Evidence-Based Approach to Hospital Preparedness

1
Evidence-Based Approach to Hospital Preparedness

• Robert Powers RN, BSN, EMT-P
• Emergency Preparedness Coordinator
• WakeMed Health and Hospitals
• Raleigh, NC

2
Objectives

• Describe the impact disasters can create in a
  community and on a healthcare system
• Discuss research findings from recent disasters
• Identify overall lessons learned from past
  disaster events and their specific application to
  hospital planning

3
Evidence-Based Medicine

• The Center for Evidence-Based Medicine explains
  that EBM is the conscientious, explicit, and
  judicious use of current best evidence in making
  decisions about the care of individual patients.
• It relies on research findings to support
  treatment methods
• 
  
  www.cebm.net/glossary.asp

4
Disaster Research

• Application of available disaster research to
  clinical treatment
• Strongest EBM method is the randomized,
  double-blind, placebo-controlled trial
• Look to guidance from clinical reports of
  disaster events and apply it to our disaster
  planning

5
Applied EBM

• Rather than purely using opinions, we want the
  research incorporated into expert opinions
• Either validating or revealing possible errors in
  those opinions

6
Application Difficulties

• No standard terminology
• No standard method of collection
• Records lost or incomplete
• Gaps in research
• Retrospective in nature

7
Disaster Planning Issues

• Contamination/Exposure issues
• Chemical
• Emerging Infectious Diseases
• Surge
• Immediate impact
• Gradual impact
• Communication
• Evacuation

8
Contamination-Tokyo Subway

• 0755- Attack occurs
• 0816- Notification of a gas explosion
• 0828- First patients arrives at St.Lukes
• 0900-TMFD identifies chemical as acetonitrile
• 0940- University MD calls advises to suspect
  sarin
• 0940- Found low cholinesterase levels
• Started using 2-PAM
• 1100- Police analysis identifies chemical as
  sarin. Hospital learns this from TV news.
• 
  Okumura AEM 1998

9
Contamination-Tokyo Subway

• St Lukes Hospital
• In chapel, 45.8 workers there developed
  signs/symptoms of exposure (38/83)
• In ICU, 38.7 workers (12/31)
• 23 of 472 reporting staff members developed
  signs/symptoms of exposure
• 1 nurse admitted (with nausea/headache)
• 135 EMS workers out of 1364 developed acute
  symptoms (9.9)
• 
  Okumura AEM 1998

10
Contamination-Tokyo Subway

• Keio University Hospital
• 40 minutes in resuscitation room
• 11 of 15 MDs symptomatic
• Dim vision, rhinorrhea
• 
  
• 
  Nozaki ICM 1995

11
Contamination-SARS

• Toronto-
• During first wave, 73 of those contracting SARS
  were healthcare workers (51)
• During second wave, 29 were healthcare workers
  (39)
• Taiwan-
• 33 cases were healthcare workers
• 
  MMWR Taiwan 2003
• 
  www.sars.ca

12
Contamination-U.S.

• ATSDR Hazardous Substances Emergency Events
  Surveillance (HSEES)
• Study of US events from 16 reporting states
• When hospital decon was needed
• 10 events with 52 patients total in rural
  settings
• 82 events with 889 patients total in urban
  settings
• 
  Berkowitz PDM 2004

13
Contamination-U.S.

• Urban events
• 377 patients from public
• 170 patients were first responders
• 342 patients were healthcare workers
• 
  Berkowitz PDM 2004

14
Contamination-U.S.

• Rural events
• 11 patients from public
• 29 patients were first responders
• 12 patients were healthcare workers
• Berkowitz PDM 2004

15
Contamination-U.S.

• HCWs
• 23 rural
• 38 urban
• First responders
• 56 rural
• 19 urban
• 
  Berkowitz PDM 2004

16
Contamination-HCWs
17
Contamination-Hospital Planning

• Whether the event is small or large, the hospital
  stands to have a quarter of its ED staff exposed.
• Not only is the hospital now operating with
  decreased staffing numbers, but the staff have
  become patients and increased the patient load

18
Contamination-Hospital Planning

• Staff education on procedures for dealing with
  potentially contaminated patients
• Proper removal of patient to decon area
• Proper PPE education for staff
• Proper assessment of patient in need of isolation
  or decontamination

19
Contamination-Hospital Planning

• Staff must have rapid access to decontamination
  equipment
• Decontamination must be able to occur rapidly
  (Scaleable)

20
Contamination-Hospital Planning

• Staff must have rapid access to the PPE they need
• Staff must have adequate amounts of PPE
• The Japanese government budgeted for 4 PPE suits
  per hospital after the Tokyo Subway event
• Lack of N95 compliance in Toronto

21
Contamination-Hospital Planning

• Staff must be aware of on-going events worldwide
  and aware of any changes that need to take place
  at triage
• Toronto-SARS
• Medical staff were originally unaware of events
  taking place in Hong Kong and China
• Lack of health alerts concerning SARS
• Didnt know to ask pertinent questions at triage,
  e.g. travel history

22
Contamination-Hospital Planning

• Staff education on WMD signs and symptoms
• Cant wait on lab results or reports from the
  scene
• Staff should not feel any repercussions for
  jumping the gun when there are suspicions of
  contamination

23
Surge

• Immediate impact on hospitals
• Explosive and Chemical events
• Gradual impact on hospitals
• Infectious disease events

24
Surge

• Istanbul bombing
• Single hospital study TERSH hospital
• 418 patients total/16 hospitals
• 184 patients in first hour at TERSH
• 88 (48) by EMS
• 28 (15) admitted
• 18 (10) to OR
• 7 (4) critically injured
• 
  Rodoplu PDM 2004

25
Surge-Oklahoma City Bombing

• Study of 13 hospitals
• 388 total patients
• 48 were pediatric patients
• First patients arrived within 15 minutes
• Peak at 60-90 minutes
• Within 3 hours, 227 patients at hospitals
• 33 arrived by EMS
• 
  Mallonee JAMA
  1996
• 
  Hogan AEM 1999

26
Surge-Oklahoma City Bombing

• Median ED stay was 55 minutes
• 63.6 patients went to 5 major hospitals within
  1.5 miles of the explosion site
• 72 (18.6) admitted
• 158 were seen by a private MD
• 
  Mallonee JAMA 1996
• 
  Hogan
  AEM 1999

27
Surge-London Bombing

• Study of Royal London Hospital
• Approx. 700 patients total event
• 194 total patients at Royal London
• First patient 120 minutes after first blast
• 90 mins later peaked with 95 patients
• Over in 2 hours
• 27 admits
• 8 ICU admissions
• 
  Mohammed PDM 2006

28
Surge- NYC 9/11

• St Vincents Hospital
• First patient 114 minutes after first plane
• Around 300 patients in first 2 hours
• NYU Downtown Hospital
• 350 patients in first 2 hours
• 448 patients total for first day
• 24 admitted
• 12 ICU patients
• 5 to OR
• 
  Kirschenbaum CCM 2005
• 
  Cushman J Trauma 2003

29
Surge-Egyptian Border Bombing

• Yoseftal Hospital
• First patient arrived in 32 minutes
• 168 patients total
• 50 in first 2 hours peaks in 2 hours
• 2 admissions
• 1 to OR
• 23 evacuated to trauma center
• 
  
  Leiba PDM 2004

30
Surge-Tsunami

• Patong Hospital Thailand
• Around 700 patients in first 2 hours
• 59 patients over next 22 hours
• 1.4 admission rate
• 5.1 evacuated to secondary hospital
• 
  
  Leiba PDM 2006

31
Surge-Tokyo Subway

• 5500 patients went to 280 medical facilities
• 1046 admitted to 98 hospitals
• 20 admitted to ICUs
• 688 transported through EMS coordination
• 452 via ambulance
• 236 via minivans
• 25 of patients transported by taxi
• 2 of 3 cardiac arrests arrived via private
  vehicle
• 
  Okumura AEM 1998
• 
  
  Pangi BCSIA 2002

32
Surge-Tokyo subway

• St Lukes Hospital
• Closest hospital to half of the affected subway
  stations and the most heavily impacted hospital
• 0755 Attack occurs
• 0816 Notice of a gas explosion
• 0828 First patient arrives
• On foot
• Has visual complaints
• 0840 First ambulance arrives
• 0843 First cardiac arrest arrives by pov
• 
  Okumura AEM 1998

33
Surge-Tokyo Subway

• St Lukes Hospital
• 641 total patients first 24 hours
• 500 patients in the first 90 minutes
• 107 with moderate symptoms admitted
• 4 ICU admits
• 
  
  Okumura AEM 1998

34
Surge
35
Surge-Admissions
36
Surge-ICU
37
Surge Planning

• Variance in first patient arrival time
• 15-90 minutes after event
• May or may not have time to begin set-up before
  patients arrive
• May or may not have notification of an event
• Some of this time is spent determining there has
  been an event
• London bombings 17 minutes before notified of a
  suspected event and another 19 minutes before a
  major incident declared
• This time while events are sorted out decreases
  chance of early notification by public safety

38
Surge Planning

• 50 to 70 of patients arrive via other methods
  than EMS
• The critical patients are not able to self-direct
  themselves to area hospitals so tend to be the
  ones EMS transports
• Ones self-referring tend to be the ambulatory,
  walking wounded
• EMS needs to plan for measures that can rapidly
  gather and transport these walking wounded
  patients to farther hospitals

39
Surge Planning

• Supplies should be in place and ready to go for
  initial impact
• Close storage
• No vendors necessary to bring supplies
• Disaster plan should be able to be implemented
  immediately
• Existing staff is well-versed and able to
  implement disaster plan

40
Surge

• Triage should be aimed at rapidly sorting these
  patients and relocating them to MTA away from the
  ED
• Rapid triage system
• Keep it simple
• Initially surge manpower into extra triage
  stations to rapidly process incoming walking
  wounded

41
Surge Planning

• MTA area
• Rapid set-up
• Staff from areas outside ED
• Large setting

42
Surge Planning

• Temporary Surge Admission Area or Holding Area
• Hold these patients during peak period
• Prioritize resources for incoming ICU or OR
  patients during peak period

43
Surge-Treatment

• Advanced Airway Procedures
• 2 bus bombings
• 52 patients
• 42 intubated
• 2 open-air bombings
• 190 patients
• 7 intubated
• Oklahoma City
• 388 patients
• 2 intubated
• 1 surgical airway
  
  
• Hogan AEM
  1999/Halpern PDM 2003

44
Surge-Intubations
45
Surge Planning-Respiratory

• Respiratory Therapy should be incorporated into
  the plan
• ED MDs and Anesthesia have other roles
• Surge airway supplies should be rapidly available

46
Hospital Services- Radiography

• Oklahoma City bombing
• 45 of 265 patients
• Manchester
• 50 of 208 patients
• Bologna bombing
• 43 of 107 patients
• 
  
• 
  Halpern PDM 2003

47
Hospital Services

• Oklahoma City bombing
• 19 of patients had CT Scan
• Chi-Chi Earthquake- Taiwan
• 30 of 95 patients with crush syndrome needed
  hemodialysis
• 
  Hogan AEM 1999
• 
  Chan PDM
  2006

48
Hospital Services Planning

• Almost half of patients from an explosive or
  collapse event will need x-ray
• Services such as CT, dialysis and the lab will be
  impacted
• These departments need to be involved in hospital
  disaster planning

49
Hospital Services Planning

• Utilize portable x-ray machines
• Plan for a prioritization of all these services
  beforehand

50
Surge-Field Teams

• Deployment of personnel from hospital to the
  scene
• Tokyo
• NYC
• London

51
Surge-Field Teams

• Tokyo- St Lukes Hospital
• Sent 8 MDs, 3 nurses
• No emergency procedures performed
• London
• Sent MD teams to various scenes
• Arrived 30-40 minutes after bombing
• Only Grade-I Trauma Center in London
• Patients arriving at hospital 20 minutes after
  bombing
• 
  Okumura AEM 1998
• 
  Mohammed PDM
  2006

52
Surge-Field Teams

• NYC
• Chelseas Pier Triage Area
• Group of MDs from NYU Downtown Hospital
• No critical patients
• Bellevue had MD teams at WTC site
• No critical patients
• Minor cuts and bruises
• 
  Cushman J Trauma 2003

53
Surge-Field Teams

• Limited value
• Late arrival/Leaving nearby hospitals
• Utilize hospitals farther away if extended scenes
• Have a developed plan not ad hoc

54
Surge-Crowds

• Large number of non-patients at hospital
• Seeking shelter and food
• Seeking information about family members
• Plan must address these arrivals

55
Surge-Gradual Impact

• SARS
• Toronto
• Hong Kong
• Taiwan

56
Surge-Toronto

• Toronto- Scarborough Grace Hospital
• 3/7/03 Mr. T patient seen in ED 2 other patients
  exposed (16 hours in ED in Obs bed)
• 3/16 Mrs. M at ED 7 visitors and 1 patient
  exposed
• 3/17 Mr. M intubated in ICU 3 nurses and 1 MD
  exposed
• 3/21-4/1 Average 8-10 staff members sick a day
• 3/26 Hospital closed due to staffing shortages
• 6/5 ED re-opened
• 
  
• 
  www.sars.ca

57
Surge-Toronto

• Toronto
• 3/23 Re-commissioned TB hospital with 25
  isolation beds
• 3/26 Opened first SARS assessment center
• 
  www.sars.ca

58
Surge-Toronto

• Canadas HSC
• Study noted patient volume decreased during SARS
  outbreak
• 133 baseline patient visits per day
• Broke down SARS into 3 periods and found patient
  volume down an average of 36 patients per day
  (27)
• 
  Boutis CMAJ 2004
• 
  

59
Surge-Toronto

• SARS I (3/7-4/19)
• 144 SARS cases
• 128 suspected
• 247 total admissions
• 29 of 144 admitted to ICU (20)
• 20 of those 29 received ventilators (14 overall)
• SARS II (5/23-6/4)
• 74 SARS cases
• 
  
  www.sars.ca
• 
  Booth
  JAMA 2003

60
Surge-Toronto

• 375 total cases March-June 2003
• Southern Ontario population 11 million
• 10-20,000 quarantined in Ontario
• Surviving patients 74 discharged by Day 14
• Median stay 10 days
• Peak of 8 probable cases per day
• 
  
  Booth JAMA 2003

61
Surge-Hong Kong

• Feb-June 2003
• 1755 probable SARS cases
• Hong Kong area population 110 million
• 
  
  Lau EID 2004

62
Surge-Hong Kong

• 138 SARS patients at Prince of Wales Hospital
  during period of outbreak from March 11-25
• 32 admitted to ICU (23)
• 19 on ventilators (14)
• Median stay 22.1 days
• Median stay for intubated patients 26.8 days
• 
  
  www.sarsreference.com
• 
  Lee NEJM
  2003

63
Surge-Taiwan

• March-July
• 668 total SARS admissions
• Peak approx. 15-25 probable cases per day during
  period 4/20-5/25
• 22 million population
• 
  
  McDonald EID 2004

64
Surge-Taiwan

• National Taiwan University Hospital
• 270 SARS patients
• Maximum admits in 24 hours was 12
• Overall bed occupancy decreased 48
• ED visits decreased 37
• 
  
  Chen EID 2004

65
Surge-Taiwan

• National Taiwan University Hospital
• SARS screening unit established
• 3/15-4/22 median 6 patients screened a day
• 4/23-5/12 median 36 patients screened a day
• 4/23-5/12 754 patient screened with 63 admitted
• 
  
  Chen EID 2004

66
Surge-Taiwan

• China Medical University Hospital, Taiwan
• ED visits 33.4 lower during outbreak
• 15 hospitals in Taiwan studied
• Overall bed occupancy decreased 20
• 
  Chen BMC 2006
• 
  Chen Med Care
  2005

67
Surge Planning

• Fever clinics
• Kept hospitals functioning by screening prior to
  entrance
• Assessed patients while minimizing transmission
  potential
• Prevented ED overcrowding
• At hospitals or coordinated with public health
• Construct or retrofit

68
Surge Planning

• N95
• Canada hospitals non-compliant
• North York Hospital 2-day supply
• 4/2/03 Staff were required to wear N95 at all
  times while at work
• Taiwan issues with private company and individual
  hording of masks
• Hospitals should increase par levels, lessen
  dependence on outside vendors

69
Surge Planning

• Gradual increase of patients
• Involves regional planning
• Canada stopped hospital transfers from taking
  place at certain hospitals

70
Surge Planning

• Plan on surging in place or regional planning to
  identify a location
• Identify an area
• Supplies
• Staffing
• Incorporation into planning and drills

71
Surge-ED visits
72
Surge-Hospital Occupancy
73
Surge Planning

• Shortages of ED and ICU staff
• Decrease in other admissions can help in finding
  additional staff and supplies
• Plan to close general non-isolation beds and
  re-assign staff to newly created surge isolation
  co-horts

74
Communications

• Istanbul bombings
• Complete city phone and cell phone system failure
• Tulane Hospital- Katrina
• Complete failure to communicate caused an
  inability to implement their disaster plan
• 
  
• 
  Gray Urban 2006
• 
  Rodoplu
  PDM 2006

75
Communications

• London bombings
• Mobile networks failed
• In-coming calls blocked phone lines
• Pager system went offline
• St Lukes Hospital- Tokyo Subway
• Communications were jammed
• Yelling down halls to communicate
• 
  Mohammed PDM 2006
• 
  Okumura AEM 1998
• 
  

76
Communications

• Tokyo EMS
• Couldnt communicate with hospitals as a result,
  couldnt get permission to intubate
• Couldnt acquire hospital availability
  information
• Forced to attempt communication through public
  telephone lines
• 
  Okumura AEM
  1998

77
Communications

• St. Vincents Hospital- NYC 9/11
• No public telephone services
• No cell phone services
• 
  Kirschenbaum CCM 2005
• 
  

78
Communications Planning

• Hospitals have an over reliance on communication
  systems and computer-based systems
• Relatively small events, e.g. bombings, are going
  to cause a failure in the local communication
  system

79
Communications Planning

• Large scale events are going to disrupt the
  infrastructure that supports both civilian and
  medically-utilized communication systems
• Emergency dispatchers will be overwhelmed with
  incoming calls
• Surviving hospital communication systems will be
  overwhelmed with incoming calls from the
  community

80
Communications Planning

• Must have basic back-up plans in place
• 2-way radios not reliant on outside systems
• Runners
• Disaster plans that can be implemented without
  the requirement of extensive communication

81
Communications Planning

• Plans for EMS that are not dependent on
  communication to implement
• standing orders for MCIs
• regional transportation pre-plan in place for
  MCIs

82
Hospital Evacuation

• Northridge Earthquake
• 6 hospitals evacuated within 24 hours of
  earthquake
• 5 of which had non-structural damage only (water
  damage and loss of power)
• 1 with suspected structural damage evacuated
  emergently clearing ambulatory patients first
• Hospital evacuated via stairs
• Flashlights, manual ventilations
• Carried patients with blankets, backboards and
  mattresses
• Schultz NEJM 2003

83
Hospital Evacuation- Katrina

• Charity/Tulane
• Hospitals evacuated ambulatory/stable patients
  ahead of the storm
• Generators in basement flooded at Charity
• Power loss, flooding, loss of communications
• Individual hospitals working out their own
  evacuation processes
• 
  Gray Urban 2006

84
Hospital Evacuation

• Tulane evacuation 4 day process
• ICU patients evacuated first
• Patients carried to garage then to roof landing
  pad by truck
• Spinal boards needed for patient movement had to
  be brought up from storage in Baton Rouge
• 2 patients with 500 lb heart pumps
• 2 bariatric patients each over 600 lbs.
• 
  Gray Urban 2006

85
Hospital Evacuation

• Houston
• Flooding in basement caused failure of electrical
  switchgear to emergency generators
• Over 31 hours
• 169 patients discharged
• 406 transferred by ground and air
• Backboards utilized for pt movement 5 neonates
  strapped to one board
• 
  
  
• 
  
  www.semp.us

86
Hospital Evacuation Planning

• Hundreds of people seeking shelter
• Evacuating critical first or last
• Planning must be regional and involve local EM
• Accessibility of needed supplies
• Plans for refueling generators

87
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