Health Care Delivery ModelHealth Care Delivery Modelfor Pandemic Influenza for Pandemic Influenza

Island County Health Island County Health Department’s ApproachDepartment’s Approach

Presented by:Presented by:

Roger S Case, MDRoger S Case, MDOctober 2007October 2007

Thanks to Charron Plumer and staff of Tacoma-Pierce County Health Thanks to Charron Plumer and staff of Tacoma-Pierce County Health Dept for making this presentation possible.Dept for making this presentation possible.

GOALGOAL

Increase Health Care Increase Health Care capacity in Island County capacity in Island County during a medical during a medical catastrophe catastrophe

Minimize morbidity & Minimize morbidity & mortalitymortality

Island County Flu ImpactIsland County Flu ImpactA WORST CASE SCENARIOA WORST CASE SCENARIO

24,000 patients seek care (30% attack rate)24,000 patients seek care (30% attack rate)

Up to 5,200 will be hospitalized (22 % of those ill)Up to 5,200 will be hospitalized (22 % of those ill)

Up to 720 will require ICU care (3% of hospitalized)Up to 720 will require ICU care (3% of hospitalized)

Up to 950 will die (4% of those seeking care)Up to 950 will die (4% of those seeking care)

Beds and staff exceeded quickly – 25 beds currently Beds and staff exceeded quickly – 25 beds currently staffedstaffed

Pandemic Severity IndexPandemic Severity IndexCDC 2/07CDC 2/07

Based on a population estimate of 80,000 with 30% ill< 0.1%

> 2%

1 - < 2%

0.5% - < 1%

0.1 - < 0.5%

< 24

> 480

240 - < 480

120 - < 240

24 - < 120

Case Fatality Ratio

Projected Number of Deaths in Island County

Category 1

Category 2

Category 3

Category 4

Category 5

Work Group ObjectivesWork Group Objectives

Engage community health care partners in Engage community health care partners in developing modeldeveloping model

Design and implement a coordinated Design and implement a coordinated system to deliver medical care during a system to deliver medical care during a medical catastrophemedical catastrophe

Develop triage protocols to guide Develop triage protocols to guide allocation of scarce resources, e.g. allocation of scarce resources, e.g. equipment, staff, suppliesequipment, staff, supplies

Initial Work Group – Initial Work Group – Planning OrganizationPlanning Organization

FacilitiesFacilitiesLogisticsLogistics

OperationsOperations

Community Community

Medical Medical

Coordination Coordination

Triage andTriage and

TreatmentTreatment

ProtocolsProtocolsPre-Tier 1, Tier 1

& Tier 2

Started early in 2005

Concept of OperationsConcept of Operations

Care delivered Care delivered outside of hospitalsoutside of hospitals– HomeHome– Alternate care facilities Alternate care facilities

– divert pts away from – divert pts away from ERSERS

– Hospitals – Hospitals – acute/critical careacute/critical care

Care site based on Care site based on severity of illness & severity of illness & resourcesresources

Concept of OperationsConcept of Operations

Altered Standards of CareAltered Standards of Care

Insured/non-insured seen Insured/non-insured seen – Relax insurance limitationsRelax insurance limitations– Discussion elevated to state Discussion elevated to state

levellevel– Legal consultantLegal consultant

Staff 24/7 with community Staff 24/7 with community medical providers and medical providers and Medical Reserve CorpsMedical Reserve Corps

Ethical ConsiderationsEthical Considerations

To guide our Planning, we rely on the following principles:

• To the greatest extent possible, everyone in Island County who becomes ill should be given the best care we can provide at that time, regardless of that person’s social worth.

• To maximize our ability to implement this model, caregivers who work directly with patients and essential healthcare support workers should be considered a priority group for all preventive healthcare resources.

• If resources become so scarce that we cannot provide all patients with the care they need, care should be given to the patients likely to receive the most benefit from those resources.

• If it should become necessary to restrict individual liberties for the sake of the public health, the least restrictive interventions likely to be effective should be employed.

Four Tiered System*Four Tiered System*

Pre-Tier 1 – EMS (including 911) and Health Pre-Tier 1 – EMS (including 911) and Health Care Information linesCare Information lines

Tier 2 – Neighborhood Emergency Help CentersTier 2 – Neighborhood Emergency Help Centers– Triage, Outpatient Treatment and Referral functionTriage, Outpatient Treatment and Referral function

Tier 3 – Alternate Care FacilitiesTier 3 – Alternate Care Facilities– Expanded bed capacity with limited careExpanded bed capacity with limited care

Tier 4 – HospitalsTier 4 – Hospitals– Higher acuity, lower censusHigher acuity, lower census

*Adapted *Adapted Based on Modular Emergency Medical SystemBased on Modular Emergency Medical SystemDeveloped for mass casualty bioterrorism eventsDeveloped for mass casualty bioterrorism eventsUS Army Soldier and Biological Chemical Command 6/1/02US Army Soldier and Biological Chemical Command 6/1/02

FacilitiesFacilities

?? NEHC Tier 1 sites ?? NEHC Tier 1 sites identifiedidentified

?? ACFS Tier 2 sites ?? ACFS Tier 2 sites identifiedidentified

Memoranda of Memoranda of AgreementsAgreements

Facilities will be Facilities will be standardizedstandardized

Pre-Tier 1Pre-Tier 1

EMS - 911 medical dispatching EMS - 911 medical dispatching protocols developedprotocols developed

Not all calls will get an ambulanceNot all calls will get an ambulance

EMS empowered to triage EMS empowered to triage patients to appropriate levelspatients to appropriate levels

Including care and comfort at Including care and comfort at homehome

Nurse Triage LinesNurse Triage Lines– Similar protocols to 911Similar protocols to 911– Can refer patients to Tier 1 or send Can refer patients to Tier 1 or send

EMSEMS

Pre-Hospital Straw PersonPre-Hospital Straw PersonPre-Tier 1/Phone TriagePre-Tier 1/Phone Triage

Call to 911 or other

public safety answer point

Unstable?

EMS sent

Evaluated by Nurse lineN

Y

Tx toTier 3

Tx toTier 2N

Y

Hypoxic,Hypertensive

Call to

Nurse line*

*Nurse lines are run by multiple health care organizations, will require standardization between organizations and agencies. May also require standardization across counties.**Antiviral medications***Neighborhood Emergency Help Center

Needs in-personevaluation?

Refer toTier 1

NEHC***Y Arrange for AVM

Info only

Y

N

AVM**eligibleN

Consideration: special access phone # for high priority personnel to access nurse line

Create mechanism for nurse to communicate with Tier 1 = nurse phone order AVM

Refer patients to Tier 1 location to p/u AVM

Require Transport?

Y

N

Tier 1 - Tier 1 - Triage & Neighborhood Emergency Triage & Neighborhood Emergency Help Center (NEHC)Help Center (NEHC)

Triage and basic evaluationTriage and basic evaluation– dispense antiviral medicationsdispense antiviral medications

Patient receiving area; separate Patient receiving area; separate pts by severity of illnesspts by severity of illness

Flu kits and home care Flu kits and home care information information

Holding areas - Pts waiting on Holding areas - Pts waiting on transport to higher tiertransport to higher tier

Tier 2Tier 2

For patients referred from Tier 1, or For patients referred from Tier 1, or step down from Tier 3step down from Tier 3– Persons not sick enough for hospital, need Persons not sick enough for hospital, need

care that cannot be provided in home, or care that cannot be provided in home, or palliative carepalliative care

Short stay (I.e. dehydrated) Short stay (I.e. dehydrated)

Limited testing capabilityLimited testing capabilityO2 saturations, Chemistry/glucoseO2 saturations, Chemistry/glucose

Oxygen, IV fluidsOxygen, IV fluids

Antiviral medications, abx for Antiviral medications, abx for secondary bacterial pneumoniasecondary bacterial pneumonia

Tier 3 Tier 3 Alternate Care FacilitiesAlternate Care Facilities

Pre-id sites for surge capacity medical carePre-id sites for surge capacity medical care

Mostly high schoolsMostly high schools– Geographically located around Island CountyGeographically located around Island County

Facility set up in 50 bed unitsFacility set up in 50 bed units

Continue to expand until full capacityContinue to expand until full capacity

Tier 3 Tier 3 (continued)(continued)

Rest area for family care giversRest area for family care givers

Palliative care areaPalliative care area

Occupational Health officeOccupational Health office

Functioning cafeteria – 24/7Functioning cafeteria – 24/7

Staff break and sleeping areaStaff break and sleeping area

Chapel & morgueChapel & morgue

Children under 3 y/o receive care Children under 3 y/o receive care at Tier 3 – eliminates need for cribsat Tier 3 – eliminates need for cribs

Posters, videos w/ care instructions Posters, videos w/ care instructions & infection control& infection control

Patient Tracking SystemsPatient Tracking Systems

Tracking system – “Iris”Tracking system – “Iris”– Bar coded wrist bandBar coded wrist band– Tracks from first physical contact until Tracks from first physical contact until

dispositiondisposition– Can be used to track staff as wellCan be used to track staff as well

Joint Information CenterJoint Information Center Risk Messaging Risk Messaging

Switch to alternate care systemSwitch to alternate care system

Home health care information Home health care information

How to contact health information line How to contact health information line

When to enter the system and go to Tier 1When to enter the system and go to Tier 1

How to get to nearest Tier 1 SiteHow to get to nearest Tier 1 Site– What to bring: clean linens/pillow, personal What to bring: clean linens/pillow, personal

hygiene products, routine meds, one family hygiene products, routine meds, one family caregivercaregiver

StaffingStaffing

Medical Coordination and Medical Coordination and RecruitingRecruiting– Medical Reserve CorpsMedical Reserve Corps– Registration Registration – JITT - JITT - Safety trainingSafety training, , Triage and Triage and

treatment protocols, Job Action treatment protocols, Job Action

Sheets, Infection Control, PPESheets, Infection Control, PPE

Medical Reserve CorpsMedical Reserve Corps

A group of community A group of community based medical volunteers based medical volunteers called upon to serve in called upon to serve in large-scale emergency, large-scale emergency, natural disaster, or public natural disaster, or public health incidenthealth incident

Liability ConcernsLiability Concerns

Liability concerns permeate Liability concerns permeate the discussionthe discussion

Pandemic or mass casualty Pandemic or mass casualty event creates uncertainty event creates uncertainty and unpredictability as to and unpredictability as to how courts will interpret the how courts will interpret the legal standards in medical legal standards in medical malpractice actionsmalpractice actions

LiabilityLiabilityWA State assumes considerable liability WA State assumes considerable liability for damage to property, injury or death for damage to property, injury or death that might occur during an emergency or that might occur during an emergency or medical disaster for registered workermedical disaster for registered worker

Generally, Emergency workers, Generally, Emergency workers, including state and local employees are including state and local employees are indemnified by the State; state will pay indemnified by the State; state will pay judgment for public employee who is judgment for public employee who is found liable (if not due to gross found liable (if not due to gross negligence or willful misconduct)negligence or willful misconduct)

Covered (Registered) Volunteer Covered (Registered) Volunteer emergency workers are immune from emergency workers are immune from liabilityliability

LiabilityLiability

In order for an emergency worker to be protected, In order for an emergency worker to be protected, emergency management must have assigned a emergency management must have assigned a mission number to approved missions and other mission number to approved missions and other emergency activities emergency activities

Citizens who are commandeered into service are Citizens who are commandeered into service are entitled to the same privileges, benefits and entitled to the same privileges, benefits and immunitiesimmunities

Covered volunteer emergency workers are Covered volunteer emergency workers are granted immunity only when engaged in a granted immunity only when engaged in a covered activity and acting within the scope of covered activity and acting within the scope of his/her duties, under the direction of a local his/her duties, under the direction of a local emergency management or law enforcementemergency management or law enforcement

Worker RegistrationWorker Registration

Critical to register emergency Critical to register emergency workersworkers

Registered workers receive Registered workers receive training on medical disaster training on medical disaster system system

Statewide medical disaster Statewide medical disaster system standard of care is system standard of care is implemented (proposed)implemented (proposed)

Emergency Workers vs. Covered Emergency Workers vs. Covered Volunteer Emergency WorkerVolunteer Emergency Worker

Emergency WorkerEmergency Worker = Any person = Any person who is registered with a local who is registered with a local emergency management emergency management organization or the state military organization or the state military deptdept

Holds an ID card issued by the Holds an ID card issued by the above for the purpose of engaging above for the purpose of engaging in authorized emergency in authorized emergency management activitiesmanagement activities

Or is an employee of WA State or Or is an employee of WA State or any political subdivision called upon any political subdivision called upon to perform emergency management to perform emergency management activitiesactivities

Covered Volunteer Covered Volunteer Emergency WorkerEmergency Worker

An Emergency Worker, such An Emergency Worker, such as an MRC volunteer, not as an MRC volunteer, not receiving compensation as an receiving compensation as an emergency worker from the emergency worker from the state or local government.state or local government.

Is not a state or local Is not a state or local government employeegovernment employee

Registration criticalRegistration critical

Altered Standards of CareAltered Standards of Care

Community clinical Community clinical decision makers will be decision makers will be identified who will assess identified who will assess the evolution of the illness the evolution of the illness and coordinate existing and coordinate existing and changing standards of and changing standards of care within PC and the care within PC and the StateState

Altered Standards of Care Altered Standards of Care PrinciplesPrinciples

Goal of an organized and coordinated response to Goal of an organized and coordinated response to a mass casualty event should be to maximize the a mass casualty event should be to maximize the number of lives savednumber of lives saved

Rather than doing everything possible to save Rather than doing everything possible to save every life, it will be necessary to allocate scarce every life, it will be necessary to allocate scarce resources in a different manner to save as many resources in a different manner to save as many lives as possiblelives as possible

Process must be fair and clinically sound, Process must be fair and clinically sound, transparent and judged by public to be fairtransparent and judged by public to be fair

Triage protocols need to be flexible as event grows Triage protocols need to be flexible as event grows

Statewide StandardsStatewide Standards

Suggested that WA approach the issue of Suggested that WA approach the issue of Altered Standards of Care in a Statewide Altered Standards of Care in a Statewide mannermanner

Seek approval of proposed altered standards Seek approval of proposed altered standards by professional organizationsby professional organizations

Submit to accreditation organizations for Submit to accreditation organizations for reviewreview

Adoption of statewide standard of care would Adoption of statewide standard of care would give medical providers increased guidance give medical providers increased guidance and increased likelihood of liability protectionand increased likelihood of liability protection

Tier 3 Work Group GoalsTier 3 Work Group Goals

Increase hospital capacity to Increase hospital capacity to care for acutely ill during a care for acutely ill during a pandemic flupandemic flu

Identify patient type categories Identify patient type categories to facilitate triage during a to facilitate triage during a pandemic flupandemic flu

Develop triage guidelines to Develop triage guidelines to guide allocation of scare guide allocation of scare hospital/ICU resourceshospital/ICU resources

Develop Response Matrix Develop Response Matrix outlining triage guidelinesoutlining triage guidelines

Work started early January 2007

Hospitals Hospitals PH, EMSPH, EMSMilitaryMilitary DEMDEM

Participants

AssumptionsAssumptions

Pandemic severity index, WHO Pandemic severity index, WHO Phases and Federal Response Phases and Federal Response Stages will be the triggers Stages will be the triggers guiding response and guiding response and implementing the tiered triage implementing the tiered triage protocolsprotocols

Standards of Care will be Standards of Care will be altered as incident progresses altered as incident progresses and emergency declaredand emergency declared

Focus on keeping health care Focus on keeping health care systems functioningsystems functioning

Patient Types Patient Types

•Massive respiratory failure – overwhelming entry of inflammatory cells (Cytokine storm)

•Rapid onset of SOB, cyanosis, tachypnea

•This type of response likely to occur in the younger, healthier persons – 15-40 years old

•If treated in ICU/ventilators – survival rate – 50%

Ref: Grattan Woodson, M.D. 2/13/07

RED – very poor prognosis, expected to die within 2-3 days

A matrix has been developed that outlines and defines patient types. Four types have been identified: RED, YELLOW, GREEN, and BLUE

Patient Types Patient Types

•Pulmonary and/or cardiovascular complications

•Elderly, very young, adults with chronic medical condition

•Significant co-morbidities, e.g. diabetes, heart disease, HTN, asthma

•Pregnant women at high risk

•Survival rate is 85% if treated with IV abx, ICU and ventilator when needed

•50% mortality rate if left at home

Ref: Grattan Woodson, M.D. 2/13/07

YELLOW – Very ill, survival past 3 days

Patient TypesPatient Types

•Majority of those ill with pan flu

•Dependent upon others (household members) to care for them

•Fever, cough, malaise

•No cyanosis, hypoxia, or hemorrhage

•Co-morbidities under control

•Survival rate – 99% if admitted to hospital when needed; 95% if treated at home

•Death primarily due to dehydration

Ref: Grattan Woods, M.D. 2/13/07

GREEN – greatest chance of survival

Patient Types Patient Types

– May be unconsciousMay be unconscious– Will receive palliative Will receive palliative

carecare

BLUE – near death

TIER 3 (HOSPITAL): PATIENT TRIAGE DURING PANDEMIC INFLUENZA 

Tier 3 Patient Typing Definitions

RED (Type 1 Patient)

Prognosis: Poor: die within 2-3 days of onset of symptoms

Age: 15-40 year -olds due to cytokine storm

Clinical signs: rapid onset SOB, cyanosis, tachypnea, bleeding from sites

 

 

 

 

 

 

Survival: 50% survival rate w/ access to ICU/Vents; 95% mortality if left at home 

YELLOW (Type 2 Patient) Prognosis: Very ill, survival past 3 days; pulmonary and/or cardiovascular complications.

Age: All elderly, very young, or adults with chronic medical disorders

Clinical Signs: Often improve then relapse with malaise, aches, pains and then fever. Significant co-morbidities: Emphysema, chronic bronchitis, children with asthma, diabetes, coronary heart disease, high BP. Ppregnant women are at high risk

Survival: 85% survival rate with IV antibiotics, diagnostic testing, ICU, vent when needed. 50% mortality rate if left at home

GREEN (Type 3 Patient) Prognosis: Greatest chance of survival; majority of those ill with flu; dependent on others for care.

Clinical Signs: Fever, cough, malaise, no cyanosis, hypoxia or hemorrhage. None or controlled co-morbidities.

Survival: 99% survival rate if admitted to hospital when needed; 95 % survival rate if treated at home. *Death is primarily due to dehydration. 

BLUE (Patients in extremis) Near deathUnconsciousSupportive care only  

 

Triggers: Phases and Triggers: Phases and Stages of a PandemicStages of a Pandemic

WHO (World) Phases

Phase 6 – Pandemic Phase: increased and sustained transmission in general population

Fed Govt Response Stages

• Stage 3 – Widespread human outbreak in multiple locations overseas

• Stage 4 – First human case in N. America

• Stage 5 – Spread throughout U.S.

• Stage 6 – Recovery & prep for subsequent waves

Response GuidelinesResponse Guidelines

TriggersTriggers

Fed Govt Stage 4Fed Govt Stage 4

First human cases in First human cases in

North AmericaNorth America

1-2 ICU cases in Is. Co.1-2 ICU cases in Is. Co.

Full hospital resourcesFull hospital resources

Category 1 – Usual Standards of Care

ActionsActions

Alert and Standby Tiers 1 Alert and Standby Tiers 1 & 2& 2Conduct JITT of staffConduct JITT of staffAdmit all patient typesAdmit all patient typesRefer Green patients for Refer Green patients for home health monitoringhome health monitoringNormal Critical care Normal Critical care admission admission Elective procedures Elective procedures continuecontinue

Response GuidelinesResponse Guidelines

TriggersFed Govt Stage 5 Fed Govt Stage 5

Spread throughout U.S. Spread throughout U.S.

Pan Flu in W. WAPan Flu in W. WA

Up to 10 ICU cases in ICUp to 10 ICU cases in IC

Diminished Hospital Diminished Hospital capacitycapacity

Emergency DeclarationEmergency Declaration

Category II – Altered Standards of Care

Actions

Triage ED patients to TierTriage ED patients to Tier 1, as appropriate 1, as appropriate

Refer GREEN patients toRefer GREEN patients to Tier 1 Tier 1

Admit to CC based onAdmit to CC based on ventilator, homodynamic ventilator, homodynamic support needs support needs

Admit YELLOW and REDAdmit YELLOW and RED when ICU beds available when ICU beds available

Once ICU beds filled,Once ICU beds filled, YELLOW patients receive YELLOW patients receive priority priority

Response GuidelinesResponse GuidelinesCategory II Actions (continued)Category II Actions (continued)

Lift EMTALA by decree of Declaration of EmergencyLift EMTALA by decree of Declaration of Emergency

Activate surge capacity and emergency response Activate surge capacity and emergency response plansplans

ACFS – operationalACFS – operational

Hospital Command Centers communicate on patient Hospital Command Centers communicate on patient triage and movementtriage and movement

Elective procedures decreasedElective procedures decreased

Implement early discharge protocolsImplement early discharge protocols

Response GuidelinesResponse Guidelines Category III– Altered Standards of Care

TriggersTriggers

Fed Govt Stage 5: Fed Govt Stage 5:

Community Spread Community Spread

ICU cases greater than 10ICU cases greater than 10

Hospital resources are nearly Hospital resources are nearly or completely diminishedor completely diminished

Category III– Altered Standards of Care

ActionsActionsImplement criteria for inclusion or Implement criteria for inclusion or exclusion to CCexclusion to CCAdmit YELLOW patients with Admit YELLOW patients with greater chance of survivabilitygreater chance of survivabilityAssess RED patients case by Assess RED patients case by case (if ICU bed is available and case (if ICU bed is available and no YELLOW patient is waiting, no YELLOW patient is waiting, admit RED)admit RED)Refer RED patients to hospice, Refer RED patients to hospice, Home Health, Tier 2 Palliative Home Health, Tier 2 Palliative carecareExclude elective surgeriesExclude elective surgeriesEmergency surgeries – traumas, Emergency surgeries – traumas, appendectomies will be continuedappendectomies will be continued

Response GuidelinesResponse GuidelinesCategory III Actions (continued)Category III Actions (continued)

Activate resource conservation, conversionActivate resource conservation, conversion– Convert surgical suites, day surgery, recovery suites Convert surgical suites, day surgery, recovery suites

in CC bedsin CC beds– Shift human resources from OR and Recovery to CCShift human resources from OR and Recovery to CC

Cancel elective proceduresCancel elective procedures

Hospital Command Center coordinates Hospital Command Center coordinates movement of patients between hospitalsmovement of patients between hospitals

Response GuidelinesResponse GuidelinesCategory III – Critical Care Inclusion/Exclusion GuidelinesCategory III – Critical Care Inclusion/Exclusion Guidelines

Critical Care Inclusion

• Requires ventilator support

• Requires homodynamic support

Critical Care Exclusion

• Severe trauma, severe burns, cardiac arrest

• Severe baseline cognitive impairment

• Advanced untreatable neuromuscular disease

• Metastatic malignant disease

• Advanced immunocompromised

• Advanced/irreversible neurologic event

• End-stage organ failure

• Elective palliative surgery

Ref: CMAJ 11/21/06: Development of a triage protocol for critical care during an influenza pandemic

Tier 3 – Triage & Admission Tier 3 – Triage & Admission GuidelinesGuidelines

Tier 3 Response MatrixTier 3 Response MatrixCateg

oryTriggers Available

ResourcesAdmission & Triage

GuidelinesAction

 I

UsualStandardOf Care

Fed Govt Stage 4: First human cases in North America  1-2 ICU cases in Island County

Full Resources Admit all Patient types: RED, YELLOW, & GREEN, if able. GREEN patients: assess home environment; identify family members that can provide care; assess ability to take oral fluids; refer to home health monitoring as appropriate (guidelines to be developed)

Critical Care Admission: Normal triageContinue Elective procedures 

 

Increase surveillance (tool to be developed) Alert and Standby Tier 1 & 2 SitesConduct Just-in-time Training of staff for Tier 1, 2Acquire anticipated resources (pre-planning needs identified) Activate Facility Emergency PlansActivate EOC & ESF 8 Alert Home Health/Hospice/LTCF to activate Emergency Plans Alert status: activation of hospitals’ surge capacity

 

Category

Triggers Available Resources

Admission and Triage Guidelines

Action

II 

&

III 

Altered Standard of Care

Fed Govt. Stage 5:Community spread Greater than 20 ICU cases in County Note: gradual transition from Category II to II.

Hospitals maxed outLimited equipment, supplies, staff

Admit YELLOW patients – those identified as having greater survivability.

Critical Care Inclusion: (ref: 1)

- Require ventilator support- Require homodynamic support

Critical Care Exclusion: (ref 1)

- Severe trauma- Severe burns- Cardiac arrest- Severe baseline cognitive impairment- Advanced untreatable neuromuscular disease- Metastatic malignant disease- Advanced/irreversible immunocompromised- Advanced/irreversible neurologic event or condition- End-stage organ failure - Age > 85- Elective palliative surgery RED Patients: assess case by case – if bed available, and no Yellow patient is waiting, admit to ICU; when ICU beds not available, refer RED patients to hospice, home-health, Tier 2 Palliative Care Continue emergent surgical, non-flu procedures (traumas, appendectomies, stent replacement)

Activate Critical Care Inclusion/Exclusion Criteria.  Assess function and effectiveness of Community Tier 1 & 2 sites (develop assessment tool). Activate resource conservation/conversion: surgical suites, day surgery, recovery suites into CC units.Shift of human resources, i.e. from OR, Recovery to CC.  Cancel all elective procedures Implement established withdrawal of Critical Care guidelines for patients with non-survivability conditions. (Clarify ??) Hospitals’ ECO coordinate between hospitals transfers of yellow patients where beds available. 

 

Tier 3 – Response Matrix

Pediatric Triage & TreatmentPediatric Triage & TreatmentCurrent workgroupCurrent workgroup

Expand Tier 1 and Tier 2 protocolsExpand Tier 1 and Tier 2 protocols

Incorporate pediatric protocols into Tier 3 Incorporate pediatric protocols into Tier 3 matrixmatrix

Pediatric modifiers for Patient Type Pediatric modifiers for Patient Type descriptionsdescriptions

Admission Guidelines of pediatric patients Admission Guidelines of pediatric patients to adult hospitalsto adult hospitals

Pediatric ModifiersPediatric ModifiersPatient TypesPatient Types

Little available in literature Little available in literature re clinical presentation or re clinical presentation or historical models of peds historical models of peds during pan fluduring pan flu

Additional complexity: family Additional complexity: family treatment modality – makes treatment modality – makes social distancing more social distancing more difficultdifficult

Pediatric Patient TypesPediatric Patient Types

RedRed ( (very poor prognosis, expected to die within 2-3 days)– Peds: robust immune Peds: robust immune

system, primary flu, system, primary flu, suspected high suspected high inflammatory inflammatory response, young response, young adults in good healthadults in good health

< 15 y.o not likely to < 15 y.o not likely to be categorized as be categorized as Red TypeRed Type

>15 y.o likely to have >15 y.o likely to have higher immune higher immune system response, system response, therefore thought to therefore thought to be at higher riskbe at higher risk

Pediatric Patient TypesPediatric Patient Types

Yellow (Yellow (very ill, survival past 3 days)– Peds: Main risk is secondary infection creating

compromised health

Green (Green (greatest chance of survival)– Peds: Very ill and symptomatic, but with a high

survival rate

Blue (near death) – very ill, routed to holding area

Concept of OperationsConcept of Operations

Altered Standard of Care for peds Altered Standard of Care for peds – minimize risk for providers, I.e. – minimize risk for providers, I.e. delay of pediatric elective surgerydelay of pediatric elective surgery

Use of step-down beds and Use of step-down beds and reallocation of ICU resourcesreallocation of ICU resources

Develop standing orders and Develop standing orders and guidelines for non-pediatric guidelines for non-pediatric hospitals to take lower acuity peds hospitals to take lower acuity peds if main pediatric hospital is fullif main pediatric hospital is full

PediatricsPediatrics

Demarcation for adult care Demarcation for adult care physiologically is not very different physiologically is not very different for typical child > 15 y.o.for typical child > 15 y.o.

Concern is the social & familial Concern is the social & familial support needs for childsupport needs for child

> 18 y.o independent admission> 18 y.o independent admission

< 18 y.o. need family present< 18 y.o. need family present

Pediatrics - NotesPediatrics - NotesCategories I-III – most children < Categories I-III – most children < 15 y.o. manageable by non-15 y.o. manageable by non-pediatricianspediatricians

< 40 kg. Cannot use adult vents< 40 kg. Cannot use adult vents

Ped patient >3 y.o. triaged as a Ped patient >3 y.o. triaged as a Green patient can be managed Green patient can be managed at Tier 2 site – following at Tier 2 site – following standardized protocols & standardized protocols & accompanied by legal guardianaccompanied by legal guardian

Skill set for starting IV same in Skill set for starting IV same in child > 3 y.o. as in adultchild > 3 y.o. as in adult

Pediatrics - NotesPediatrics - Notes

Peds already admitted to hospital Peds already admitted to hospital at time of emergency declaration at time of emergency declaration would not have care removedwould not have care removed

Need to reserve vents in NICU – Need to reserve vents in NICU – might use survivability of pre-term might use survivability of pre-term neonates as a thresholdneonates as a threshold

Under elevated category Under elevated category conditions, NICU vents can be conditions, NICU vents can be used for babies < 12 months old.used for babies < 12 months old.

Pediatrics - Pediatrics - Critical Care Exclusion

• Severe trauma, severe burns, cardiac arrest

• Severe cognitive impairment – totally dependent for all ADLs

• Advanced untreatable neuromuscular disease

• malignant disease with poor survivability

• Advanced, irreversible immunocompromised

• End-stage organ failure

• < 28 weeks gestational age

• Elective palliative surgery

• Major congenital anomaly with decreased survivability

• End-stage pulmonary disease

• Heart transplant patients

• Unrepaired cyanotic heart disease patients

Current Work GroupsCurrent Work Groups

Respiratory TherapyRespiratory Therapy

PediatricsPediatrics

Just-in-time TrainingJust-in-time Training

MRC – system MRC – system designed; beginning designed; beginning implementation and implementation and recruitmentrecruitment

Parking LotParking Lot

Surveillance Tool: “It’s coming…” Surveillance Tool: “It’s coming…” projections, number of cases, projections, number of cases, severityseverityTool to Activate Tiers 1 & 2 – phased Tool to Activate Tiers 1 & 2 – phased approach, number and locationsapproach, number and locationsTool to assess function & Tool to assess function & effectiveness of Tiers 1 & 2effectiveness of Tiers 1 & 2Pregnancy CarePregnancy CarePalliative Care protocolsPalliative Care protocolsCriteria for phasing out elective Criteria for phasing out elective surgeriessurgeriesCriteria for withdrawal of supportCriteria for withdrawal of support

SummarySummary

A work in progressA work in progress

Attempt at a needs-based Attempt at a needs-based response to a situation with response to a situation with scarce resourcesscarce resources

Attempts to maximize resource Attempts to maximize resource utilization by applying county-utilization by applying county-wide triage protocolwide triage protocol

Standardizes care across countyStandardizes care across county

Addresses application of limited Addresses application of limited resourcesresources

For more informationFor more information

Roger S Case, MD @ 360 914-0840

Larry Wall @ 360-661-2924