Planning for Surge Capacity in Health Care Services Betsey Lyman Deputy Director, Public Health Emergency Preparedness California Department of Public.

Planning for Surge Planning for Surge Capacity in Health Care Capacity in Health Care

ServicesServices

Betsey LymanBetsey LymanDeputy Director, Public Health Deputy Director, Public Health

Emergency PreparednessEmergency PreparednessCalifornia Department of Public HealthCalifornia Department of Public Health

California Faces Disasters on a California Faces Disasters on a Regular BasisRegular Basis

Examples of disasters since 2006:Examples of disasters since 2006: 2006 Extreme Heat2006 Extreme Heat 2007 Lake Tahoe Wildfire2007 Lake Tahoe Wildfire 2007 Southern California Wildfires2007 Southern California Wildfires 2008 Northern California Wildfires2008 Northern California Wildfires 2008 Chino Hills Earthquake2008 Chino Hills Earthquake 2008 Los Angeles Metro Link Crash2008 Los Angeles Metro Link Crash 2008 Southern California Wildfires2008 Southern California Wildfires 2008 Severe Cold2008 Severe Cold

The ChallengeThe Challenge

Meeting the public health and medical Meeting the public health and medical needs of Californians during and following needs of Californians during and following disastersdisasters

Addressing statewide needs during a Addressing statewide needs during a catastrophic event when mutual aid is catastrophic event when mutual aid is limited limited

…………an excess in demand over capacity in an excess in demand over capacity in

hospitals, long-term care facilities, community hospitals, long-term care facilities, community

care clinics, public health departments, other care clinics, public health departments, other

primary and secondary care providers, primary and secondary care providers,

resources and/or emergency medical resources and/or emergency medical

servicesservices

What is a Healthcare Surge?What is a Healthcare Surge?

The frequent emergency department overcrowding experienced by The frequent emergency department overcrowding experienced by healthcare facilities (for example, Friday/Saturday night emergencies).healthcare facilities (for example, Friday/Saturday night emergencies).

A local casualty emergency that might overcrowd nearby facilities but A local casualty emergency that might overcrowd nearby facilities but have little to no impact on the overall healthcare delivery system.have little to no impact on the overall healthcare delivery system.

What is NOT a Healthcare What is NOT a Healthcare Surge?Surge?

Surge Capacity BasicsSurge Capacity Basics

BedsBeds:: Acute care and critical care beds Acute care and critical care beds

StaffingStaffing:: Licensed healthcare professionals and Licensed healthcare professionals and support staff support staff

Medical supplies and equipmentMedical supplies and equipment:: pharmaceuticals, personal protective equipment, pharmaceuticals, personal protective equipment, portable and fixed decontamination systems, portable and fixed decontamination systems, isolation beds, ventilators, masks isolation beds, ventilators, masks

Measuring the Gap: Measuring the Gap: 2006 California 2006 California Healthcare Surge Capacity SurveyHealthcare Surge Capacity Survey

Standardized definitions for crisis care:Standardized definitions for crisis care:• Nurse-to-patient staffing ratio of 1:5 for Critical Nurse-to-patient staffing ratio of 1:5 for Critical

Care Beds and 1:20 for Other Medical-Surgical Care Beds and 1:20 for Other Medical-Surgical BedsBeds

•     Assume self-sustainment within the facility for a Assume self-sustainment within the facility for a minimum of 72 hours without re-supply of minimum of 72 hours without re-supply of equipment, supplies or staffequipment, supplies or staff

• Assume 30% of staff will not report to workAssume 30% of staff will not report to work

Measuring the Gap (cont)Measuring the Gap (cont) ResponseResponse::

324 hospital: 80 percent of California’s 73,000 324 hospital: 80 percent of California’s 73,000 operating licensed acute care hospital bedsoperating licensed acute care hospital beds

California’s local health departmentsCalifornia’s local health departments 172 community clinics172 community clinics

Identified Identified 19,96319,963 beds California hospitals said beds California hospitals said they can surgethey can surge Bed shortages:Bed shortages:

• Los Angeles areaLos Angeles area• Pediatric bedsPediatric beds

Greater Gaps in Meeting Needs of Greater Gaps in Meeting Needs of a Catastrophic Eventa Catastrophic Event

Using CDC’s FluSurge 2.0 computer Using CDC’s FluSurge 2.0 computer modeling program for pandemic influenza:modeling program for pandemic influenza:

California needs California needs 58,72358,723 surge beds for a surge beds for a moderatemoderate pandemic influenza pandemic influenza

38,76038,760 beds or 194% above the beds or 194% above the 19,96319,963 surge surge beds California hospitals said they can surge.beds California hospitals said they can surge.

Analysis of 2006 Survey ResultsAnalysis of 2006 Survey Results

California has California has sufficientsufficient surge capacity for surge capacity for a Moderate event: regional earthquake, a Moderate event: regional earthquake, fire, flood, or bioterrorist attack. fire, flood, or bioterrorist attack.

California’s surge capacity is California’s surge capacity is insufficient insufficient for a Catastrophic event: statewide impact, for a Catastrophic event: statewide impact, e.g., Katrina-like event or pandemic e.g., Katrina-like event or pandemic influenza. influenza.

2006 Healthcare Surge Initiative 2006 Healthcare Surge Initiative The State of California spent $172 million to The State of California spent $172 million to

improve its medical surge capacityimprove its medical surge capacity

ItemItem NeedNeed BoughtBought CostCost

MasksMasks (N95 Respirators) (N95 Respirators) 100 million100 million 50.9 million50.9 million $19.9 million$19.9 million

Ventilators Ventilators 24,00024,000 2,4002,400 $30.6 million$30.6 million

Antiviral medicinesAntiviral medicines -- enough to -- enough to treat 25 percent of California's treat 25 percent of California's populationpopulation 8 million courses8 million courses

3.7 million courses3.7 million courses90% Tamiflu,90% Tamiflu,10% Relenza10% Relenza $54.6 million$54.6 million

Mobile Field HospitalsMobile Field Hospitals 3 - 200 bed3 - 200 bed $18.3 million$18.3 million

21,000 extra 21,000 extra bedsbeds with supplieswith supplies for for alternate care sitesalternate care sites 42,00042,000 21,00021,000 $33.4 million$33.4 million

Developing Developing new hospital guidelines new hospital guidelines and standardsand standards $5 million$5 million

Alternate Care Site Supplies and Alternate Care Site Supplies and EquipmentEquipment

State Alternate Care Site Caches contain over State Alternate Care Site Caches contain over 300 items, ranging from patient cots and linens, 300 items, ranging from patient cots and linens, routine nursing supplies, suture equipment, routine nursing supplies, suture equipment, airway breathing supplies, etc. airway breathing supplies, etc.

Supplies and equipment are packed in caches to Supplies and equipment are packed in caches to support 50 patientssupport 50 patients

Each cache is stored on 20 palletsEach cache is stored on 20 pallets

Standards and Standards and Guidelines for Guidelines for

Healthcare Healthcare Surge during Surge during EmergenciesEmergencies

Standards of care for healthcare facilities and Standards of care for healthcare facilities and licensed healthcare professionals during an licensed healthcare professionals during an emergency emergency

Liability of healthcare facilities and licensed Liability of healthcare facilities and licensed healthcare professionalshealthcare professionals

Reimbursement of care provided during an Reimbursement of care provided during an emergencyemergency

How to operate Alternate Care SitesHow to operate Alternate Care Sites Surge capacity operating plans at individual Surge capacity operating plans at individual

hospitalshospitals

Focus of the ProjectFocus of the Project

Project ApproachProject Approach

Developing and managing a Developing and managing a processprocess that that includes government agencies, providers, includes government agencies, providers, stakeholders, and other relevant parties as stakeholders, and other relevant parties as participants in this project.participants in this project.

Developing Developing written standards and guidelineswritten standards and guidelines for delivery of medical care services in a for delivery of medical care services in a surge environment.surge environment.

2008 Deliverables2008 Deliverables

Foundational Knowledge document Foundational Knowledge document provides platform for all volumes provides platform for all volumes

Manuals focused on target audience:Manuals focused on target audience: HospitalsHospitals Alternate care sitesAlternate care sites PayersPayers

Reference Manual including legal analysisReference Manual including legal analysis

Volumes under DevelopmentVolumes under Development

Licensed healthcare professionals, Licensed healthcare professionals, including Crisis Careincluding Crisis Care

Long term care facilitiesLong term care facilities

ClinicsClinics

When is a Healthcare Surge Declared?When is a Healthcare Surge Declared?

LocalLocal Surge EmergencySurge Emergency

Regional Regional Level Level SurgeSurge

Statewide Statewide Surge Surge LevelLevel

Surge Surge Level Level GreenGreen YellowYellow OrangeOrange Red Red BlackBlack

Enabling Enabling AuthoritiesAuthorities

Regulatory/ Regulatory/ Accrediting Accrediting Agency Agency WaiverWaiver

Regulatory/ Regulatory/ Accrediting Accrediting Agency Agency WaiverWaiver

Regulatory/ Regulatory/ Accrediting Accrediting Agency Agency Waiver/ Waiver/ Local Local Emergency Emergency DeclarationDeclaration

Local Local Emergency Emergency DeclarationDeclaration

Local Local Emergency Emergency DeclarationDeclaration

State of State of Emergency Emergency DeclarationDeclaration

Federal Federal Emergency Emergency DeclarationDeclaration

Surge Monitoring Guidelines Table

Green: Usual day to day status. No assistance requiredYellow: Surge managed locally. No assistance requiredOrange: Additional healthcare assets required within jurisdiction Red: Assistance needed outside local jurisdiction or area. Black: Significant assistance needed outside local jurisdiction.

HOSPITAL PREPAREDNESSHOSPITAL PREPAREDNESS

Hospital Connection to Incident Hospital Connection to Incident Command SystemCommand System

Ensuring hospitals have internal Incident Ensuring hospitals have internal Incident Command SystemsCommand Systems

Community planning: connecting hospitals Community planning: connecting hospitals to local Emergency Response Structureto local Emergency Response Structure

Expanding hospital capacity to meet surge Expanding hospital capacity to meet surge needsneeds

ReimbursementReimbursementMaintaining existing revenue streams is Maintaining existing revenue streams is critical to hospitals during a healthcare critical to hospitals during a healthcare surge. Key concepts surrounding surge. Key concepts surrounding reimbursement during surge include:reimbursement during surge include:

Advanced planning and collaboration with Advanced planning and collaboration with commercial health plan partnerscommercial health plan partners

Acquiring detailed knowledge of the resources Acquiring detailed knowledge of the resources available to hospitals during surge conditions available to hospitals during surge conditions

Methods to access additional resources from Methods to access additional resources from federal and State funded programsfederal and State funded programs

Establishment of a Establishment of a Government-Authorized Government-Authorized

Alternate Care SiteAlternate Care Site

A location that is not currently providing healthcare A location that is not currently providing healthcare services services

Will be converted to enable the provision of healthcare Will be converted to enable the provision of healthcare services to support, at a minimum, inpatient and/or services to support, at a minimum, inpatient and/or outpatient care required after a declared catastrophic outpatient care required after a declared catastrophic emergencyemergency

Will help absorb the patient load after all other healthcare Will help absorb the patient load after all other healthcare resources are exhaustedresources are exhausted

What is a Government-Authorized What is a Government-Authorized Alternate Care Site?Alternate Care Site?

Types of Government-Authorized Alternate Care SitesTypes of Government-Authorized Alternate Care Sites

Mobile Field Hospitals Mobile Field Hospitals ArenasArenas

SchoolsSchools ChurchesChurches

Shuttered HospitalsShuttered Hospitals StadiumsStadiums

A government-authorized Alternate Care SiteA government-authorized Alternate Care Site is NOT is NOT part of the expansion of an existing healthcare facility, such part of the expansion of an existing healthcare facility, such asas

extensions of general acute care hospitalsextensions of general acute care hospitals clinics, or clinics, or long-term care facilitieslong-term care facilities

What is NOT a Government-What is NOT a Government-Authorized Alternate Care Site?Authorized Alternate Care Site?

Government-Authorized Alternate Care Sites DO NOT include:Government-Authorized Alternate Care Sites DO NOT include:

Tents set up for patient care in the parking lot of a hospital and Tents set up for patient care in the parking lot of a hospital and under their controlunder their control

Sites set up for patient triage by Emergency Medical ServicesSites set up for patient triage by Emergency Medical Services

Any temporary space set up for patient care under the authority Any temporary space set up for patient care under the authority of an existing healthcare facilityof an existing healthcare facility

2009: Current Challenges in Surge 2009: Current Challenges in Surge Capacity Capacity

Gap in needed surge capacity remains Gap in needed surge capacity remains significantsignificant 2006 Healthcare Surge Initiative 2006 Healthcare Surge Initiative

addressed approximately half of the gap addressed approximately half of the gap in needed bedsin needed beds

California hospitals are struggling for California hospitals are struggling for financial survival. Loss of hospitals would financial survival. Loss of hospitals would increase the gap increase the gap

Current Challenges in Surge Current Challenges in Surge Capacity (cont)Capacity (cont)

Unfunded: Unfunded: Maintaining surge supplies in operating orderMaintaining surge supplies in operating order Refreshing expiring supplies (e.g. Refreshing expiring supplies (e.g.

pharmaceuticals)pharmaceuticals) Updating medical equipment Updating medical equipment Training staff to manage, deploy and operate Training staff to manage, deploy and operate

surge bedssurge beds

Current Challenges in Surge Current Challenges in Surge Capacity (cont)Capacity (cont)

California’s economic situation is resulting California’s economic situation is resulting in:in: Decreased expenditures for public health, Decreased expenditures for public health,

with negative impact on the infrastructure to with negative impact on the infrastructure to respond to public health emergenciesrespond to public health emergencies

Layoffs of trained Local Health Department Layoffs of trained Local Health Department staff trained in public health emergency staff trained in public health emergency preparednesspreparedness

Current Challenges (cont)Current Challenges (cont)

Federal funds are the financial Federal funds are the financial support for public health emergency support for public health emergency response capacityresponse capacity

From 9-11 to current year, California’s From 9-11 to current year, California’s federal grants for public health federal grants for public health emergency preparedness decreased emergency preparedness decreased 25 percent25 percent..

Accessing the Standards and Accessing the Standards and Guidelines for Healthcare Surge Guidelines for Healthcare Surge During Emergencies: During Emergencies:

http://bepreparedcalifornia.ca.gov/EPO/CDPHPrograms/PublicHealthPrograms/

EmergencyPreparednessOffice/EmergencyPreparednessOffice/EPOProgramsServices/Surge/EPOProgramsServices/Surge/