Medical Sheltering Best Practices and Lessons Learned. Presented by: BCFS Health and Human Services Emergency Management Division

Transcription

1 Medical Sheltering Best Practices and Lessons Learned Presented by: BCFS Health and Human Services Emergency Management Division

2 Presenter: Dee Grimm RN, JD Director of Business and Program Development Emergency Management Division BCFS Health and Human Services

3 BCFS Agency History Who we are Founded in 1944, BCFS is an international system of nonprofit health and human service corporations Programs and services are offered domestically and internationally. BCFS serves over 1M worldwide annually. Funding is derived from fees for service, contracts, grants, philanthropic and endowment revenue Texas California Arizona Colorado Oregon Florida Illinois New York Washington, DC Latin America Africa Eastern Europe Southeast Asia 3

4 BCFS Health and Human Services What We Do Medical and Mental Health Services Residential Campuses for Children and Adults Foster Care and Adoption Placement Social Services International Humanitarian Aid Emergency management response, consultation & training (EMD)

5 BCFS Emergency Management Division Medical Sheltering All-Hazard Incident Management Team Base Camp Operations Medical Staffing National Immediate Disaster Case Management Jurisdictional Consultation, Training and Plan Development Mass Fatality Plans and Training/Exercise Alternate Care Site Planning and Operations Functional Needs Support Services Medical Surge and Healthcare Emergency Preparedness 5

6 Large Incident Response History Southeast Asia Tsunami Hurricane Emily Hurricane Katrina Hurricane Rita Hurricane Dean FLDS Event Hurricane Dolly Hurricane Gustav Hurricane Ike H1N1 Flu Haiti Earthquake Hurricane Alex Bastrop, Texas Wildfire Response USHHS ORR Influx 2012/2014 Ebola Outbreak, Dallas Texas

7 Medical Capacity in Disasters

8 Shortfall in Medical Preparedness Incorrect assumptions are being made about existing medical capabilities to treat mass casualties. In reality, hospital surge capacity and specialized medical capability across the United States has never been more restricted. While the public and the political communities assume that the healthcare systems are adequately preparing for terrorism incidents that would generate catastrophic casualty loads, the medical community is struggling just to maintain its everyday capacity Barbera,J.A., Macintyre,A.G., DeAtley, C.A. Ambulances to Nowhere: America's Critical Shortfall in Medical Preparedness for Catastrophic terrorism (October 2001)

9 Status of Medical Surge Capacity 2004 bombing of Madrid, Spain commuter trains 177 killed instantly 2000 injured 15 hospitals received victims In 3 hours one hospital received 270 patients

10 Findings Over half of ED beds (59%) were operating above capacity Nr. Of total ED beds in all 7 cities was less than total nr. Of victims treated at one Madrid hospital (270) L.A. 3 of 5 hospitals on divert Washington D.C. 0 ED beds in their Level One Trauma Centers None of the Trauma Centers had sufficient critical care or regular inpatients beds

11 Resource Shortfalls Just-in-time inventory systems - provide minimum on-site storage of supplies, equipment, and pharmaceuticals Re-supply and back-up mechanisms are often shared by all local facilities Decline in the ratio of trained healthcare workers to patients

12 Disaster Assumptions Resources will be overwhelmed Medical facilities already at capacity levels Staffing levels may not be what you expect Federal government will not be able to help everyone Decisions will be made at the local level Despite all our planning, situations will arise that are not anticipated Us.blog.com Beaumont Enterprise

13 Medical Surge Disaster Assumptions Growing number of people living at home with chronic medical conditions Aging population in the United States = chronic medical conditions and increase in disabilities needs Advanced technology allowing people to live longer at home with medical conditions and disabilities CDC estimates 5% to 7% of evacuating population will have some level of medical need Los Angeles - Sacramento - San Francisco - San Diego -

14 Aging Trends + Medical Conditions 34.7 million people (12.7% of the US population) are 65 years and older Approximately 50% of persons age 65+ have 2 or more chronic health conditions In California, 46 percent of the population (approximately 16 million) has chronic health conditions. Nearly half of those have multiple chronic conditions 7.6 million Americans are utilizing home healthcare 30-50% of persons using long-term care diagnosed with dementia In California, 122 percent increase statewide by 2020 for individuals in the 65 and older age group. SOURCES: US Census, NAHC&H, CDC and California Department of Aging Statistics/Demographics _about_elderly.asp

15 Elderly in Disasters Preparedness: Live in homes that are more prone to suffer damage (older/in disrepair) Less likely to have means of transportation Less likely to have access to technology Response: Evacuation of frail, older persons can be complex, difficult, and dangerous Older persons are less likely to evacuate after being warned Require more resources to safely evacuate (personnel, equipment) Recovery: Recovery can be prolonged Loss of pre-disaster services can be profound Henry J. Kaiser Family Foundation Report, Sander et. Al., L Geron Soc Work 2003

16 Disability Populations 54 million people in the United States have a disability. More than 1.4 million people live in nursing homes Approximately 900,000 people live in assisted living facilities nationwide. 61% of people with disabilities have not made plans to quickly and safely evacuate their homes. Only 24% of people with disabilities have made emergency plan preparations specific to their disability. Vulnerable populations least likely to evacuate, most likely to be impacted

17 Historic Response to People with Disabilities in Disasters People with disabilities comprised 25 to 30 percent of those impacted by Hurricane Katrina 50% of the people who died in New Orleans were over 75 years Only 11.7% of total population was over 75 years old Over 35% of those who did not evacuate in Katrina were either physically unable to leave or were caring for a person with a disability

18 2013 Disaster Lessons Learned Lack of medical shelter capacity: People inappropriately placed in institutional facilities (previously living independently) People with low acuity medical needs evacuated or self-ambulate to Emergency Departments at health care facilities Sandy: 8 hospitals and 40 nursing homes evacuated. NYU Langone Medical Center shut down for 2 months. 18

19 BCFS Operations - Hurricanes Gustav & Ike 32 Shelters / 3 Cities 2784 Shelter Guests 542 Medical Staff 245 IMT/Shelter Management Staff 370 Volunteers 5839 Prescriptions 40% O2 Dependent 430 Hospital Beds 59 Bariatric Beds Youngest Guest-newborn Oldest Guest 98 Duration 4 Months Estimated over 50% were people with disabilities and others with access and functional needs

20 Medical Surge Medical surge is the ability to provide adequate medical evaluation and care during incidents that exceed the limits of the normal medical infrastructure of an affected community. It encompasses the ability of the healthcare system to survive a hazard impact and maintain or rapidly recover operations that have been compromised. SOURCES: ttp://

21 Pandemic Influenza DHS AND DHHS VIEWS PANDEMIC FLU AS THE MOST LIKELY AND MOST LETHAL OF ALL THREATS FACING THE UNITED STATES.

22 The US Perspective The United States with 310 Million People 300 drugs in short supply or not available Hospitals at or near maximum surge In case of a pandemic there are not enough beds not enough staff, not enough medical supplies or equipment 85% of ventilators are in use on any given day in the US Supplemental oxygen will be in short supply No vaccine is presently available for any emergence of a new viral entity

23 Influenza Pandemic An attack rate will be 30% to 35% or higher in the general population. 50% will seek outpatient medical care. 15% of hospital admitted patients with Pandemic Influenza will require Intensive Care 75% or half of those admitted to ICU with Pandemic Influenza will require ventilators 70% of deaths related to Pandemic Influenza are projected to occur in a hospital

24 Medical Surge Influenced by: Facility s current census and capacity Incident type Number of casualties Dimensions: Influx (volume rate) Resource demand (consumption, degradation) Will Include: Worried well Displaced people with chronic medical needs Displaced people who lose DME, CMS, PAS 24

25 Expanding Care Strategies Early discharge and elective procedure cancellations Medical Surge Plans Patient to staff ratios Cohorting patients/doubling rooms Use of staff in different roles Volunteer and emergency credentialing policies Home based care in cooperation with Public Health Alternate Care Facilities

26 Standards, Regulations and Guidance Medical profession s code of ethics (AMA, ANA) Federal and state regulatory agencies (CMMS, OSHA) Federal (Stafford Act, NRF, ADA, FEMA) State Acts Industry standards of care (Joint Commission, AHRQ, IOM) Case law

27 Deviating for the Norm -Acceptable Exceptions Granting of extraordinary powers (MSEPA) Disaster Declarations (Emergency, State or Presidential) EMTALA/HIPAA deviation Ability to extend healthcare facilities Waiver of licensure via EMAC s/esar-vhp Just in Time Training EUA s

28 Grey Areas? Altering Standards (Standard precautions, infection control, reuse of equipment) Working outside the scope of practice Alternative care delivery Liability risks Triage decisions and allocation of resources Individual rights vs. common good Duty to Provide Care

29 Crisis Standard of Care Crisis standards of care - a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive or catastrophic disaster. Deviates from a standard that has been established by peers and often codified into laws and regulations Institute of Medicine - Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, 2009

30 Conventional, Contingency, Crisis Capacity Conventional capacity The spaces, staff, and supplies used are consistent with daily practices within the institution. Contingency capacity The spaces, staff, and supplies used are not consistent with daily practices, but provide care that is functionally equivalent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident Crisis capacity Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the setting of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Institute of Medicine - Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, 2009

31 Conventional to Crisis Care Institute of Medicine - Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, 2009

32 Palliative Care To provide the greatest comfort and minimize suffering to those whose lives will be shortened as a result of the incident Identification of those in not expected to survive category Palliative care is not abandonment, euthanasia, or hastening of death 32

33 Expectant Category Palliative care patients might be: Those expected to die (too sick/injured to live) Already existing palliative care population Vulnerable population who become palliative care persons due to lack of resources during or after event Brad Loper/Dallas Morning News

34 Providing Care in Disasters Standard of Care may have to be deviated from in a disaster Catastrophic events are poor times to ask people to make ethical judgments and decisions Healthcare providers should not be placed in positions of peril because of someone else s failure to plan The time to discuss crisis care is before the crisis

35 Alternate Care Sites and Medical Shelters

36 Sheltering Obligation or Option?

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38 Medical Shelter vs. Government Authorized Alternate Care Site Medical shelters are established to provide medical care to displaced individuals that do not require hospitalization. Alternate care sites are established during a healthcare surge to care for patients that require hospital level of care, but cannot be accommodated within existing healthcare facilities. California Guidance on Sheltering Persons with Medical Needs, CDPH 2014

39 Purpose of a Medical Shelter The intent of a medical shelter is to address the medical needs of individuals who have been displaced from their residence as a result of a disaster and require temporary housing and medical support. The medical needs of these individuals require medical care beyond what can be accommodated in a general population shelter, but not complex or severe enough to necessitate hospitalization. To provide sufficiency of care to maintain their usual level of health. The term Special Needs no longer appropriate

40 Functional Needs Support Services (FNSS) Guidance FEMA Guidance 2010, authored by BCFS Further defined existing requirements for supports individuals in general populations shelters Services that enable children and adults to maintain their usual level of independence in general population shelters. These services include: Reasonable accommodations to policies, practices and procedures Durable medical Equipment (DME) Consumable Medical Supplies (CMS) Personal Assistive Services Other goods and services as needed

41 FNSS in Sheltering One of governments primary responsibilities is to protect residents and visitors by providing emergency sheltering during disasters Shelters are sometimes operated by governments More commonly, shelters are operated by the American Red Cross Regardless of who operates a shelter, the ADA requires equal access to the benefits provided in shelters SOURCE: Chapter 7 Addendum 2: The ADA and Emergency Shelters Access for All in Emergencies and Disasters (DOJ 2007)

42 Durable Medical Equipment Walkers Wheelchairs Medical equipment Feeding Machines Ventilators Glucometer Insulin pump Oxygen tanks (resupply)

43 Consumable Medical Supplies Diapers Catheters Ostomy supplies Feeding tubes Oxygen tubing Wound care supplies

44 Personal Assistance Services Grooming Eating Bathing Toileting Dressing and undressing Walking or transferring Maintaining health and safety Taking medications Communicating Accessing programs and services

45 Examples: Medical Shelter Guests Individuals requiring active monitoring, management or intervention by a medical professional to manage their medical condition. Examples include: Hospice patients requiring IV interventions Tracheotomy which requires suctioning Extensive wound management requiring a sterile environment or wound vac Requiring isolation due to infectious disease Dysrhythmia management (stable) Receive skilled nursing care at home Previously from a skilled nursing facility

46 Command and Control, Medical Shelter Management Using ICS

47 Who Determines Medical Shelter Use? The determination on how a medical shelter will be utilized and the level of care rendered is based on: Decisions by or direction of local authorities - Public Health Officer Mayor, City Manager, EMC Availability of appropriate staff Availability of necessary resources Establishment of appropriate/necessary protocols

48 Command and Control What would your command structure look? Where does it fit? Who is in charge of your Medical Shelter? Who manages it? What coordination will there be between ESF 8 (Health and Medical) and ESF 6 (Mass Care)? 48

49 ICS Organizational Chart Incident Commander Public Information Officer Safety Officer Liaison Officer Operations Section Planning Section Logistics Section Finance Section

50 ICS Org Chart Incident Commander Safety Officer Operations Section Planning Section Logistics Section Finance Section Health Branch Law Enforcement Branch Fire Branch Public Works Branch Mass Care Branch Medical Fire Suppression General Population Shelters Public Health Search and Rescue Medical Sheltering EMS

51 ICS Organizational Chart Incident Commander Safety Officer Operations Section Planning Section Logistics Section Finance Section Health Branch Law Enforcement Branch Fire Branch Public Works Branch Human Services/Mass Care Branch Medical Fire Suppression General Population Shelters Public Health Search and Rescue Medical Shelter EMS

52 Medical Shelter Capacity Building

53 Facilities of Opportunity School Warehouse Church Civic Building

54 ClearSpan or soft-sided structures

55 Facility Considerations Building size & footprint Proximity to healthcare system Accessibility/ADA Vehicle ingress / egress Proximity to hazards

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57 Facility Considerations Electrical Primary power Backup power (transfer switch) Power outlets & circuit distribution

58 Medical Shelter Operations and Resources

59 Shelter Space Considerations General Population Shelter 40 sq. ft. per guest for healthy adults and children sq. ft. per guest requiring FNSS Medical Shelter square feet per guest

60 Shelter Configuration Front Desk Outdoor Rec Sleeping Indoor Rec Dining Interpretive Svcs Admin Shower Trailer Medical Clinic Smoking Medical Isolation Storage area Case Mgt 60

61 Key Operational Areas Controlled entry/registration area Sleeping area (floor plan diagram) Dining area Restrooms Medical clinic Nurses station Pharmacy area Isolation areas Staff area Secure storage area Lighting plan

62 Configuration of Beds Cot setup: Rows of 10 cots each (RN 1:10) Cots or beds should be configured to allow minimum 36 wide aisles (accessibility) Create floor plan diagram of main sleeping area for bed assignments. Be prepared to update frequently as census changes Utilize privacy screens or pipe and drape to provide privacy, where needed Be prepared for guests with service animals

63 Cot types Standard/Universal Medical Bariatric beds Hospital beds 63

64 Guest arrival and Tracking Greet Registration (name, basic info) Intake (Medical Staff /EMT s) Assign cot/bed space; update floor diagram Provide facility tour Review schedule and shelter rules Assess immediate medical needs including access or functional needs Projected guest needs within next 6-8 hrs Re-assess guest needs periodically

65 Resource Allocation Issues Don t Assume: You are going to get this Because you may get this By Paul Rioux/Times Picayune

66 Resource Considerations What are you going to need? (supplies, equipment, staff) How are you going to get it? Where are you going to store it? Expiration dates? Reliability of vendors? Who is going to get it?

67 Shelter Resources Shelter Set Up Module Administrative tools, including forms Cots/blankets/linens/pillows/hygiene kits Standard/universal cots Medical cots Bariatric beds, hospital beds as required

68 Shelter Resources OTC kit DME CMS PPE Patient monitoring tools Respiratory therapy tools Uniformity of modules Medical Clinic Module

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78 BCFS Mobile Command Platforms 78

79 Mobile Medical Unit (MMU-1)

80 Vendor Support Considerations Food service Pharmaceuticals Personal assistance services Case management Waste and Bio-waste removal Portable toilets and showers Laundry Transportation Security

81 Laundry Services Commercial: Linens Personal: Clothing* Mesh bags BCFS Portable capability Utilization of existing wash-n-fold infrastructure *Schedule: Every other day after 3 rd day

82 Restrooms and Showers Portables Space for portables Outdoor 110v electrical Outdoor hose spigots Ratio for restrooms (1:15) Ratio for shower heads (1:15) Ratio of ADA toilets (1:5) Black/grey water removal

83 Medical Shelter Staffing

84 BCFS EMD Incident Command System (ICS) Org Chart Pubic Information Officer Liaison Officer Incident Commander Safety Officer Operations Section Planning Section Logistics Section Finance Section Medical Shelter Branch Director ACS/FMS Branch Director Medical Staffing Director Situation Unit Comm Unit Cost Unit Division A Supervisor Division A Supervisor Triage Group Resource Unit IT Unit Time Unit Division B Supervisor Division B Supervisor Nurse Staffing Coordinator Food Unit Procurement Unit Division C Supervisor ACS/FMS Registration Group Physicians Group Ground Support Unit Division D Supervisor Mental Health Group Supply Unit Med Shelter Registration Group Nurse Staff Trainer Ordering Manager

85 Shelter Organization

86 Shelter Medical Staffing Manager A/B Paramedic Group Supervisor Pharmacy Coordinator Unit I RN Manager Unit II RN Manager Unit III RN Manager Unit IV RN Manager Unit V RN Manager RN RN RN RN RN BCFS Medical Staffing Org Chart Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest Guest

87 Shelter Professional Staffing Physician (daily rounds; on-call 24/7) Charge Nurse RNs, LVNs, CNAs Paramedics, EMT-Bs DDS (on-call 24/7) MHMR (on-call 24/7) Case Management (business hours) Law Enforcement (24/7)

88 Medical Shelter Staffing Supervision The Chief Medical Officer provides standing orders and oversight of: Medical Command Primary Care Physicians (rounds) RN Manager/Charge RN RN s, LVN s, CNA s EMT-B s, EMT-I s, EMT-Paramedics Respiratory therapists Pharmacy Coordinators Dialysis Coordinators

89 Standing Orders Chief Medical Officer writes standing orders Vitals range O2 Meds OTC (Tylenol, Motrin, Benadryl) Meds (other) Phenergan Topical ointments Pepcid Emergency procedures

90 Medical Shelter Recommended Volunteer Org Chart

91 Operational Best Practices

92 Medication Administration On-demand collection of guest medications difficult to enforce Retention and administration of meds by staff occurs if guest requests it, or if prescribed Verification of prescription may be necessary Physician evaluation if unverified, short duration prescriptions if confirmed by doc Meds are to be stored/secured/administered in accordance with state and federal laws

93 Shelter Resources Medical forms may include: Initial Triage Assignment form Medication Administration Record (MAR) Physician s orders Vitals Record Dialysis Record Medical Progress notes Hospital release form Copies of prescriptions Lab reports Immunization records Seizure report Medical station visits

94 Controlled Access and privacy Secure all points of entry Everyone uses sign-in/out sheet Restrict access Protect privacy Family visits Dignitary visits Media visits

95 Service Animals Service animals remain with their handlers Shelters provide relief area and provide periodic cleaning of the area Shelters provide food/water for service animals

96 Service Animals Service animals are defined as dogs that are individually trained to perform tasks for people with disabilities. Reasonable accommodations for miniature horses, if the horse has been individually trained to perform tasks The work or task performed by a service animal must be directly related to the person s disability. Must be harnessed, leashed or tethered Two questions you may ask Difference between service animals and ESA s or therapy animals SOURCE:

97 Emotional Support Animals A companion animal that provides therapeutic benefit to an individual with a mental or psychiatric disability. A person must meet the federal definition of disability and must have a note from a medical professional stating that the person has that disability and that the emotional support animal provides a benefit for the individual with the disability. An animal does not need specific training to become an emotional support animal. Emotional support animals are typically dogs and cats, but may include other animals.

98 Shelter Signage Shelter signage in accessible formats (high contrast) Signage indicating accessible features and how to locate Floor plans, diagrams, pictograms work best Handwritten signs will work if professionally produced materials are unavailable Volunteers designated for PAS, way finding and shelter navigation are an effective means of offering reasonable accommodations

99 Shelter Rules Post shelter rules in several high-traffic areas in accessible formats Guests may be discharged for the following, but always after consultation with BCFS/on-site LEO: Possession of weapons Possession of illegal drugs Sale of prescription drugs Theft Threatening to harm or harming self or others Intoxication Smoking inside the building

100 Shelter Schedule Schedules maintain routine and relieve stress 6:30 a.m. Lights on 7:00 a.m. to 9:00 a.m. Breakfast 9:00 a.m. to 5:00 p.m. Case Management on-site 12:00 p.m. to 2:00 p.m. Lunch 1:00 p.m. to 3:00 p.m. Recreational activities 5:00p.m. to 7:00p.m. Dinner 7:15p.m. to 7:45p.m. Shelter Manager brief 10:00p.m. Lights out

101 Food Services 3 meals per day, plus snacks/drinks D.A.S.H. plan specialized nutritional menu from the National Institutes of Health Caloric intake targets Low sodium Low sugar Low fat Pureed and infant food

102 Donations Management Food donations Clothing donations

103 Emergency Case Management Development of needs assessment Clothing and personal items Location of family Financial assistance Focus on short and long term action plans Emphasis on transitional housing Transition back to home with services in place

104 Demobilization/Repopulation Shelters are only temporary solutions Transitioning guests to better living arrangements begins when the shelter opens Reinforce communications regarding availability of case management services, disaster assistance (if any) and the need for transitional planning Enhance transportation capabilities Change hot meals to cold meals Reduce shelter services Track census counts carefully and adjust shelter diagrams as census drops

105 Questions? Dee Grimm RN, JD Director of Business and Program Development Emergency Management Division