New England Society for Health Care Material Management

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New England Society for Health Care Material
Management

• Preparing for Pandemic Surge
• March 22, 2006

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New England Society for Health Care Material
Management

• Robert P. Paone, B.S., Pharm. D.
• Statewide Strategic National Stockpile
  Coordinator
• Center for Emergency Preparedness
• Massachusetts Department of Public Health
• [phone] (desk)
• [phone] (cell)
• Robert.paone_at_state.ma.us

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Objectives

• Review current impact projections of a Pandemic
  Flu in Massachusetts
• Describe Pandemic Response Plans at state and
  local levels
• Discuss surge preparations

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Potential Impact of Next Pandemic In
Massachusetts Planning Assumptions

• Outbreaks will occur simultaneously throughout
  the US
• Up to 40 absenteeism in all sectors at all
  levels
• Order and security disrupted for several months,
  not just hours or days

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Pandemic v. Usual Surge Event

• Likely to happen across Commonwealth and affect
  all regions simultaneously
• Expected to occur in at least 2 waves of
  approximately 8 weeks duration each
• Projected numbers are spread across the wave,
  with a peak occurring mid-wave
• High attack rate among healthcare workers

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Example of an Epidemic Curve
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MDPH FLU SURGE ASSUMPTIONS

• Attack rate 30
• Hospitalization rate 4 of ill
• Death rate 1 of ill
• Duration of epidemic wave 8 weeks
• Avg. length of non-ICU stay for flu related
  illness 5 days
• Avg. length of ICU stay for flu related illness
  10 days
• Avg. length of vent usage for flu related
  illness 10 days
• Flu admissions requiring ICU care 50
• Flu admissions requiring mechanical ventilation
  15
• Flu deaths assumed to be hospitalized 70
• Daily increase of cases compared to previous day
  3

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Surge Bed Definitions

• Level 1 Staffed and available
• Level 2 Licensed, Staffed
• Two types
• Beds made available through patient discharge and
  transfers. These beds are NOT additive they
  are within the Level 1 bed number, but are
  vacated and made available for surge.
• Beds made available through canceling of elective
  surgery, such as day surgery or endoscopies. Both
  the beds and the staff for those beds can be
  redirected for general hospital patients. These
  beds ADD to overall capacity. (Redirected level 2
  beds, or 2R)
• Level 3 Licensed but not staffed
• Generally equipped, including wall gases
• Level 4 Overflow beds in non-traditional patient
  care areas
• Cafeterias, lobbies, etc.
• Require purchase of equipment (including beds),
  supplies and in need of staff

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Hospital Surge Capacity
Level I 13,067 Current staffed beds Level II
2,000 Re-directed Level III 3,568 Un-staffed
beds Level IV 5,071 Non-trad.
space Total 23,706 Adjusted number reflects
omission of beds that had been double counted
through transfers out to other hospitals. This
number will decrease over time as the elective
admissions become non-elective. All beds are
ultimately dependent on available staffing, so
maximum number may not always be attainable.
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Comparison of Pandemic Planning Numbers
1957/68-like MDPH Surge Planning 1918-like
Ill 2 M (30) 2M (30) 2 M (30)
Hospitalizations 20,000 (1) 80,000 (4) 220,000 (11)
Deaths 4,600 (0.23) 20,000 (1) 42,000 (2.1)
Based on 3X 1968 projections (Trust For
Americas health report A Killer Flu,
www.healthyamericans.org, June 2005)
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outbreak 30 attack rate
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Surge Bed Capacity vs. Need
Levels 1 and 2 Level 3 Level 4 Total Bed Capacity Total Beds Needed Variance
1 (West.) 2,122 277 1,026 3,425 3,284 141
2 (Central) 1,948 460 579 2,987 2,867 120
3 (N.E.) 2,663 788 1,286 4,737 4,022 715
4AB (128) 2,879 740 915 4,534 5,096 (562)
4C (Bos.) 3,013 978 748 4,739 4,014 725
5 (S.E.) 2,761 324 517 3,283 4,277 (994)
STATE 15,061 3,567 5,071 23,705 23,560 145
Requires Purchase of Beds Supplies
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State Need 23,560out of 23,705 Beds
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128 Crescent (4AB)Need 562 more beds than
available
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Southeast (5) Need 994 more level 4 beds than
available
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Gaps in Bed Capacity

• All 6 regions expected to fill 100 of level 3
  beds (licensed but unstaffed)
• All regions will need to open some level 4 beds
  (overflow areas)
• Two regions will exceed their surge capacity
  (Regions 4AB and 5)
• Staffing and supplies required for ALL level 3
  and 4 beds
• Equipment, supplies, and staffing needed for
  level 4 beds

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Hospital Surge Capacity

• Despite operational changes, hospitals may become
  overwhelmed depending on usage in communities
  served
• Alternate care spaces will need to be identified
  to expand hospital capacity
• Pre-hospital triage will be needed to relieve
  pressure on hospital operations

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Alternate Care Sites (ACS)

• Hospitals flu patients requiring mechanical
  ventilation, or those with complex medical
  management needs
• ACS Sickest flu patients not meeting the
  criteria for hospital admission but for whom home
  care is not possible
• Location and number to be determined by local
  hospital bed availability.

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Federal Medical Station Type III (Basic)(FMS
TIII)
SNS Stakeholders Conference
February 21, 2006
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FMS Goal

• Address the nations potential shortfall in
  all-hazard mass casualty care events and create a
  federal-level contingency care program as
  directed in HSPD 10.
• Deploy a surge capability throughout the Nation,
  pre-positioned and configured to respond rapidly
  and effectively to all types of public health
  emergencies, from significant incidents to
  large-scale catastrophic disasters

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FMS TypesStandardized Capabilities Across
Agencies

• Type I (Advanced) Has capability to care for
  severely ill or injured patients, equivalent to
  conventional operating room, ICU, and basic
  laboratory (Lead DHS) (DHS uses FMCS)
• Type II (Specialized) Configured for specific
  clinical scenarios, such as respiratory isolation
  and burn care. Future prototypes to be
  developed. (Lead DHHS)
• Type III (Basic) Low to mid-level acuity of
  care to provide platform for DMAT teams, special
  needs shelters, quarantine function, alternate
  care facility to augment community hospital
  capability (Lead DHHS)
• Type IV (FMS) Special Needs Shelter (Lead DHHS)

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FMS TIII (Basic)Concept

• A Federal, deployable medical asset designed to
  support regional, state, and local healthcare
  agencies responding to catastrophic events. It
  provides two critical capabilities
• - Inpatient, non-acute treatment capability for
  areas where hospital bed capacity has been
  exceeded.
• - A quarantine capability to isolate persons
  suspected of being exposed to or affected by a
  highly contagious disease.
• Features
• - Consists of three core modules and bed
  expansion module
• - Very few recoverable items in the FMCS kit
• - Easily adapted to meet a range of mass medical
  care needs following disaster
• - Deploys with SNS technical team to facilitate
  FMCS set up and transfer to Federal Health Care
  Professionals

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FMS TIII 250 Bed Module FMS TIII 250 Bed Module
Configuration e Configuration
Type III Basic Treatment
Type III Basic Pharmaceutical
Type III Basic Base Support With Quarantine

• Pharmaceutical
• Special Medications
• Prophylaxis

• Administration
• Support
• Feeding
• Quarantine
• Beds(50)
• Housekeeping
• First Aid Equipment
• Pediatric Care
• Adult Care
• Personal Protective Equipment

• Primary Care
• Non-acute Treatment
• Special Needs
• Non-acute Treatment
• Special Needs

• Beds
• Bedding
• Bedside Equipment

• Current Pack
• 634 items - 3 days supply
• 170 pallets (uni-pacs and pallets)
• 4 tractor trailer (53 ft) loads

FMS
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Staffing

• Remains biggest challenge we face
• Legal protections are key to recruiting personnel
• Large number of non-clinical personnel also
  needed
• Potential sources of clinical surge personnel
• Internal Hospital Strategies
• MSAR volunteers
• Medical Reserve Corps that are not included in
  hospital staff
• Retired, inactive health professionals
• Students (medical, nursing, pharmacy)
• Connect and Serve (www.mass.gov)

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Health Care Professionals

• Professional qualifications must be checked and
  verified ahead of time
• Volunteers cannot be assigned to take care of
  patients until their specific knowledge and
  skills are understood
• It takes time to do this volunteers who have
  not been pre-registered and pre-credentialed may
  be delayed in receiving an assignment

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Masks v. Respirators
http//www.fda.gov/cdrh/ppe/masksrespirators.html

• Viruses spread primarily by droplet spray
  therefore surgical mask is appropriate protection
  if working within three feet of infected
  patients. (Upon entering the patients room)
• Respirators (i.e. N-95 masks, properly fitted)
  should be worn by HCWs who are involved with
  patients undergoing procedures in which
  aerosolized particles may be generated.
  (endotracheal intubation, suctioning, nebulizer
  therapy, etc.)

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Oxygen Needs

• Model presumes that patients in Level IV and ACS
  who require oxygen will require oxygen therapy at
  4-6 liters/minute (l.p.m.) flow.
• Level IV and ACS model is based on 50 patients
  being treated for 10 day period.
• Assumption is that at any given time, 25 patients
  will require constant oxygen.
• Cost estimates derived from preliminary survey of
  local vendors.

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Delivery Systems

• Oxygen Gaseous Cylinder
• Oxygen Concentrator
• Liquid Oxygen
• Stockpile/Cache Planning

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Gaseous Cylinder

• H tank cylinder being used at 4-6 l.p.m. will
  last approximately 1 day per patient.
• Therefore, each ACS will need a minimum of 250 H
  cylinders worth of oxygen.
• Most oxygen vendors lease H cylinders to end
  users and recycle the empties replacing them with
  full tanks (similar to bottled water cooler set
  ups used in offices)

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Oxygen Concentrators

• Different models can be used at 1 to 6 liters per
  minute.
• Each patient would need their own concentrator.
• Primarily used for lower flow (1-2 l.p.m.)
  applications, however units do exist that do 6
  l.p.m. and more expensive units could provide
  oxygen up to 10 l.p.m.
• Concentrators produce oxygen from room air and
  therefore do not require any gaseous or liquid
  oxygen to be supplied.

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Liquid Oxygen

• Based on cryogenic technology.
• Most hospitals have liquid oxygen tanks on their
  premises used to supply oxygen throughout
  facility.
• Cost is based on pounds.
• It is estimated that at approx. 6 l.p.m., each
  patient would probably use approx. 280 pounds for
  a 10 day period

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Oxygen Stockpile/Cache Planning

• MDPH representatives have started to conduct
  outreach such as attending New England Medical
  Equipment Dealers quarterly meeting Dec. 8th in
  Boxboro, MA.
• MDPH will contact major medical supply
  vendors/distributors including local and regional
  oxygen suppliers to explore the topic of securing
  adequate oxygen supplies during a regional,
  statewide and national pandemic surge situations.
  

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Ventilators

• Hospital Ventilators cost approx. 25,000/unit.
• Portable ventilator contained within SNS stock
  costs approx.7,900/unit.
• Looking into prices for portable ventilators.
• MDPH will work with ventilator suppliers and
  manufacturers to explore state and nationwide
  ventilator availability.

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Ventilators

• Massachusetts Department of Public Health is
  currently in the process of evaluating
  ventilators and O2-concentrators.
• DPH is considering purchasing 1000-2000 vents and
  O2-concentrators for our state wide stockpile.

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Surge Supply Caches Total Cost for 50 Bed ACS
250,000

• Approx. 5000 per patient
• Approx. 20,000 Oxygen and Suction supplies
• Approx. 40,500 durable medical supplies
• Approx 17,600 for Intravenous related supplies
• Approx. 78,800 for infrastructure/administrative
  supplies

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Alternate Care Site Costs (cont.)

• Approx 28,000 for support service costs
  (laundry, food, lab-work etc.)
• Approx. 46,600 Pandemic related medicines
• Approx 7500 for acute/non-emergent maintenance
  meds
• Approx. 13,000 for stocked Crash Cart

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Maximizing the Supply Chain

• Identify items for surge
• Increase par levels for on site cache
• For pharmaceuticals, distributors maintain 21
  day inventory
• Work with suppliers
• Place orders early in pandemic
• Identify alternate sources

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Maximizing the Supply Chain (cont.)

• What else?
• All suggestions are welcomed!

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Pandemic Response Actions Timing and Potential
Impacts
Pandemic influenza disease
Impact
Vaccination
Time
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Local Infectious Disease Emergency Planning

• Most of the impact and most of the response will
  be local.