthcare industry end-users, and the not-for-profit organization, Healthcare Association of Southern California (HASC). After years of continuous use, testing and refinement, ReddiNet® provides emergency communications reliability to ensure continuous information sharing between emergency medical professionals during times of disaster.⁶

ReddiNet® provides emergency response professionals with crucial information, including:

• Hospital diversion status and reports.
• Day-to-day resource assessment information.
• Daily law enforcement bulletins.
• Disaster assessment information.
• Emergency preparedness information.
• Managing incidents of weapons of mass destruction.
• Extreme weather and environmental advisories.
• Epidemics and other health crisis alerts.
• Mass Casualty Incident management.
• Metropolitan Medical Response System capabilities (MMRS).
• Victim search capabilities.

This information is updated automatically, instantaneously and around the clock. The system not only improves decisionmaking at every level of emergency response, but also provides many day-to-day benefits and reporting functions. ReddiNet® helps coordinate hospital and paramedic services in the event of a major emergency. In non-emergency situations, ReddiNet® provides hospitals with daily diversion status updates to determine which hospitals can provide appropriate patient care.

State Hospital Capacity Web System

This hospital resource capacity system was developed four years ago by Harborview Medical Center and University of Washington and is currently being used in Washington, Oregon and South Carolina. Additional States that are considering this system are Vermont, New Hampshire, Idaho and Nevada.

This system includes dedicated, secure Web access allowing hospitals to exchange status and other information to support daily and crisis operations. The system incorporates many features to support patient planning assumptions on a regional and Statewide basis. The secure, password protected Web site is designed to be updated daily by all hospitals, assuring that hospitals will use this critical resource in an emergency situation. This system allows hospitals to update status in real-time and at a time convenient to the hospital. This assures a common tool for all hospitals in a State to collect and disseminate critical information during a significant disaster event.  Its use on a daily basis assures that hospitals are familiar with the Web page and can access it during the time of crisis.⁷

The Washington State Hospital Capacity Web System collects the following information:

• Emergency Department Status.
• Hospital Status.
• Bed Census.
• Supplies Status.
• Support Services Status.
• Calendar of Events.
• Phonebook.
• Radio Test.
• Hospital and Support Services Reference Information.
• Damage Assessment.
• Patient Management.
• Incident Log.
• Announcements.
• Smallpox Reporting.
• Stage Announcements.
• Compliance QA.
• Diversion QA.
• Documents.
• Web Links.
• Drill Site.

Of note, one component of this hospital inventory system is the hospital bed capacity report where hospitals identify bed availability using the 6 categories of beds defined by NDMS as well as operating room and emergency department beds. Each of the participating hospitals can view the other hospitals' information, assisting in the coordination of the sharing or resources during a disaster or emergency.

Figure 3 depicts the States that either have or are considering the hospital divert reporting systems and hospital inventory systems described above.

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B. Review of Patient Tracking Systems

TRANSCOM Regulating and Command & Control Evaluation System—TRAC²ES

TRAC²ES is a patient tracking/movement/destination-assignment integrated software program developed for the Department of Defense to provide for the world wide transport of ill or injured soldiers.  The initial development of TRAC²ES was begun by Science Applications International Corporation (SAIC) and completed by Booz Allen Hamilton. TRAC²ES is administered by USTRANSCOM, headquartered at Scott AFB, Illinois and utilizes four patient movement requirement centers (three fixed, one mobile).  Future expansion of TRAC²ES may provide for patient movement, tracking and destination assignment for NDMS. At the present time, there are no other systems that interface with TRAC²ES; it operates as an independent system.

From an operational perspective, a request for patient movement is made to a TRAC²ES patient movement requirement center after the soldier has received initial medical care at a facility. The coordinators at the center then match the patient to an available military hospital bed as well as available transport modalities and manpower capabilities. Patient information gathered as part of the movement request includes identification number (Social Security number or other), current facility, ready date, reason for regulation (movement), classification (ambulatory, litter, etc), precedence, type of space required and space requirement estimate.

TRAC²ES currently supports bed availability from DOD, VA and NDMS hospitals. In normal operating mode, total bed numbers (not available beds) are updated twice a year from these institutions. In contingency mode, available/vacant bed numbers from these institutions may be updated on a daily basis. This contingency mode was last utilized at the beginning of the Iraq ground campaign.

St. Louis Metropolitan Medical Response System (MMRS)—Raytheon

The St. Louis EMS and MMRS utilize a patient tracking system that was developed in conjunction with the Raytheon Corporation. This system utilizes a bar-coded patient tag (Figure 4) which is placed on a patient in the field and is scanned via a wireless device and transmitted to a central computer along with the following data: patient condition; destination hospital; decontamination status and optional information of patient name, age, race, etc. Currently, modified Nextel phones are used for this data gathering and transmission function. 

This system is in daily operation for approximately 65-70% of prehospital ambulance runs in the St. Louis metropolitan area. Once the patient has arrived at the destination hospital, their patient tag is scanned and these data transmitted to the central system. Patient location information may then be obtained via a Web site inquiry of this central database. This system is designed to support any mass casualty event as well.

Recurring costs for this system include telecommunications charges of approximately $50 per month per ambulance. Patient tags cost $.40 per tag for routine operation and $1.00 per tag for the expanded disaster tags. This system is in the process of being deployed in Lansing, Michigan.

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C. Hospital Bed Definitions

Through Advisory Group advice and consensus, definitions were created and agreed upon by all participants for the reporting of different statuses of a hospital bed and the available types of beds to be reported to the HAvBED system (Appendix F). In the HAvBED system, "Vacant/Available Beds" refers to beds that are vacant and to which patients can be immediately transported. These must include supporting space, equipment, medical material, ancillary and support services and staff to operate under normal circumstances. These beds are licensed, physically available and have staff on hand to attend to the patient who occupies the bed. In the HAvBED project, the term "Current Beds Available" refers to "Vacant/Available Beds". The relationship between the different types of bed statuses is depicted in Figure 5.

A description of the types of beds to be reported to the HAvBED project includes the following:

• Adult Intensive Care Unit (ICU): beds that can support critically ill/injured patients, including ventilator support.
• Medical/Surgical: also thought of as "Ward" beds.
• Burn: thought of as Burn ICU beds, either approved by the American Burn Association or self-designated. (These beds are NOT to be included in other ICU bed counts.)
• Pediatric ICU: as for Adult ICU, but for patients 17 years and younger.
• Pediatrics: "Ward Medical/Surgical" beds for patients 17 and younger.
• Psychiatric: "ward" beds on a closed/locked psychiatric unit or ward beds where a patient will be attended by a sitter.
• Negative Pressure/Isolation: Beds provided with negative airflow, providing respiratory isolation. Note: This value may represent available beds included in the counts of other types.
• Operating Rooms: An operating room that is equipped and staffed and could be made available for patient care in a short period of time.

The Advisory Group requested, for the purposes of estimating institutional surge capability in dealing with patient disposition during a large mass casualty incident, the following bed availability estimates also be reported for each of the bed types described above:

• 24 hr Beds Available: This value represents an informed estimate as to how many vacant (staffed, unoccupied) beds for each bed type above the current number that could be made available within 24 hours. This would include created institutional surge beds as well as beds made available by discharging/transferring patients.
• 72 hr Beds Available: This value represents an informed estimate as to how many vacant (staffed, unoccupied) beds for each bed type above the current number that could be made available within 72 hours. This would include created institutional surge beds as well as beds made available by discharging/transferring patients.

Through use of these standardized definitions of bed statuses, bed types and estimates of future bed availability, there will be greater consistency amongst hospitals in reporting their bed availability information.

The Advisory Group also recommended the following hospital characteristics also be reported as data elements for the HAvBED project:

• Emergency Department Status:
  • Open—Accepting patients by ambulance.
  • Closed—Not accepting patients by ambulance.
  • N/A—Not Applicable (Hospital does not have an ED).
• Mass Decontamination Facility Availability:
  • Available— The institution has chemical/biological/radiological multiple patient decontamination capability.
  • Not Available— The institution is unable to provide chemical/biological/radiological patient decontamination.
• Ventilators:
  • Available: The number of ventilators that are present in the institution but are currently not in use and could be supported by currently available staff.

Figure 6 summarizes the data elements specified for the HAvBED demonstration system and depicts the HAvBED Web form for manual hospital data entry. The "AHA Beds" numbers are preloaded for each institution from their American Hospital Association (AHA) Annual Hospital Survey. These data can be updated, if necessary.

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D. Development of System-to-System Communication Protocol

As one of the main tenets of this project was the demonstration of the utility of amalgamating data from multiple existing systems, it was important to develop a standardized protocol for communicating with these systems. The Denver Health Working Group identified and worked with a volunteer non-profit group, the Emergency Interoperability Consortium that was facilitated by the ComCARE Alliance. These groups receive technical support from the Disaster Management eGov Initiative and have worked on the Common Alerting Protocol which is currently being implemented by the Department of Homeland Security, the National Oceanographic and Atmospheric Administrative and the US Department of Justice.

The goal of this affiliation was to attempt to define a National Incident Management System (NIMS)-compliant data exchange specification to provide standardized messages for: incident reporting; resource requesting, reporting, and dispatching; mass care reporting, and intelligence reporting. This specification is based on the EXtensible Markup Language (XML) and is called Emergency Data Exchange Language (EDXL). This specification is being submitted for stakeholder and industry review and formalization.  This communication specification (schema) allows straight-forward Web services communication between otherwise incongruent computer systems. The HAvBED data elements, as defined in EDXL, are shown in Appendix G. The full EDXL schema is contained in Appendix E. A sample of the HAvBED EDXL schema is shown in Figure 7.

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E. Database and Web Development

The high level system architecture and data flow are shown in Figure 8. The database is comprised of a SQL (Server Query Language) server. This hospital database was designed to maintain an historical record of bed availability updates and allows the addition of new institutions to support the concept of creation of alternative care sites that could also be tracked by HAvBED. All Web access is through a secure internet server.  All programming in the system was written in Microsoft .NET, ASP.NET and C#. 

A detailed description of the database and Web services programming is provided in Appendix H.

The hospital database was preloaded with the following information using data from the American Hospital Association 2003 hospital survey (latest available as of Fall 2004):

• Hospital name.
• Hospital street address.
• Hospital phone number.
• Hospital American Hospital Association (AHA) identification number.
• Hospital geographic coordinates (latitude/longitude).
• Total beds in each HAvBED bed category.

The database is primarily indexed and accessed by AHA number. For institutions without a designated AHA number (such as new hospitals, non-AHA member hospitals or alternative care sites), a pseudo-AHA number was assigned outside the range of the actual AHA numbers.

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F. Geographic Information System (GIS) Development

For improved usability, especially for information retrieval, a GIS component was developed, implemented and included in the HAvBED demonstration system. To provide this support ArcIMS 9.0 (ESRI, Inc) was installed and configured on the applications server and interfaced with the Web services software.  This configuration is described in detail in Appendix I. This functionality permitted retrieval and graphic display of information that could be viewed at a regional, State, county, city or street map level. Specific color-coding of display elements provided rapid visual information of hospital status with mouse-over links to specific hospital information.

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