Pandemic Pandemic InfluenzaInfluenza

Hospital and Clinic Hospital and Clinic PlanningPlanning

Daniel T. O’Laughlin, MD, Daniel T. O’Laughlin, MD, FACEPFACEP

Medical Director of Medical Director of Emergency Emergency

PreparednessPreparednessAbbott Northwestern Abbott Northwestern

HospitalHospital

Assistant Professor of Assistant Professor of Emergency MedicineEmergency Medicine

University of MinnesotaUniversity of Minnesota

September 10, 2009

Successful Pandemic Successful Pandemic Preparedness Defined ?Preparedness Defined ?

“Every hospital, in collaboration with other hospitals and with public health agencies, will be able to provide appropriate care to flu victims requiring hospitalization while maintaining other essential medical services in the community, both during and after a pandemic.”

Eric Toner and Richard Waldhorn. Perspective: What Hospitals Should Do to Prepare for an

Influenza Pandemic. Biosecurity and Bioterrorism. Volume 4, Number 4, 2006

Economic RealitiesEconomic Realities ““Just In Time” economy affects healthcare as Just In Time” economy affects healthcare as wellwell

Hospitals, if profitable, only have a thin Hospitals, if profitable, only have a thin profit margin (avg 1.9%)profit margin (avg 1.9%) 30% of US hospitals are currently losing money30% of US hospitals are currently losing money

Average US hospital has 41 days of cash on Average US hospital has 41 days of cash on handhand

A hospital’s ability to offset typical lost A hospital’s ability to offset typical lost revenue from illness related hospitalizations revenue from illness related hospitalizations with elective procedures will be greatly with elective procedures will be greatly reduced or eliminated altogetherreduced or eliminated altogether

Hospital Planning Priority Hospital Planning Priority ConsiderationsConsiderations

1.1. Regional collaborative Regional collaborative planning that is realisticplanning that is realistic

2.2. Infection Control Infection Control Limit nosocomial spreadLimit nosocomial spread

Protects HCW, other inpatients Protects HCW, other inpatients and prevents hospitals from and prevents hospitals from amplifying the disease spreadamplifying the disease spread

Hospital Planning Priority Hospital Planning Priority ConsiderationsConsiderations

3.3. Hospital workforce Hospital workforce managementmanagement

4.4. Allocation of scare Allocation of scare resourcesresources

Potential Planning Potential Planning RoadblocksRoadblocks

Healthcare surge capacity is lowHealthcare surge capacity is low Personal preparedness is poorPersonal preparedness is poor Hospital administration buy-in is variableHospital administration buy-in is variable Financial support is poor Financial support is poor Staff absenteeismStaff absenteeism Union concernsUnion concerns Insufficient PPE/Meds/Vaccine for HCWsInsufficient PPE/Meds/Vaccine for HCWs Workforce licensing restrictions & rapid Workforce licensing restrictions & rapid credentialingcredentialing

Specialization / Compartmentalization of Specialization / Compartmentalization of healthcarehealthcare

Minnesota HospitalsMinnesota Hospitals 134 Acute Care Hospitals in MN134 Acute Care Hospitals in MN

Over 2/3 are private, nonprofit Over 2/3 are private, nonprofit organizationsorganizations

Urban Location – 53Urban Location – 53 Rural Location – 81Rural Location – 81

79 are designated 79 are designated Critical Access HospitalsCritical Access Hospitals

29 % of MN acute care hospitals operate 29 % of MN acute care hospitals operate either in the red or with a < 5% either in the red or with a < 5% operating marginoperating margin

(based on 2007 HCCIS data)(based on 2007 HCCIS data)

MSP Metro Acute Care MSP Metro Acute Care HospitalsHospitals

Bed Type Available TotalPercent Staffed and Available

Adult ICU 52 513 10.14%

Burn Care 1 35 2.86%

Med-Surg 172 2398 7.17%

Non CC monitored 61 888 6.87%

Peds ICU 10 95 10.53%

Peds Medical 49 429 11.42%

Behavioral Health 14 559 2.50%

NICU 20 193 10.36%

MNTrac Snapshot from 09-09-09

Facility-based SurgeFacility-based Surge10-20% operating bed capacity could 10-20% operating bed capacity could

be mobilizedbe mobilized Get ‘em up and get ‘em out (ED, clinics)Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing Discharges and transfers (eg: nursing home)home) Discharge holding areaDischarge holding area

Board patients in hallsBoard patients in halls Cancel elective proceduresCancel elective procedures Convert procedure/PACU areas to patient Convert procedure/PACU areas to patient carecare

Accommodate vents on floor (or BVM or Accommodate vents on floor (or BVM or austere O2 flow powered ventilators)austere O2 flow powered ventilators)

Supply and staffing issues (72h ahead)Supply and staffing issues (72h ahead)

Surge Capacity C S TSurge Capacity C S T

The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationsCommunications CoordinationCoordination

* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get you don’t ‘get all C’s’all C’s’

The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial

The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport

StaffStaff ALL job categories will have ALL job categories will have significant absenteeismsignificant absenteeism From NYC Healthcare Worker SurveyFrom NYC Healthcare Worker Survey

>50% had childcare issues>50% had childcare issues ~27% had eldercare issues~27% had eldercare issues ~30% had a spouse expected to respond~30% had a spouse expected to respond

Creative use of volunteers may be Creative use of volunteers may be neededneeded

Rapid credentialing process for Rapid credentialing process for volunteersvolunteers

MN EMS ResourcesMN EMS Resources

78% of Minnesota EMS personnel are 78% of Minnesota EMS personnel are volunteervolunteer

<40% of EMS personnel rated EMS as <40% of EMS personnel rated EMS as their 1their 1stst priority in a disaster priority in a disaster

N95’sN95’s((Estimated hospital inpatient need)Estimated hospital inpatient need)

Assume mask use for 2 hours on Assume mask use for 2 hours on averageaverage

Does not include home care, ACS, Does not include home care, ACS, family, ….family, ….

Estimate of Estimate of 275 masks / inpt bed 275 masks / inpt bed for for 8 week pandemic duration for direct 8 week pandemic duration for direct patient care deliverypatient care delivery

3,300,0003,300,000 N95s for usual operational N95s for usual operational bed capacity in MN over 8 weeksbed capacity in MN over 8 weeks

Community-Community-Based Based SurgeSurge

ClinicsClinics HomecareHomecare Nursing homesNursing homes Procedure centersProcedure centers Family-based careFamily-based care Alternate Care SitesAlternate Care Sites Flu CentersFlu Centers

Flu CentersFlu Centers

Provide a consistent assessment of Provide a consistent assessment of patients with influenza symptoms.patients with influenza symptoms.

Triage and refer patients.Triage and refer patients.

Provide access to self-care Provide access to self-care information & treatment for lay home information & treatment for lay home care.care.

Distribute medications as appropriateDistribute medications as appropriate

Overarching Goal for Overarching Goal for Scarce Resource AllocationScarce Resource Allocation

Do the greatest good Do the greatest good for the greatest for the greatest

number of persons you number of persons you can based upon the can based upon the resources availableresources available

Patient Care Strategies for Patient Care Strategies for Scarce Resource Situations TOOL Scarce Resource Situations TOOL

KITKIT1.1. Oxygen Conservation StrategiesOxygen Conservation Strategies2.2. Medication Utilization StrategyMedication Utilization Strategy3.3. Hemodynamic Support and IV FluidsHemodynamic Support and IV Fluids4.4. Mechanical VentilationMechanical Ventilation5.5. StaffingStaffing6.6. NutritionNutrition

Documents can be found at:Documents can be found at:

http://www.health.state.mn.us/oep/http://www.health.state.mn.us/oep/healthcare/index.html#pandemichealthcare/index.html#pandemic