Pandemic Influenza Hospital and Clinic Planning Daniel T. O’Laughlin, MD, FACEP Medical Director of Emergency Preparedness Abbott Northwestern Hospital Assistant Professor of Emergency Medicine University of Minnesota September 10, 2009

Successful Pandemic 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

“ 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 Realities “ Just In Time” economy affects healthcare as well Hospitals, if profitable, only have a thin profit margin (avg 1.9%) 30% of US hospitals are currently losing money Average US hospital has 41 days of cash on hand A hospital’s ability to offset typical lost revenue from illness related hospitalizations with elective procedures will be greatly reduced or eliminated altogether

“ Just In Time” economy affects healthcare as well

Hospitals, if profitable, only have a thin profit margin (avg 1.9%)

30% of US hospitals are currently losing money

Average US hospital has 41 days of cash on hand

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

Hospital Planning Priority Considerations Regional collaborative planning that is realistic Infection Control Limit nosocomial spread Protects HCW, other inpatients and prevents hospitals from amplifying the disease spread

Regional collaborative planning that is realistic

Infection Control

Limit nosocomial spread

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

Hospital Planning Priority Considerations Hospital workforce management Allocation of scare resources

Hospital workforce management

Allocation of scare resources

Potential Planning Roadblocks Healthcare surge capacity is low Personal preparedness is poor Hospital administration buy-in is variable Financial support is poor Staff absenteeism Union concerns Insufficient PPE/Meds/Vaccine for HCWs Workforce licensing restrictions & rapid credentialing Specialization / Compartmentalization of healthcare

Healthcare surge capacity is low

Personal preparedness is poor

Hospital administration buy-in is variable

Financial support is poor

Staff absenteeism

Union concerns

Insufficient PPE/Meds/Vaccine for HCWs

Workforce licensing restrictions & rapid credentialing

Specialization / Compartmentalization of healthcare

Minnesota Hospitals 134 Acute Care Hospitals in MN Over 2/3 are private, nonprofit organizations Urban Location – 53 Rural Location – 81 79 are designated Critical Access Hospitals 29 % of MN acute care hospitals operate either in the red or with a < 5% operating margin (based on 2007 HCCIS data)

134 Acute Care Hospitals in MN

Over 2/3 are private, nonprofit organizations

Urban Location – 53

Rural Location – 81

79 are designated Critical Access Hospitals

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

(based on 2007 HCCIS data)

MSP Metro Acute Care Hospitals MNTrac Snapshot from 09-09-09 Bed Type Available Total Percent 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%

Facility-based Surge 10-20% operating bed capacity could be mobilized Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home) Discharge holding area Board patients in halls Cancel elective procedures Convert procedure/PACU areas to patient care Accommodate vents on floor (or BVM or austere O2 flow powered ventilators) Supply and staffing issues (72h ahead)

Get ‘em up and get ‘em out (ED, clinics)

Discharges and transfers (eg: nursing home)

Discharge holding area

Board patients in halls

Cancel elective procedures

Convert procedure/PACU areas to patient care

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

Supply and staffing issues (72h ahead)

Surge Capacity C S T The 4 C’s Command Control Communications Coordination * Surge capacity CANNOT occur if you don’t ‘get all C’s’ The 4 S’s Space Staff Stuff Special The 3 T’s Triage Treat Transport

The 4 C’s

Command

Control

Communications

Coordination

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

The 4 S’s

Space

Staff

Stuff

Special

The 3 T’s

Triage

Treat

Transport

Staff ALL job categories will have significant absenteeism From NYC Healthcare Worker Survey >50% had childcare issues ~27% had eldercare issues ~30% had a spouse expected to respond Creative use of volunteers may be needed Rapid credentialing process for volunteers

ALL job categories will have significant absenteeism

From NYC Healthcare Worker Survey

>50% had childcare issues

~27% had eldercare issues

~30% had a spouse expected to respond

Creative use of volunteers may be needed

Rapid credentialing process for volunteers

MN EMS Resources 78% of Minnesota EMS personnel are volunteer <40% of EMS personnel rated EMS as their 1 st priority in a disaster

78% of Minnesota EMS personnel are volunteer

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

N95’s ( Estimated hospital inpatient need) Assume mask use for 2 hours on average Does not include home care, ACS, family, …. Estimate of 275 masks / inpt bed for 8 week pandemic duration for direct patient care delivery 3,300,000 N95s for usual operational bed capacity in MN over 8 weeks

Assume mask use for 2 hours on average

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

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

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

Community- Based Surge Clinics Homecare Nursing homes Procedure centers Family-based care Alternate Care Sites Flu Centers

Clinics

Homecare

Nursing homes

Procedure centers

Family-based care

Alternate Care Sites

Flu Centers

Flu Centers Provide a consistent assessment of patients with influenza symptoms. Triage and refer patients. Provide access to self-care information & treatment for lay home care. Distribute medications as appropriate

Provide a consistent assessment of patients with influenza symptoms.

Triage and refer patients.

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

Distribute medications as appropriate

Overarching Goal for Scarce Resource Allocation Do the greatest good for the greatest number of persons you can based upon the resources available

Do the greatest good for the greatest number of persons you can based upon the resources available

Patient Care Strategies for Scarce Resource Situations TOOL KIT Oxygen Conservation Strategies Medication Utilization Strategy Hemodynamic Support and IV Fluids Mechanical Ventilation Staffing Nutrition Documents can be found at: http://www.health.state.mn.us/oep/healthcare/index.html#pandemic

Oxygen Conservation Strategies

Medication Utilization Strategy

Hemodynamic Support and IV Fluids

Mechanical Ventilation

Staffing

Nutrition

Documents can be found at:

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