Israel surge capacity feb 2010 (3)


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Israel surge capacity feb 2010 (3)

  1. 1. Hospital Surge Capacity : Lessons from Israel2LT Laura CookmanJim Holliman, M.D., F.A.C.E.P., Program ManagerAfghanistan Health Care Sector Reachback ProjectCenter for Disaster and Humanitarian Assistance Medicine(CDHAM)Professor of Military and Emergency MedicineUniformed Services University of the Health Sciences (USUHS)Clinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A. February 2010
  2. 2. Lecture Objectives• To define surge capacity and surge capability• To outline the basic principles of surge capacity including the 3 S’s and patterns of sudden impact versus prolonged events• To outline Israel’s disaster response plans with suggestions of what can be applied to the United States (U.S.)• To identify challenges facing the U.S. in disaster planning
  3. 3. Definition of Surge by Webster’s Dictionary 1 “to rise suddenly to an excessive or abnormal value”
  4. 4. 2Definition of Surge Capacity“a healthcare system’s ability to manage a sudden or rapidly progressive influx of patients within the currently available resources at a given point in time” :American College of Emergency Physicians (ACEP)
  5. 5. 3Definition of Surge Capability “refers to the ability to manage patients requiring unusual or very specialized medical evaluation and care” : U.S. Department of Health and Human Services (HHS)
  6. 6. U.S. Department of Homeland Security (DHS) Defined Critical Infrastructure and Key Resources• Agriculture and Food • Energy• Banking and Finance • Government Facilities• Chemical • Healthcare and Public Health• Commercial Facilities • Information Technology• Communications • National Monuments and Icons• Critical Manufacturing • Nuclear Reactors, Materials & Waste• Dams • Postal and Shipping• Defense Industrial Base •Transportation Systems• Emergency Services • Water
  7. 7. DHS CriticalInfrastructure and Key Resources Sectors
  8. 8. The Basic Problem for Disaster Planning : Demand > Supply
  9. 9. The 3 S’sFrom Koenig andSchultz’s Disaster Medicine, 20104 (And maybe there should be a 4th “S”: System)
  10. 10. Surge Capacity Sudden Impact Event Prolonged EventEarthquake, hurricane, bomb, chemical attack Pandemic Influenza, Bioterrorist attack, Can lead to… outbreak Staff Stuff Structure System
  11. 11. Sudden Impact Event versus Prolonged Event Sudden Impact Event Prolonged Event Earthquake, hurricane, Pandemic Influenza, bomb, chemical Bioterrorist attack From Barbisch and Koenig5
  12. 12. IsraelBackground Information6• Area : 20,330 sq. km (7,850 sq. miles)• Population : 7.23 million• Similar to New Jersey in size & populationKey Differences vs. U.S.:• Health insurance for all residents• One national Emergency Medical Service (EMS) – Magen David Adom (“Red Star of David”)• No military hospitals – General hospitals treat both civilian and military casualties• History of repetitive attacks on country – Since independence in 1948 : 7 major conflicts fought – Terrorist suicide bombs, rocket attacks, etc.
  13. 13. The Middle East
  14. 14. Excellent Summary Reference Peleg K, Kellermann A. Enhancing hospitalsurge capacity for mass casualty events. JAMA 2009; 302(5): 565-567.
  15. 15. Peleg and Kellerman’s List of Key Planning Principles 71. Nationally coordinate 6. Avoid ED crowding and resources. promptly clear EDs.2. Establish goals and prepare 7. Reinforce medical standard operation workforce and designate procedures. adjoining site to treat pts3. Constantly monitor surge with minor injuries. capacity. 8. Designate a triage4. Design expandable hospital. facilities. 9. Practice, practice, practic5. Coordinate EMS with e. healthcare facilities.
  16. 16. 1. Nationally Coordinate Resources• Supreme Health Authority – Defines and enforces the nation’s health policies for disasters and mass casualty events• Result of having centrally coordinated authority is clear command, control and communication• Stockpiles prepositioned at each hospital and some national distribution centers
  17. 17. 2. Establish goals and prepare standard operation procedures (SOPs)• National standard – Every hospital must be prepared to care for additional 20 % of normal hospital capacity• SOPs – Based on national doctrine written by Israeli Ministry of Health (MOH) – Uses internal and external call-up systems – Standard procedures for each hospital nationally
  18. 18. 3. Constantly monitor surge capacity• Standard format• Daily report to MOH – Inpatient and Intensive Care Unit (ICU) occupancy by specialty – Hospital’s overall bed capacity – Number of patients receiving ventilator support out of ICU
  19. 19. 4. Design Expandable Facilities• Capability to quickly expand in Mass Casualty Event (MCE) Edith Wolfson Medical Center’s Basement 500 Bed Expansion Emergency Department
  20. 20. Examples of expandable facilities Left : Rambam Hospital, Haifa, IsraelRight : Sheeba Tel HaShomer Hospital, Tel Aviv
  21. 21. 5. Coordinate Emergency Medical Services (EMS) with healthcare facilities• EMS coordinated by national and regional command & control centers – Command and control center notifies the hospitals closest to event• Distributes severely injured casualties among several hospitals• EMS liaison at each receiving hospital
  22. 22. 6. Avoid Emergency Department (ED) crowding and promptly clear EDs• Israeli hospitals aim to keep ED clear• No boarding• In Israel it takes 10-15 minutes to CLEAR ED after MCE• Nearest hospitals notified by EMS Tel Aviv Sourasky Medical Center
  23. 23. 7. Reinforce medical workforce and designate adjoining site to treat patients with minor injuries• Nonemergency physicians and other health care providers report to staging area next to ED• Patients with minor injuries and psych trauma placed in temporary walk-in clinic in close proximity to ED
  24. 24. 8. Designate a triage hospital• When casualties overwhelm resources, the hospital stops functioning as an admitting hospital and converts to a triage hospital
  25. 25. 9. Practice, practice, practice• Annual Drills : Nationally coordinated• MOH determines scope, type and timing• Evaluators at each hospital• After action review (AAR) following drill
  26. 26. Other Lessons from Israel• Maintenance of outdated ambulances as “back-up” vehicles for MCE’s• Extensive use of case simulation training for EMS personnel• Armored ambulances
  27. 27. Israeli EMS Simulation Training Simulation Training Center at Sheeba Medical Center in Tel Aviv
  28. 28. Israeli Armored AmbulancesArmored Corps Museum, New MDA armored Latrun, Israel ambulance (2010)
  29. 29. Application of the Israeli lessons learned to the United States
  30. 30. Application to U.S.:1. Nationally coordinate resources• National Response Framework (NRF)8 – Guide to how the Nation conducts all-hazards response – Gives authority to organizations – 15 Emergency Support Functions (ESFs) • ESF # 8 : Public Health and Medical Services; Department of Health and Human Services (HHS)• National Disaster Medical System (NDMS)5 – Partnership between Department of Health and Human Services (HHS), Departments of Defense (DOD), Veterans Affairs (VA), Federal Emergency Management Agency (FEMA) – Coordinating agency is HHS – 3 primary missions: field medial response, patient transport, and definitive care• Strategic National Stockpile (SNS) – Designed to supplement and re-supply state and local governments with medical material supplies – Federal Medical Stations : designed to provide for 250 non-acute and special needs patients over 30 days
  31. 31. Application to the U.S.: 1. Nationally coordinate resources (continued)• However must consider… – State sovereignty : U.S., unlike Israel, has 50 sovereign states – Communication : Different organizations must learn to communicate with one another• New Idea : – Give authority to members of the organizations that are coordinating with other organizations – Instead of DOD calling the Pentagon with HHS’s request, have the Pentagon send a DOD member with authority to allocate Pentagon resources
  32. 32. Application to the U.S.: 2. Establish goals and prepare SOPs• Establish goals – No national standard for surge capacity – Blanket 20 % for all hospitals may not be appropriate for U.S. with diverse geographical and population distribution – Resources / needs should be assessed
  33. 33. Application to the U.S.: 2. Establish goals and prepare SOPs (continued)• Prepare SOPs : – Joint Commission does some of this, however broad. • Plan must contain 4 components of Comprehensive Emergency Management (Mitigation, Preparedness, Response, Recovery) • Must include hospital emergency incident command system (HEICS) • Hospitals required to test emergency management plan 2x / year either in response to actual emergency or planned exercise • Must conduct at least one exercise / year that includes an influx of actual or simulated patients • If defined role in the community, must participate in at least 1 community exercise a year (table top ok) • Planned activities must be based on hazard vulnerability analysis • Evaluate key components • Identify strengths / weaknesses – More guidance on SOPs ; no JCAHO requirement for surge capacity – Tabletops are helpful, however actual live drills should be conducted regionally every few years
  34. 34. Application to the U.S.: 3. Constantly monitor surge capacity• No national requirement for hospitals to report capacity – Exceptions • Federal hospitals • ICU beds : if all ICU beds are closed then ED may go on diversion• Absolutely essential to know what resources are in case of a disaster; once the disaster happens it is too late to determine surge capacity of nearest hospitals• Develop National Capacity Monitoring Tool – Medical Capability Assessment and Status Tool (MCAST) • Sponsor federal and non-profit hospitals to report capacity • Under development – Record capacity status of each hospital so that if an event happens patient delivery can be coordinated based on status
  35. 35. Application to the U.S.: 4. Design Expandable Facilities• ED Design Guide by ACEP9 – Decontamination shower / area addressed but no room allocated for “surge”• Structure Lacking – 1990 to 1999 hospitals lost 103,000 staffed medical-surgical beds & 7,800 ICU beds10 – 2001 study : 38 % ED directors reported doubling up patients in exam rooms and 59 % reported using hallway stretchers11 – Must address staff issue also; empty beds do not take care of patients• In U.S. there is limited space and financial resources – Adjust existing structures rather than build new structures – Use of outside facilities i.e., schools, churches12 – Hospitals can work together: share resources and capability status in case of a disaster
  36. 36. Application to the U.S.: 4. Design Expandable Facilities (continued)• An example of a federal, a military, and a private hospital working together13 – In Bethesda, Maryland : National Naval Medical Center (NNMC), Suburban Hospital Healthcare System (SHHS), and the National Institutes of Health Clinical Center (NIHCC) – Have conducted 4 complex drills to test communication, coordinatio n, planning, and educational efforts From Henderson et al
  37. 37. Application to the U.S.: 5. Coordinate EMS with the Healthcare Facilities• “EMS system models in the U.S. are numerous and varied making a fully encompassing description impossible”14• Governmental and privately supported• Most coordinated by state or region – No national coordination• Attempt made to distribute severely injured casualties by chief EMS officer on site – However no national surge monitor (unsure of what area hospitals’ capacities are)• No EMS liaison at each hospital – This could benefit U.S. system
  38. 38. Application to the U.S.: 6. Avoid ED crowding and promptly clear EDs• Over ½ of all EDs are at or over capacity – National Hospital Survey 200715 : 65 % of urban hospitals at or above; 73 % of teaching hospitals at or above• Ambulance Diversion – 56 % of urban and 64 % of teaching hospitals have been on ambulance diversion in past year – 13 % of urban hospitals have spent 20 % or more time on diversion• Boarding is a Big Problem in U.S. – 22 % of patients in emergency department had already been admitted but were waiting for an inpatient bed11 – Real world example: Dr. Jim Holliman while working at Hershey Medical Center in Hershey, Pennsylvania reported for a day shift and of the 45 available beds in the ED, 42 were occupied by already admitted patients
  39. 39. Application to the U.S.:6. Avoid ED crowding and promptly clear EDs (continued)• How can the U.S. handle a surge of patient’s if we operate at or above capacity on a daily basis ?• Need solutions for ED crowding• Must be a hospital approach and therefore a hospital priority – Patients admitted to inpatient services should be held and cared for in an inpatient setting and not in the ED (“duh”)
  40. 40. Application to the U.S.: 7. Reinforce medical workforce and designateadjoining site to treat patients with minor injuries• Reinforce medical workforce – Staff already in short supply • 116,000 RN vacancies as of December 200615 with projected 400,000 by 2020 • 55 % of hospitals experienced gaps in specialty coverage for the ED – Increased difficulty maintaining physician ED call coverage – More than a third of hospitals now pay extra for some physician specialty ED call coverage – Coverage issues are most prevalent in orthopedics and neurosurgery – Disaster plans may erroneously assume 100 % attendance of staff during disaster • The percent of healthcare workers who show up depends n their perceived risk to themselves and their families• Adjoining site – Several disaster plans contain a plan for this and recognize the importance of having separate area to treat patients
  41. 41. Application to the U.S.: 8. Designate a triage hospital• Not done in the U.S.• Emergency Medical Treatment and Labor Act (EMTALA) – Est. 1986; Federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of citizenship, legal status or ability to pay – Every patient presenting to ED wishing to be treated must be seen and evaluated; only if stable or written consent can they be transferred – Agency for Healthcare Research and Quality (AHRQ)16 : “Recommendation : Federal officials should specifically address EMTALA-related issues, rather than waiting for a mass casualty "test case".” – This needs to be clarified before a MCE
  42. 42. Application to the U.S.: 9. Practice, practice, practice• Per the Joint Commission’s requirements 2 drills done per year• 1 has to involve the community however this can be a table top• Broader multi-institution regional drills ought to be conducted more frequently
  43. 43. Unique Planning Challenges for the U.S.1. 50 Sovereign states2. “Staff,” “Structure,” and “Stuff” shortages3. Public / private hospitals4. Uninsured patients5. Financial constraints6. No national surge capacity monitoring system7. Voluntary and not mandatory8. No frequent repetitive domestic events
  44. 44. 1. 50 Sovereign States• 50 sovereign states within United States• Medical and nursing licensing is state based• Requires coordination of federal, regional and state resources• Activation of federal resources and National Guard dependent on state governor
  45. 45. 2. “Staff,” “Structure,” “Supply” Shortages• Structure – Majority of hospitals function at or greater than capacity (AHC 2007 survey) – 1993 to 2003 : ED visits increased 26 % however number of EDs decreased by 14 %. National survey of 250 EDs : 28 % of ED directors reported doubling up patients in exam rooms and 59 % of directors reported using hallways as patient care areas – Ambulances on diversion• Staff – Nursing shortage: as of December 2006, hospitals had an estimated 116,000 nurse vacancies – Approximately 55 % of EDs have gaps in specialty coverage (esp. orthopedics and neurosurgery)• Supply – “Just-in-time” basis – Expensive to stock and keep updated excess supplies Problem: “Disasters are local” with an “erosion” of hospital capacity
  46. 46. 3. Public / Private Hospitals• Large, complex healthcare system(s) in the United States – Nonprofit – Private for-profit – Government• Generally, poor communication between facilities• No national requirements to develop integrative disaster plans or to report surge capabilities (with exceptions)
  47. 47. 4. Uninsured patients• In U.S. unlike Israel health insurance is a privilege and not a right• Over 43 million U.S. residents under 65 years old lack health coverage17 – $99 billion spent in 2001 for uninsured • Included out of pocket expenses, insurance payments if insured for part of the year, worker’s compensation, charity – $30 billion annually to compensate hospitals and clinics for services provided to the uninsured (IOM) – $5 billion annually donated by physicians
  48. 48. 5. $$$$$• Uninsured driving up healthcare costs• Money not being allocated specifically for surge• Much of healthcare expenses related to behavioral problems (obesity, violence, smoking, driving while intoxicated, etc.)
  49. 49. 6. No national surge capacity monitoring system• Unlike Israel only federal hospitals are required to report hospital surge capacity daily
  50. 50. 7. Voluntary not mandatory• No national requirement for surge capacity• Joint Commission : has several requirements for hospitals but very general
  51. 51. 8. No frequent repetitive domestic events• Although the U.S. has had several MCE including 9/11 and Hurricane Katrina, it is not at the same frequency as Israel• Unfortunately we become complacent with day-to-day activity• Often takes a disaster to motivate change
  52. 52. One Lesson Israel Could Learn from the U.S.• Better security and “chemical proofing” of major EMS dispatch and communication facilities Tel Aviv MDA Dispatch Center with open unguarded doors
  53. 53. IPRED Conference• International Preparedness and Response to Emergencies & Disasters• Tel Aviv, Israel• 11 to 14 January 2010• Organized by the State of Israel Ministry of Health and the Israeli Defense Forces Home Front Command• Over 750 attendees• International Attendance : 30 countries – Israel, U.S., Germany, U.K., Italy, Kenya, Jordan, etc.
  54. 54. IPRED Conference Hall
  55. 55. Orange Flame Drill 4• National project held every 2 years• Simulated bioterrorism event• Integrates all regional components of the medical and interface agencies that cope with such an event in the first 48 hours from its detection• Participating regional institutions in 2010 included : – 3 acute care hospitals, 14 civilian and 3 military primary care clinics, the Regional Health District bureau, EMS services, police force, Home Front Command district, Local Municipalities and additional first responders• Participation of the IPRED delegates
  56. 56. Orange Flame Drill 4• This year  smallpox outbreak affecting ~1000 people + isolation and treatment of ~20,000 people + national vaccination campaign
  57. 57. Day 1• Detection Phase – HMO clinic• Magen David Adom (EMS) control center• Outbreak Phase – Wolfson Medical Center
  58. 58. Detection Phase
  59. 59. Magen David Adom
  60. 60. Magen David Adom
  61. 61. Outbreak PhaseWolfson Medical Center, Tel Aviv
  62. 62. Outbreak Phase
  63. 63. Outbreak Phase
  64. 64. Day 2• International Press Conference• Operation of Centers for Mass Immunization and Prophylaxis
  65. 65. International Press Conference
  66. 66. Mass Prophylaxis
  67. 67. Mass Prophylaxis
  68. 68. Summary of Lessons the U.S. can learn from Israel regarding surge capacity…1. National Coordination : absolutely key; ensure clear communication and give individuals from national organizations that are communicating with one another the authority to make decisions and allocate resources.2. Goals & SOPs : Should have surge capacity national requirement based on individual hospitals and not blanket set percentage; More guidance on standard operating procedures from hospitals.3. Monitor surge: Need for national surge capacity reporting and monitoring.4. Expandable facilities : ED planning should include area for expandable facilities; additionally work with local community and area hospitals to design disaster plans.5. Coordinate EMS : Have EMS liaison at hospital; ensure city/regional center is coordinating various EMS units responding to disaster.6. Avoid ED crowding : Decrease ED crowding / boarding ; must be hospital response.7. Reinforce medical workface : Increase RN training positions at schools.8. Designate a triage hospital : EMTALA needs to be addressed with regards to what happens during MCE.9. Practice, practice, practice : don’t wait until actual disaster !
  69. 69. References1. Merriam-Webster online dictionary. “Surge” definition. Available: Accessed January 24, 20102. ACEP. “Health Care System Surge capacity Recognition, Preparedness, and Response.” Available: Accessed on January 24, 2010.3. HHS. Medical Surge Capacity Capability Handbook. Available: Accessed on January 24, 2010.4. Koenig, KL & Schultz, CH. (Eds). (2010). Disaster Medicine Comprehensive Principles and Practices. CITY: STATE: PUBLSHER.5. Barbisch, DF & Koenig, KL. Understanding surge capacity: essential elements. Acad Emerg Med 2006: 13: 1098-1102.6. CIA-The World Factbook. Israel. Available: Accessed on January 15, 2010.7. Peleg, K & Kellermann, AI.Enhancing hospital surge capacity for mass casualty events. JAMA. 2009; 302(5):565-567.8. FEMA. National Response Framework. Available: Accessed on January 19, 2010.9. Huddy, J. Emergency Department Design A Practical guide to planning for the future. ACEP 2002. 10. CDC. Department of Health and Human Services. Data and Statistics.11. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emergency department crowding: a point in time. Ann Emerg Med 2003; 42(2):167-172.12. Kanji, AH, Koenig, KL, Lewis, RJ. Current hospital disaster preparedness. JAMA. 2007. 298 (18): 2188-2190.13. Henderson, DK et al. Bethesda hospitals’ emergency preparedness partnership: a model for Tran institutional collaboration of emergency responses. Disaster Medicine and Public Health Preparedness, 2009.3(3):168-173.14. Pozner, CN, et al. International EMS systems: The United States: past, present, and future. Resuscitation. 2004; 60: 239- 244.15. American Hospital Association. National Health Survey 2007.16. Agency for Healthcare Research and Quality. Reopening Shuttered Hospitals to Expand Surge Capacity. Available at: Accessed on January 29, 2010.17. Institute of Medicine. Consequences of Uninsurance. Available at: Accessed on January 27. 2010.
  70. 70. AcknowledgementsSpecial thanks to the faculty and staff at CDHAM including Dr. Jim Holliman, Dr. Carlos Williams, Dr. Kevin Riley and Dr. J.D. Malone and finally, from Tel-Aviv University, Israel, Dr. Kobi Peleg
  71. 71. Hopeful sign froma refugee camp in Kabul
  72. 72. QUESTIONS ?Thanks for Your Attention