UNDERSTANDING REGIONAL HEALTHCARE CAPACITY CHALLENGES Preparing for a surge in hospital patients In late December 2016, Pierce County s two largest hospitals were operating at maximum capacity. Emergency medical service providers were struggling to find emergency departments with available bed space, often forcing ambulances to drive long distances to deliver patients to care. Hospitals nearly always see an increase in patients during winter flu season, but seldom to this degree. In the third week of December within CHI Franciscan Health, which operates nine hospitals in Western Washington, between 65 and 100 percent of emergency room beds were occupied by patients who were waiting to be admitted to the hospital. We quickly realized that this was not just an emergency department problem, says Cindy Miron, Program Manager of Emergency Preparedness at the Tacoma-Pierce County Health Department (TPCHD). Inpatient beds were full. Outpatient clinics were seeing higher than normal capacity. Long-term care facilities were reluctant to accept patients ready for discharge out of concern for potential outbreaks among their vulnerable residents. Response Activation Similar reports from King and Snohomish counties lead the Washington State Department of Health (DOH) to convene a call with local health officials in early January. Four days later, the Northwest Healthcare Response Network (the Network), the healthcare coalition serving King and Pierce counties, activated its Healthcare Emergency Coordination Center to gather information that would help regional and state authorities decide how to address the problem. One of the challenges was figuring out what was causing this and what, therefore, was the solution, says Nigel Turner, Director of Communicable Disease Control at TPCHD. What the Network brought to this was a structure that could allow that type of analysis to happen. Over the next six weeks, the Network polled healthcare organizations weekly regarding trends in flu cases, bed capacity, staffing shortages and strategies for addressing them. Results were compiled in Healthcare Impact Reports that were shared with local and state public health leadership and healthcare stakeholders. Hospitals all along the Interstate 5 corridor had been struggling with a rising daily census for more than two years. Since the reports indicated this was not a particularly severe flu season, it was determined that the ongoing capacity issues had become so severe that some facilities now lacked the space and resources to handle even minor surges in patients without activating their disaster plans. In A Disaster The work of the coalition allows our community to: Share information that supports crisis decision-making Analyze and report trends affecting healthcare delivery Create additional healthcare capacity when needed Work collectively to solve common problems Situational Awareness The Network s reports assured providers that their challenges were part of a larger problem that had the attention of the state s highest authorities. These communications were really helpful for me as a leader, says Margo Bykonen, Chief Nursing Officer for Swedish Health Services. It s really hard for staff trying to place all these patients and not having any bit of a break. So to be able to see that we were not alone in this, that this was a community-wide struggle, not just within the Swedish system, was a big deal.
UNDERSTANDING REGIONAL HEALTHCARE CAPACITY CHALLENGES The reports inspired some non-hospital facilities to take measures to lighten the burden on emergency departments. The Polyclinic, which includes nearly a dozen outpatient centers in King County, stepped up its standard flu season employee vaccination and education campaigns, and encouraged providers to minimize referrals to hospitals whenever safely possible. Knowing what was happening in the hospital sector gave me the information I needed to make sure we were ready if this became a bigger issue, says Judy Mitacek, the Polyclinic s Business Continuity and Compliance Coordinator for Disaster Preparedness. In an emergency, not everything can happen in the hospital setting. Outpatient settings have to share part of the burden of taking care of all of our patients in King County. To be able to see that we were not alone in this, that this was a community-wide struggle was a big deal. Margo Bykonen, Chief Nursing Officer, Swedish Health Services Planning Pays Off In addition to situational awareness from the Healthcare Impact Reports, healthcare organizations benefited from previous efforts to plan for surge situations. In recent years, the Network had hired consultants to assist regional hospitals in identifying ways to accommodate extra patients in the event of a crisis. St. Joseph Medical Center, a CHI Franciscan hospital in Tacoma, used that planning at the height of this winter s capacity challenges to add 20 temporary beds by converting single rooms in its orthopedic wing to double occupancy and implementing contingent staffing plans. Facilities across the region exercised relationships they d built through the Network to share best practices for meeting the community s healthcare needs. Several important conversations revolved around the work of the Network s Disaster Clinical Advisory Committee, funded almost entirely through the HPP. This group of providers and health department representatives meets quarterly to develop regional strategies for clinically responsible decision-making in times of crisis when the community might face a shortage of important resources ranging from staff to medicines. Having those ethically challenging conversations up front about how we provide care when there are limited clinical resources is so valuable, says Bykonen, who has served on the committee since 2012. As the flu season waned in late February, hospital censuses returned to their previous numbers, still much higher than ideal. Armed with the knowledge that daily capacity problems mean that a disaster could overwhelm the healthcare system, state and local health authorities, supported by the Network and regional healthcare leaders, are convening a task force to root out causes and seek long-term remedies. Programs funded by the U.S. Office of the Assistant Secretary for Preparedness and Response and Network members are critical to that effort. Without them, you wouldn t have the tools to support healthcare in making tough decisions about resource allocation or space allocation, says Michael Loehr, Chief of the DOH Office of Emergency Preparedness and Response. That would have to be made up on the fly, and that s not a good place to be in a disaster. About the Network We lead regional healthcare collaboration to effectively respond to and recover from emergencies and disasters in King, Pierce and Kitsap counties in Washington State. We serve the state s medical epicenter, including 3.2 million residents, 140,000 healthcare workers, almost 50% of the state s hospital beds, and nearly 2,000 healthcare organizations.
BUILDING CAPABILITIES TO SUPPORT HOSPITAL EVACUATION Getting the right patient to the right place during an evacuation When a mock fire inside Swedish Medical Center s First Hill Campus in Seattle damaged the primary electricity supply and generator on March 31, 2011, dozens of hospitals and emergency response agencies worked together during a disaster drill to evacuate 133 pediatric patients, 75 of whom required transfer to a Neonatal Intensive Care Unit (NICU). Healthcare for All Populations It is very daunting to think about all of the necessary elements needed to ensure a safe and effective evacuation, says Cindy Miron, Emergency Preparedness Program Manager at the Tacoma-Pierce County Health Department. Knowing that none of us is alone and we can rely on partners is so important, as is knowing what each other s roles are. In the 2011 exercise, some patients were sent to facilities that were not capable of providing the level of care they needed, forcing the receiving hospitals to stabilize and transfer them again, a risky and avoidable extra step brought on by a lack of understanding of which regional hospitals had certain specialty services, recalls Eileen Newton, Emergency Preparedness Manager for CHI Franciscan Health, which participated in the exercise. Swedish First Hill cares for some of the sickest babies there are, she says. You can t just move them to any hospital. Most hospitals don t have a NICU, let alone a NICU that provides as high of a level of care. The same is true for adult patients who need specialty care. From heart-lung bypass machines and continuous dialysis to behavioral healthcare for patients who are incarcerated, there are many services that are provided only at certain hospitals. Yet at the time of the exercise, there was no index of which hospitals provided which services. If you don t have that information in advance, you slow down your ability to respond appropriately, because you re having to get it on the spot, likely with compromised communication systems, says Barb Graff, Director of the Seattle Office of Emergency Management. In A Disaster The work of the coalition allows healthcare in our community to: Follow up-to-date, practiced regional evacuation plans for hospitals and long-term care facilities Place specialty patients in hospitals that can provide the level of care they need Track and reunify patients and families Share information and resources Work together to be self-sufficient As the regional healthcare coalition, the Northwest Healthcare Response Network (the Network) has created regional plans for evacuating and distributing hospital patients, as well as exercises to test them and identify gaps in preparedness.
BUILDING CAPABILITIES TO SUPPORT HOSPITAL EVACUATION Developing a Solution In Spring 2016, the Network created a list of 70 specialty services and hired consultants to conduct a survey to determine which among 33 hospitals and acute care facilities in King and Pierce counties could provide them. When the project wraps up in 2017, the information will help each county s Disaster Medical Control Center (DMCC) the hospital responsible for coordinating the distribution of patients in the event of an evacuation save time when placing patients. We have to be able to continue to provide care to patients under any condition. The Network is helping us accomplish that. Eileen Newton, Emergency Preparedness Manager, CHI Franciscan Health Preparing as a Community Exercises have also revealed the need for the local healthcare community to be prepared to help itself during a disaster, rather than rely on outside resources that may be in short supply. In the Cascadia Rising exercise, sponsored by the Federal Emergency Management Agency in June 2016, the entire region simulated a 9.0 earthquake. As part of the exercise, St. Clare Hospital, a 106-bed CHI Franciscan facility in Lakewood, Washington, learned that its local water district had installed earthquake sensors as a safety measure that would automatically shut off the water supply in the event of tremors. The lack of water would make it impossible for St. Clare s to maintain its environment of care, forcing administrators to evacuate the building. Although the healthcare players in the exercise recognized the enormous complexity of evacuating the community s sole hospital, its plight was low on the list of federal and state priorities. This signaled to Newton the important role that coalition-based collaboration has in creating regional healthcare resilience. The Value of the Network Before the Network it felt like we were running from one exercise to another and we knew we had all these gaps, but we really didn t have a strategic plan for how we were going to address them, she says. We have to be able to continue to provide care to patients under any condition. The Network is helping us accomplish that. They re helping make healthcare agencies stronger and more prepared to deal with all types of disasters. Although healthcare agencies and their emergency response partners agree that a hospital evacuation would require community-wide coordination and support, no government agency has the mandate or resources to maintain a regional healthcare evacuation plan. That work falls to the Network. Healthcare organizations are required to have plans and procedures in place to respond to disasters and emergencies and they do a really good job at that, says the Network s Planning and Preparedness Manager Aaron Resnick. But without organizations like the Network and other coalitions, there are no mechanisms to plan for emergencies outside of the walls of any individual healthcare institution. About the Network We lead regional healthcare collaboration to effectively respond to and recover from emergencies and disasters in King, Pierce and Kitsap counties in Washington State. We serve the state s medical epicenter, including 3.2 million residents, 140,000 healthcare workers, almost 50% of the state s hospital beds, and nearly 2,000 healthcare organizations.
PATIENT TRACKING IN RESPONSE TO FATAL SEATTLE BUS CRASH Tracking loved ones during a disaster On September 24, 2015, a Ride the Ducks tour vehicle collided with a charter bus carrying 45 international students and staff from North Seattle College on Seattle s busy Aurora Bridge. Five people were killed and 71 injured in the largest multicasualty incident Seattle had experienced. On what was likely one of the worst days the victims families had seen, emergency plans and tools facilitated the exchange of critical information about the patients whereabouts and conditions. Tracking Critical Information Within minutes of the crash, the Seattle Fire Department was on scene triaging injuries, while the city s Office of Emergency Management (OEM) opened its Emergency Operations Center. Once notified by OEM, the Northwest Healthcare Response Network (the Network), which leads the regional healthcare coalition, issued an alert through WATrac, an online healthcare communication and resource tracking system that hospitals use daily across the state. Each Seattle hospital was prompted to update its bed availability, facilitating the distribution of nearly 60 accident victims to seven area hospitals and one urgent care center. The OEM coordinated among 15 separate city departments and 11 partner agencies to manage complexities ranging from the massive traffic impacts to the notification of consulates representing the 14 foreign countries from which the accident victims hailed. It relied on the Network for assistance in tracking the location and condition of each of the patients. The very definition of a disaster is that there s chaotic, unconfirmed information, says OEM Director Barb Graff. Trying to get your arms around whether you got ahold of everybody is no small task. But the Network made it so easy on us. Exercises conducted through the years had identified a need for a standard way to track patients through the healthcare system in a mass casualty incident. In response to this gap, the Network began the implementation of WATrac, a web-based application that includes a patient tracking system. Within two hours of the bus crash, the Network launched the first disaster activation of WATrac, asking hospitals to input basic demographic information about the patients and update their status as they moved through the continuum of care. In A Disaster The work of the coalition allows healthcare in our community to: Distribute patients to the appropriate hospitals Track patients location and conditions Use a single point of contact for healthcare information Anticipate medical facilities resource needs The Network held the master patient roster, with staff members working as liaisons in the Emergency Operations Center. Using their strong relationships with emergency managers, they streamlined the exchange of information and minimized the number of phone calls so healthcare facilities could focus on their top priority providing quality, efficient medical care to the accident victims.
PATIENT TRACKING IN RESPONSE TO FATAL SEATTLE BUS CRASH Family Reunification The patient tracking system also allowed Public Health-Seattle & King County (PHSKC), the local health department, to provide information to families who called into its Family Reunification Hotline, which received more than 70 calls in the two days following the accident. We could not have operated the call center without the patient tracking piece, says Response Planning Program Manager Ashley Kelmore. We wouldn t have had the information to effectively respond to the callers. Trying to get your arms around whether you got ahold of everybody is no small task. But the Network made it so easy on us. Barb Graff, Director, Seattle Office of Emergency Management Managing Resources The patient tracking system also benefited non-hospital healthcare organizations involved in regional preparedness planning. Bloodworks Northwest, which has been involved with the Network since its inception as the King County Healthcare Coalition in 2005, provides blood products and services to nearly 90 hospitals in Washington, Oregon and Alaska, had been trained in the use of the WATrac patient tracking system. After the accident, staff used the tool to anticipate which healthcare facilities would likely need blood products based on the listed patient conditions. With this information, Bloodworks Northwest s ability to support the hospitals contrasted markedly with the response to a shooting at Umpqua Community College in Roseburg, Oregon, the following week, says President and CEO Dr. Jim AuBuchon. Even though all the seriously injured patients in Roseburg ended up at one facility that we serve, we had more difficulty finding out the condition of the patients, the likelihood of their need for transfusion, the availability of the components and what restocking might be needed, he says. PHSKC Preparedness Director Carina Elsenboss, who has worked in healthcare preparedness in the Puget Sound for more than 12 years, says the patient tracking system made a night and day difference compared to the many exercises she s participated in over the years in which there was no central database of patient information. Addressing the Gaps Yet the incident also highlighted further work to be done, says the Network s Western Washington Planning Support Coordinator Rebecca Lis. It was an opportunity to test where we were, but also to reinforce what we can do, Lis says. It gave us momentum with the community and an understanding that this is something we all need to invest time in, and we re on board with. Since the accident, nearly all regional healthcare facilities have been trained in the use of WATrac s patient tracking system. At Seattle OEM, Graff has partnered with the Network for years in exercises and responses to infectious disease outbreaks and weather hazards. She says the city has come to rely on the Network and its tools like WATrac to be the voice for and liaison to the regional healthcare system in emergencies, a role no city department has the expertise or relationships to fill. On our worst day, this is one thing we ve taken care of that won t go wrong for us, she says. The week that we were activated for the bus crash verified why it was vital to have that kind of a network and have a good working relationship with it. I think they proved their value in that activation. About the Network We lead regional healthcare collaboration to effectively respond to and recover from emergencies and disasters in King, Pierce and Kitsap counties in Washington State. We serve the state s medical epicenter, including 3.2 million residents, 140,000 healthcare workers, almost 50% of the state s hospital beds, and nearly 2,000 healthcare organizations.
TRAINING ALL PROVIDERS IN BASIC PEDIATRIC EMERGENCY CARE Preparing to care for children in a disaster Children are particularly vulnerable during disasters and have different medical and emotional needs than adults. Yet a 2006 study by the Institute of Medicine (IOM) determined that most hospitals in the United States were not prepared to provide nuanced care for children in an emergency. People think they can go to any hospital and kids will get the same care, and that s just not true, says Carolyn Blayney, Program Manager for Pediatrics and Burns at Seattle s Harborview Medical Center. Kids are not small adults. They come in all different shapes and sizes, which means equipment has to be different, medications are different, and how you talk to them has to be different. Addressing a Gap in Service In 2010, Mary King, the Director of Harborview s Pediatric Intensive Care Unit, and colleagues partnered with the local healthcare coalition, now known as the Northwest Healthcare Response Network (the Network), to study the geographic distribution of local pediatric resources. They found that although about 78 percent of children in King County live outside of the city of Seattle, more than 80 percent of pediatric healthcare resources hospital beds, doctors and nurses are inside the city. An earthquake of the magnitude Seattle is predicted to experience in coming years would likely damage the bridges that provide access to the city, effectively cutting children off from the doctors and facilities that are specifically trained to care for them. We have to think about how we re going to get the resources to those kids or the kids to the resources, or at least better prepare everybody to take care of kids, and feel they have a duty to do so, King says. Innovative Tools To address this gap, the Network launched a Pediatric Triage Task Force to develop tools and trainings to prepare providers who typically see adults to care for children. These resources are designed to build capabilities that not only help during emergencies, but also on a day-to-day basis since the IOM study reported that 82 percent of pediatric visits to emergency departments are to non-children s hospitals and departments. Every hospital is going to see children and every emergency room has to be prepared for that, says Dr. Vicki Sakata, the Network s Senior Medical Advisor and a physician at Mary Bridge Children s Hospital in Tacoma. Preparedness practices have to become part of everyday practice, not something used only in a disaster. The Network s Pediatric Disaster Toolkit encourages non-children s hospitals to identify pediatric champions and provides resources like supply lists, strategies for managing unaccompanied minors and job action sheets to help staff understand their responsibilities in disasters that affect children. They also include templates of tools that Harborview has developed to improve its own pediatric emergency care. In A Disaster The work of the coalition allows healthcare in our community to: Access easy-to-use pediatric emergency medicine tools Utilize training on the nuances of caring for children Provide care for children at non-pediatric facilities Share best practices in pediatric preparedness and response to support other communities
TRAINING ALL PROVIDERS IN BASIC PEDIATRIC EMERGENCY CARE We are an adult hospital that takes care of kids, Blayney says. Even though we re a Level 1 Trauma Center, they re a small part of our population we admit 800 kids a year, but thousands of adults. It s a lot harder to stay good and keep interested in pediatrics when you re caring for adults all the time. Every hospital is going to see children and every emergency room has to be prepared for that. Dr. Vicki Sakata, Physician, Mary Bridge Children s Hospital Harborview has developed a suite of easy-to-use resources based on the internationally respected Broselow Tape, a color-coded system that measures a child s height and weight to determine sizeappropriate medication dosages and equipment. Each child who comes into Harborview is tagged with a bracelet printed in his or her Broselow color. Since all pediatric supplies and medications stocked in the hospital are labeled with color-coded stickers, providers can quickly identify the right item for a patient and use color-coded medication sheets to determine appropriate dosing. These innovative tools have spread beyond the hospital. In summer 2016, the six King County emergency medical service (EMS) agencies began using cards with standard color-coded pediatric dosing instructions and formularies that King helped them develop to standardize care and eliminate the need for risky on-the-spot calculations. It takes out 10 steps and 10 chances for error to try to make it so that when we resuscitate a child, we do it the same way every time, and we do it the same way we do for adults, King says. After six months, the percentage of paramedics who reported that they were comfortable performing pediatric resuscitation had increased from 24 to 33 percent. Preparing the Region and Beyond Since 2011, the Network has also conducted Pediatric Disaster Response Workshops, providing opportunities for more than 800 non-pediatric clinicians and EMS personnel across Washington to develop the skills and self-assurance to provide better pediatric care. Lessons include use of the Broselow Tape, management of pediatric pain and recognition of mental health challenges. If you get people up and start practicing things, it builds confidence, Sakata says. Mason General Hospital in Shelton, Washington, saw the value immediately. The weekend following a Pediatric Disaster Workshop there in May 2016, a pediatric patient came in to the emergency department and the providers on shift used the techniques they had just learned to quickly stabilize and prepare the child for transfer to Mary Bridge. A year later, Monitor Technician Mariah Pede says the staff has continued to reap benefits from the training. We loved the tips regarding the Broselow Tape and exact dosing for medications, she says. It has made for faster, more efficient pediatric care. The Pediatric Triage Task Force s work has caught the attention of others around the country, and the Network has helped physicians in Oregon and California launch their own workshops to make sure regional providers are prepared to care for children in emergencies. Representatives from the Network and Harborview have presented their work nationally and contributed to the development of the National Pediatric Disaster Coalition and other initiatives dedicated to advancing care for children in emergencies. About the Network We lead regional healthcare collaboration to effectively respond to and recover from emergencies and disasters in King, Pierce and Kitsap counties in Washington State. We serve the state s medical epicenter, including 3.2 million residents, 140,000 healthcare workers, almost 50% of the state s hospital beds, and nearly 2,000 healthcare organizations.
UNDERSTANDING REGIONAL HEALTHCARE RESPONSE CHALLENGES Planning a communitywide response to acute infectious disease As individuals, we create and test plans every day, usually without realizing it. Some plans are simple, like scheduling a meeting with a colleague. Other plans, such as organizing a potluck dinner party, are a bit more complicated. If the plan (in this case, an invitation) was adequately scoped, clearly written and communicated, you won t end up with all desserts and no entrees. And then there are far more complex plans. One way the Network helps bolster the disaster resiliency of the Puget Sound healthcare community is to create, test and maintain collaborative regional plans. Like the dinner party plan, these plans must be well scoped and clearly written to elicit the desired response. However, unlike our potluck scenario, the Network doesn t wait for the event to test it. Instead, they approach plan creation and testing as a progressive, multiyear process, allowing for plan refinement and mastery at each level before moving to the next. Let s take the Regional Acute Infectious Disease (AID) Response Plan as an example. In late 2014, the threat of the Ebola virus was circling the globe. As Seattle is an international hub for travel, commerce and tourism, there was justified concern the virus could make its way to the Puget Sound region. The Network responded by activating its Healthcare Emergency Coordination Center to support coordination and information sharing within the healthcare community. This activation was the catalyst to develop a regional response plan to address not only Ebola, but the broader category of acute infectious disease. Specifically, the plan would define roles and responsibilities of regional response agencies, including healthcare, public health and other regional and state partners for a coordinated regional response related to the potential consequences of an acute infectious disease outbreak. In A Disaster The work of the coalition allows our community to: Share information that supports crisis decision-making Address community-specific needs Quickly operationalize response plans Work collectively to solve common problems By January 2016, the Network had conducted research and interviews with representatives from Public Health Epidemiology in King and Pierce counties, Washington State Department of Health Epidemiology, hospitals, outpatient care, and emergency medical services. A draft plan was created, input was gathered and gaps were addressed. Attention could now turn to testing the plan.
UNDERSTANDING REGIONAL HEALTHCARE RESPONSE CHALLENGES The Testing Cycle For the Network, testing typically starts with a plan training, where key stakeholders are provided with the plan background and overview. Next, those same stakeholders participate in a tabletop exercise, which involves talking through a scenario with the goal of identifying gaps in the plan. Once those gaps are addressed, a functional exercise is conducted and a broader group of stakeholders play out a scenario, often focusing on key parts of the plan with a goal of resolving issues. Several functional exercises may occur, depending on the readiness of the plan and participating organizations. Lastly, if deemed appropriate and resources are available, a full exercise is conducted. In a full scale exercise, participants play out larger events as if they are actually happening and often include people role-playing as patients. Plan testing is often seen as a walk, jog, run process, building in complexity and capability.it s also a cycle of plan, train, exercise the plan and fix gaps. Rebecca Lis, Western Washington Planning Support Coordinator, NWHRN Drawing from lessons learned at the tabletop exercise, the Network created an improvement plan with the input of their Acute Infectious Disease Advisory Group, drove the development of curriculum, and hosted the webinar-based trainings to address gaps. The functional exercise took place in August of 2017, and focused on testing the decision-making and communications protocol. The plan is ready to be activated by public health or the Network when needed. As there is great benefit in collaboratively planning for a regional response before a disaster strikes, the Network has created and maintains several other plans, including: Regional Healthcare Situational Awareness Procedure Regional Scarce Resource Management and Crisis Standards of Care Concept of Operations Regional Patient Tracking Concept of Operations King & Pierce County Long-term Care Mutual Aid Plan (LTC-MAP) for Evacuation and Resource Sharing The following plans are being updated: Regional Hospital Evacuation Plan Regional Healthcare System Emergency Response Plan Preparing as a Community The Network hosted its AID plan training webinar in February of 2016, followed by the discussion-based tabletop exercise in April. Fifty participants from four counties (King, Pierce, Snohomish, and Kitsap) and the state were given an evolving scenario to react to and discuss, resulting in collaborative conversations covering AID screening processes, precautions, notification coordination, operational protocol, laboratory protocol and how to transfer a suspected AID patient. About the Network We lead regional healthcare collaboration to effectively respond to and recover from emergencies and disasters in King, Pierce and Kitsap counties in Washington State. We serve the state s medical epicenter, including 3.2 million residents, 140,000 healthcare workers, almost 50% of the state s hospital beds, and nearly 2,000 healthcare organizations.