Chapter 6. Alternative Care Sites
By Stephen Cantrill, M.D., Lead Author,a
Carl Bonnett, M.D.,b Dan Hanfling, M.D.,c Peter Pons, M.D.d
a Associate Director, Department of Emergency Medicine, Denver Health Medical Center
b Emergency Medical Services Fellow, Department of Emergency Medicine, Denver Health Medical Center
c Director, Emergency Management and Disaster Medicine, Inova Health System
d Professor of Emergency Medicine, Department of
Surgery, University of Colorado Health Sciences Center
This chapter discusses the issues surrounding non-Federal, non-hospital-based
alternative care sites (ACSs). It describes different types of ACSs as well as
critical issues and decisions that will need to be made regarding these sites during
mass casualty event. Potential barriers are addressed, and examples of case studies
are included. |
Alternative Care Sites (ACS) Issues and Recommendations At A Glance Major Challenges to Successful ACS Planning and Establishment
- Lack of regional and State planning with clear delineation of responsibilities
and authority
- The requirement that multiple groups work together who traditionally
have not done so, including health care providers with conflicting
institutional allegiances, hospitals, emergency managers, regional
planners, and local and State health departments
- Lack of financial inducements to create, drill, and execute the
plan
- Issues regarding professional licensing; verification; and supervision,
both intra-and interstate
- Funding and compensation issues
Recommendations for ACS Planners
- Ensure that all communities have an integrated mass casualty event
(MCE) plan in place to provide for expansion of health care services
into ACSs when existing health care providers and institutions become
overwhelmed.
- Constitute a planning and implementation committee comprised of,
at a minimum, emergency managers, planners, public health departments,
health care providers and institutions, local and regional government
representatives, and appropriate private partners.
- Ensure that a concept of operations (CONOPS) document is prepared
to define in advance the anticipated role that the ACS facility will
serve.
- Identify and assess potential sites for implementation of an ACS
prior to an incident. Whenever possible, put in place agreements to
permit such use.
- Obtain, stockpile, and store supplies, equipment, and pharmaceuticals
sufficient to meet the anticipated role for the ACS as defined in
the CONOPS in a fashion that will permit rapid deployment to a selected
site.
- Prepare a plan for personnel staffing sufficient to meet the anticipated
role for the ACS as defined in the CONOPS.
- Anticipate and plan for operational and logistic support of the
ACS.
- Plan for the needs of pediatric patients.
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Background
The impact of an MCE of any significant magnitude likely will overwhelm—and indeed may render inoperable—hospitals and other traditional
venues for health care services. This situation will necessitate the establishment
of ACSs for the provision of care that normally would be provided in an inpatient
facility, including acute, subacute, and chronic care.
The concept of providing medical care in a nonhospital ACS has been demonstrated
throughout history: during the Civil War, the aftermath of the San Francisco
earthquake of 1906, the influenza pandemic of 1918-1919, and more recently
the aftermath of Hurricane Katrina. During the Cold War in the 1950s and 1960s,
this concept was developed and formalized by the U.S. Civil Defense Agency in
cooperation with the Department of Health, Education and Welfare as "Packaged
Disaster Hospitals" (PDHs). These PDHs consisted of modularized, predeployed
units for 50, 100, or 200 beds. In 1972, Congress discontinued its support
funding for the PDH concept. The 2,500 deployed units were declared to be
surplus and were discarded over the next decade. More than three decades later,
however, we find ourselves in the interesting position of rediscovering, resurrecting,
and refining the concept of ACSs.
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ACSs in the Context of an MCE
The focus on catastrophic bioterrorism over the past decade has resulted in some
key efforts in the development of the concept of ACSs. The most widely recognized
effort has been the development of the Acute Care Center (ACC) and Neighborhood
Emergency Health Center (NEHC) concepts by the U.S. Army Soldier and Biological
Chemical Command (SBCCOM).
NEHC and ACC Concepts Under the auspices of the Department of Defense and the Domestic
Preparedness Program, the Biological Weapons Improved Response Program
developed the Modular Emergency Medical System (MEMS) to provide systematic,
coordinated, and effective medical response in the event of a large-scale
biological terrorism incident. MEMS strategy established a framework
for which outside medical resources could be used to enhance local response
efforts in two types of expandable patient care modules: the NEHC and
the ACC. The NEHC is designed to function as a high-volume casualty
reception center, performing victim triage and dispensing medicines
and information. The ACC is designed and equipped to treat patients
who need inpatient treatment but do not require mechanical ventilation
and those who are likely to die from an illness resulting from an agent
of bioterrorism.
Sources: Acute Care Centers: A Mass Casualty Care Strategy
for Biological Terrorism Incidents (December 2001), and Neighborhood
Emergency Help Centers: A Mass Casualty Care Strategy for Biological
Terrorism Incidents (May 2001). Both documents prepared in response
to the Nunn-Lugar Domestic Preparedness Program by the Department of
Defense. Go to: http://www.nnemmrs.org/resources/surge_capacity_guidance/index.html.  |
The innovative body of work surrounding the development of the ACC and NEHC
concepts has addressed several key issues related to the delivery of care
outside of established hospitals, including:
- The level and scope of care to be delivered
- The physical plant required for the establishment of such facilities
- Staffing requirements for delivery of such care
- Medical equipment and supplies requirements
- The incident management system required to integrate such facilities with
the overall delivery of health care in the context of a disaster.
In the aftermath of the September 11, 2001, attacks, more concerted focus was
placed on the definition and development of public health and medical surge capacity.
A distinction was drawn between health care facility surge capacity and
community surge capacity, with the understanding that community surge capacity
strategies were focused on the creation of out-of-hospital solutions to the delivery of
health care, closely mirroring the ACC concept.
This understanding led to the emergence of a new definition of ACS, one that
included a location for the delivery of medical care that occurs outside the
acute hospital setting for patients who, under normal circumstances, would
be treated as inpatients. In addition, the ACS has come to be viewed as a
site to provide event-specific management of unique considerations that might
arise in the context of catastrophic MCEs, including the delivery of chronic
care; the distribution of vaccines or medical countermeasures; or the quarantine,
cohorting, or sequestration of potentially infected patients in the context
of an easily transmissible infectious disease.
Surge Capacity
Further conceptual development of surge capacity was conducted by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) and focused on the establishment
of "surge hospitals." The JCAHO identified three types of surge
hospitals:
- Facilities of opportunity, which are defined as
nonmedical buildings which, because of their size or proximity to a medical center,
can be adapted into surge hospitals
- Mobile medical facilities, which are mobile
surge hospitals based on tractor-trailer platforms with surgical and intensive
care capabilities
- Portable facilities, which are mobile medical
facilities that can be set up quickly and are fully equipped, self-contained,
turnkey systems usually stored in a container system and based on military
medical contingency planning.
All three types of contingencies were used and deployed in the aftermath of
Hurricane Katrina.
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Challenges to Successful ACS Planning and Implementation
While recent experiences with Hurricanes Katrina and Rita clearly demonstrate
the need for ACSs to provide medical care at the time of an MCE, there are
multiple impediments to successful ACS planning and establishment. The most
significant challenges include:
- Lack of regional and State planning with clear delineation of responsibilities
and authority
- The requirement that multiple groups work together who traditionally
have not done so, including health care providers with conflicting institutional
allegiances, hospitals, emergency managers, regional planners, and local
and State health departments
- Lack of inducements to create, drill, and execute
the plan
- Issues regarding health professional licensing; verification; and
supervision, both intra- and interstate
- Funding issues.
Key Issues in ACS Planning
To respond effectively to an MCE, advance planning is critical. Community
planners (from municipal agencies, including public safety, public health,
and emergency management as well as representatives from local health care
organizations or institutions) must conceive of a plan for how the ACSs would
deliver wide-ranging medical services to the population in need. This planning
must be done with existing health care facilities (hospitals, outpatient clinics,
and multispecialty group offices) and home care entities. Planners must delineate
the specific medical functions and treatment objectives that the ACS facility
would need to accomplish.
This approach assumes that an organized mechanism exists for triage of patients
into high-acuity, moderate-acuity, low-acuity, and expectant/expired categories,
so that patient needs are matched with available medical resources. The division
of patients also must identify those patients for whom no manner of medical
intervention is likely to result in a positive outcome and are therefore candidates
for palliative care. Such planning also assumes that the most severely ill
or injured high-acuity patients can receive medical care commensurate only
with what would be expected within the setting of a hospital facility or an
ACS that is outfitted to serve as an acute care hospital, which is unlikely.
The biggest challenge, however, is the fact that most communities will not
be able to procure the amount and complexity of resources or the level of
staffing required to extend hospital facilities into designated ACSs. For
this reason, most ACSs will be located in "buildings of convenience." It is imperative
for planners to establish clear operational definitions of what can and cannot
be accomplished in the setting of an ACS.
Getting Started with an ACS What To Do?
The most important step in attempting to overcome the challenges to successful
ACS planning and implementation is to begin the planning process. How To Do It?
A single individual or group must recognize that planning for ACS is
a mandatory part of all hazards preparedness and identify or establish
an administrative structure to begin the planning process. Who Should Be Involved?
Participants in this process should include emergency managers, community
planners, public health (local and State), public safety, emergency medical
services (EMS), area health care facilities, and health care providers. |
The development of ACS plans will not be accomplished in a vacuum. Key planning
issues to consider include the following:
- Local health care and emergency management systems all should be involved
not only in the ACS planning process but in the commitment of financial
support as well.
- Any regional health care alliance that is formed to plan for response
to disasters must integrate ACSs into their operating plans. As such, these
facilities must fit within the broader spectrum of medical and health care
incident management. Community planners must identify the logistical support
necessary for establishing such ACSs.
- Community planners should identify
and create protocol-driven patient management objectives, based on assumptions
about the types of patients that would be treated in such ACS facilities.
Different Uses of an ACS ACS facilities ultimately may be developed to serve different
purposes depending on the circumstances requiring their use. An
ACS might be designed to serve as one of the following:
- A primary triage point, helping decide which
patients require hospitalization, can be managed at home, might
benefit from observational care and minimal interventions available
at the ACS, or require palliative care which also might be available
at an ACS. Such a facility might be reasonably expected to cohort
a group of patients who were exposed to certain infectious agents
but do not need more than continued observation and minimal, if
any, medical intervention.
- A community-focused ambulatory care clinic that
serves as a point of distribution for medications, vaccinations,
or other medical interventions that must be delivered to a wide
population.
- A low-acuity patient care site to permit the offloading
of stable patients from hospitals to enhance their internal patient
care capability or as primary sites for the care of stable low-acuity
patients.
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Key Issues in ACS Establishment and Operation
The successful establishment and operation of an ACS is, by its very nature,
a complex undertaking, with a variety of issues to be addressed. As is the
case with all aspects of preparedness, these issues are best vetted and investigated
well before an event that necessitates their implementation. Several of the
points discussed below also will apply to the situation where a locale is not
setting up its own ACS but rather is operating in a supportive role of
a Federal Medical Station (FMS) ACS.
FMSs are designed to provide surge medical capacity (equipment, material,
pharmaceuticals) to communities overwhelmed by mass casualties. They can provide rapidly
deployable health and medical care to those patients who have nonacute medical,
mental health, or other health-related needs that cannot be accommodated or provided
for in a general shelter population. They also provide health and medical care
for patients with needs such as:
- Conditions that require observation, assessment, or maintenance.
- Chronic conditions which require assistance with the activities of daily
living but do not require hospitalization.
- Medications and vital sign monitoring,
particularly for patients who are unable to do so at home.
"Ownership," Command, and Control of the ACS
The single most important issue for the successful establishment of an
ACS is the determination of ownership, command, and control of the ACS.
These issues should be decided at a local or regional (as opposed to institutional)
level and must involve the identification of the individual(s) with the
authority to decide whether, when, and where an ACS should be opened and
the authority to operate the site.
The most effective way to make such decisions is to use and build on the
organizational and governance structure that is already functioning in the
region or State. The administrative structure for operation of an ACS should
follow the basic concepts of the hospital incident command system discussed
earlier in this guide and reviewed below.
The Hospital Emergency Incident Command System (HEICS) was developed in the
early 1990s to provide an emergency management system for hospitals for use
during a medical disaster, but the concept has been adapted to other areas
of emergency response as well and certainly lends itself to providing structure
and organization to the operation of an ACS. Indeed, many ACSs that were set
up during Hurricanes Katrina and Rita used the basic concepts of HEICS, which
were then altered to fit the unique aspects of the ACS. HEICS, now known as
HICS, provides an emergency management system that provides a logical, flexible
management structure with a clear chain of command and is compliant with the
National Incident Management System.
Hospital Incident Command System* Management Structure The Incident Command Section provides overall coordination
of the response and is the central communication point.
The Operations Section is responsible for clinical
duties including triage and treatment and directs all patient care resources.
The Logistics Section is responsible for providing
facilities; services, including food service and communications; and
materials.
The Planning Section determines and provides for the
achievement of each medical objective and manages human resources.
Finance and Administration is responsible for maintaining
accounting records, issuing purchase orders, and stressing facility
wide documentation.
*Hospital Incident Command System is the new name for
the revised Hospital Emergency Incident Command System. Planners are
encouraged to view the updates posted at http://www.emsa.ca.gov. |
Recommended Approaches to the ACS Planning Process
- Ensure that all communities (local and regional) have an integrated
MCE plan in place to provide for expansion of health care services
to ACSs when health care providers and institutions are overwhelmed.
- Convene a planning and implementation committee comprised, at a
minimum, of emergency managers, planners, public health departments,
health care providers and institutions, local and regional government
representatives, and appropriate private partners.
- Ensure that a concept of operations (CONOPS) document is prepared
to define in advance the anticipated role that the ACS facility will
serve.
- Identify and assess potential sites for implementation of an ACS
prior to an incident. Whenever possible, put in place agreements to
permit such use.
- Obtain, stockpile, and store supplies and equipment sufficient to
meet the anticipated role for the ACS as defined in the CONOPS in
a fashion that will permit rapid deployment to a selected site.
- Prepare a plan for obtaining or stockpiling pharmaceuticals sufficient
to meet the anticipated role for the ACS as defined in the CONOPS.
- Prepare a plan for personnel staffing sufficient to meet the anticipated
role for the ACS as defined in the CONOPS.
- Anticipate and plan for operational and logistic support of the
ACS, including, at a minimum: communications, internal and external
with redundancy, security, transport of patients to and from the ACS,
mechanisms for documentation of services, food services, resupply,
staff rotation and rest, laundry services, and storage capacity.
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Any ACS should be operationally integrated into a community-wide, unified
command. It also should be integrated into the local Health Alert Network,
which will allow for consistent approaches of care to the various medical
problems that will be encountered (e.g., pandemic influenza, acute radiation
syndrome).
Health Alert Network (HAN)
The HAN is a nationwide program that establishes the communications,
information, distance learning, and organizational infrastructure
for a new level of defense against health threats. The HAN will link
local health departments to one another and to other organizations
critical for preparedness and response. The Centers for Disease Control
and Prevention (CDC) is leading HAN development, working in partnership
with other health organizations. Currently, HAN is providing health
information and the infrastructure to support the dissemination of
that information at the State and local levels. Go to: http://www2a.cdc.gov/han/Index.asp. |
Decision To Establish and Open an ACS
This usually will be collaboration among local emergency managers, regional
planners, health care workers responsible for operating the facility, county
and State health officials, and any institutions that will participate in
the staffing or logistical support of the ACS.
Scope of Care To Be Delivered and Patient Population To Be Served
Although
the target patient population and scope of care to be delivered at an ACS
may be event specific, some general guidelines are outlined in Table 6.1.
Depending on the specific situation, the ACS may be used to:
- Provide delivery of ambulatory or chronic care
- Offload less ill patients from nearby hospitals, thereby increasing the
hospitals'; surge
capacity
- Provide primary victim care at a standard appropriate for the austere
situation
- Provide quarantine, sequestration, or cohorting of "exposed" patients
- Provide palliative care.
One of the key decision points in the delivery of out-of-hospital care at
an ACS is the ability to provide oxygen and respiratory therapy, particularly
the ability to provide mechanical ventilation. The logistics and expense of
sustaining oxygen delivery systems in an ACS setting, however, is extremely
complex and prohibitively expensive. The exception to this may be the use
of nursing homes and long-term care facilities in the role of alternative
care facilities, given their existing medical gas supply.
Tentative sites are best identified in advance, and the mechanism of approval
for use as an ACS should be investigated. As a rule, permission to use municipal
buildings will be easier to obtain, and it will be easier to get MOUs to use
existing staff members. Possible structures of opportunity are outlined in
Table 6.2. Each will have advantages and disadvantages, depending on the type
of MCE.
Although site selection is usually a local function, State partners should
be asked early in the planning process whether potential shelters or ACSs
have been designated at a State or regional level. If the ACS must supply
ambulatory patient care, it may help to locate it near a victim shelter to
support victims with chronic medical needs in that shelter. A list of requirements
for an ACS has been converted to a matrix tool to assist with ACS site selection
(in the table at the end of this chapter).
ACS Selection Tool
The selection of a potential building to use as an ACS is an imprecise
science and may vary based on the nature of the event. Using a consensus
process, a group of hospital engineers, facility personnel, and health
care providers developed and refined a list of infrastructure requirements
for ACSs based on some initial work by the Department of Defense. These
characteristics were then converted into a matrix tool to assist in
site selection with each characteristic being assigned a relative weight
from 0 to 5 (see the table at the end of this chapter). The values for
each structure under consideration then can be added up giving a relative
rank order of the suitability of each building. This tool is most appropriately
used in advance of any event, so a list of potential buildings for use
as ACSs can be developed and maintained. The tool is available at http://www.ahrq.gov/research/altsites.htm. |
Supplies and Equipment
Another issue that requires advance planning is the availability of supplies
for the adequate operation of an ACS. Routine supply chains will be stressed
or not operational during an MCE of any magnitude or duration. Although the
degree of need for certain supplies may be event specific (e.g., increased
need for masks during a pandemic), the need for many basic supplies can be
accurately forecasted. This is especially true for basic durable medical equipment
(cots, IV poles, wheelchairs, etc.). These supplies may be stored as portable
caches, which then may be transported to the ACS for use.
Caches can vary from a bare minimum cache ("Level I") for institutional
augmentation to the very complete cache ("Level III") as defined
for the ACC by the Soldier and Biological Chemical Command (SBCCOM). Certain
supplies have a limited shelf life and therefore will require product rotation
or replacement. As noted above, the ability to supply supplemental oxygen to
patients in the ACS is problematic, with no simple solution. Some potential partial
solutions to this problem are offered below.
The Challenge of Supplemental Oxygen The use of an ACS for patients who require supplemental
oxygen is highly problematic from a logistical point of view. Options
to supply supplemental oxygen run from a home fill unit (10L/min maximum,
less than $1,000) to deployable oxygen generation or liquid oxygen storage
and distribution system (multiple patients, high technology, upwards
of $480,000). Given the variables of cost, general availability, ease
of use and sustainability, the most promising options for supplying supplemental
oxygen would be either a bank of 10L/min home fill units or a rack of
eight interconnected
"H" oxygen cylinders, each supplying 7,000 liters of oxygen
for a cost of approximately $13,000. Even this rack setup is severely limited,
however, as the eight "H" cylinders could supply only 50 patients
at 2 liters of oxygen per minute for 8 hours. This would necessitate three
refills per 24-hour period and would require the rapid installation of
a rudimentary gas distribution system. Support for ventilated patients
would increase the rate of oxygen consumption significantly, further complicating
this issue, and most likely would not be possible.
Sources:
Agency for Healthcare Research and Quality
(AHRQ). Rocky Mountain Regional Care Model for Bioterrorist Events:
Locate Alternate Care Sites During an Emergency. Available at:
http://www.ahrq.gov/research/altsites.htm. Accessed July 21, 2006.
Anthony Rizzo, USAF, MC, SFS, Chief, Operations Division NORAD-USNORTHCOM/SG. Deployable
Oxygen Solutions for FEMA briefing. Available at:
http://www.ahrq.gov/research/altsites/alttool3.htm.
(Appendix A). Accessed July 21, 2006. |
Caches of supplies should be stored in a modular fashion in units supporting
50-100 patients, allowing an ACS to be set up in stages.
Experience with the FMS for victims of Hurricane Katrina demonstrated the
need for wheelchairs, walkers, and canes in an ACS. Local or regional resources
are not likely to be sufficient to deal with this requirement. Questions also
were raised about the appropriateness of using cots in an ACS, which require
staff members to bend over constantly and are inadequate for dealing with obese
patients. This problem may be solved by purchasing oversized cots.
Expensive diagnostic and monitoring equipment (e.g., portable x-ray machines,
ultrasounds, cardiac monitors), in most cases, will be beyond the scope of
an ACS. Advances in point-of-care clinical laboratory testing, however, may
allow some basic laboratory tests to be performed at an ACS.
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