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					  Planning for Surge
Capacity in Health Care
       Services
             Betsey Lyman
     Deputy Director, Public Health
        Emergency Preparedness
 California Department of Public Health
  California Faces Disasters on a
           Regular Basis
 Examples    of disasters since 2006:
     2006 Extreme Heat
     2007 Lake Tahoe Wildfire
     2007 Southern California Wildfires
     2008 Northern California Wildfires
     2008 Chino Hills Earthquake
     2008 Los Angeles Metro Link Crash
     2008 Southern California Wildfires
     2008 Severe Cold
            The Challenge
 Meeting the public health and medical
 needs of Californians during and following
 disasters

 Addressing statewide needs during a
 catastrophic event when mutual aid is
 limited
 What is a Healthcare Surge?


……an excess in demand over capacity in
hospitals, long-term care facilities, community
care clinics, public health departments, other
primary and secondary care providers,
resources and/or emergency medical
services
 What is NOT a Healthcare
          Surge?
 The  frequent emergency department
 overcrowding experienced by healthcare
 facilities (for example, Friday/Saturday night
 emergencies).
A local casualty emergency that might
 overcrowd nearby facilities but have little to
 no impact on the overall healthcare delivery
 system.
           Surge Capacity Basics

   Beds: Acute care and critical care beds

   Staffing: Licensed healthcare professionals and
    support staff

   Medical supplies and equipment:
    pharmaceuticals, personal protective equipment,
    portable and fixed decontamination systems,
    isolation beds, ventilators, masks
Measuring the Gap: 2006 California
Healthcare Surge Capacity Survey
Standardized definitions for crisis care:
     • Nurse-to-patient staffing ratio of 1:5 for Critical
       Care Beds and 1:20 for Other Medical-Surgical
       Beds

     • Assume self-sustainment within the facility for a
      minimum of 72 hours without re-supply of
      equipment, supplies or staff

     • Assume 30% of staff will not report to work
        Measuring the Gap (cont)
   Response:
     324 hospital: 80 percent of California’s 73,000
      operating licensed acute care hospital beds
     California’s local health departments

     172 community clinics



   Identified 19,963 beds California hospitals said
    they can surge
       Bed shortages:
         • Los Angeles area
         • Pediatric beds
 Greater Gaps in Meeting Needs of
       a Catastrophic Event

 UsingCDC’s FluSurge 2.0 computer
 modeling program for pandemic influenza:

     California needs 58,723 surge beds for a
      moderate pandemic influenza
     38,760 beds or 194% above the 19,963 surge
      beds California hospitals said they can surge.
  Analysis of 2006 Survey Results

 California  has sufficient surge capacity for
  a Moderate event: regional earthquake,
  fire, flood, or bioterrorist attack.

 California’s surge capacity is insufficient
  for a Catastrophic event: statewide impact,
  e.g., Katrina-like event or pandemic
  influenza.
 2006 Healthcare Surge Initiative
The State of California spent $172 million to
    improve its medical surge capacity
                Item                        Need               Bought               Cost
 Masks (N95 Respirators)                  100 million         50.9 million       $19.9 million
 Ventilators                                24,000               2,400           $30.6 million


 Antiviral medicines -- enough to                          3.7 million courses
 treat 25 percent of California's                             90% Tamiflu,
 population                            8 million courses      10% Relenza        $54.6 million
 Mobile Field Hospitals                                       3 - 200 bed        $18.3 million

 21,000 extra beds with supplies for
 alternate care sites                       42,000              21,000           $33.4 million

 Developing new hospital guidelines
 and standards                                                                    $5 million
    Alternate Care Site Supplies and
               Equipment
   State Alternate Care Site Caches contain over
    300 items, ranging from patient cots and linens,
    routine nursing supplies, suture equipment,
    airway breathing supplies, etc.

   Supplies and equipment are packed in caches to
    support 50 patients

   Each cache is stored on 20 pallets
Standards and
Guidelines for
  Healthcare
 Surge during
 Emergencies
           Focus of the Project
   Standards of care for healthcare facilities and
    licensed healthcare professionals during an
    emergency
   Liability of healthcare facilities and licensed
    healthcare professionals
   Reimbursement of care provided during an
    emergency
   How to operate Alternate Care Sites
   Surge capacity operating plans at individual
    hospitals
           Project Approach
   Developing and managing a process that
    includes government agencies, providers,
    stakeholders, and other relevant parties as
    participants in this project.

   Developing written standards and guidelines
    for delivery of medical care services in a
    surge environment.
            2008 Deliverables
 Foundational  Knowledge document
  provides platform for all volumes
 Manuals focused on target audience:
     Hospitals
     Alternate care sites
     Payers
 Reference     Manual including legal analysis
Volumes under Development

 Licensed  healthcare professionals,
  including Crisis Care

 Long   term care facilities

 Clinics
      When is a Healthcare Surge Declared?
                            Surge Monitoring Guidelines Table



                                     Local Surge Emergency
                                                                                      Regional    Statewide
Surge                                                                                  Level        Surge
Level         Green         Yellow         Orange        Red           Black           Surge        Level
                                           Regulatory/
                                           Accrediting
                                           Agency
              Regulatory/   Regulatory/    Waiver/
              Accrediting   Accrediting    Local         Local         Local         State of    Federal
Enabling      Agency        Agency         Emergency     Emergency     Emergency     Emergency Emergency
Authorities   Waiver        Waiver         Declaration   Declaration   Declaration   Declaration Declaration

   Green:              Usual day to day status. No assistance required
   Yellow:             Surge managed locally. No assistance required
   Orange:             Additional healthcare assets required within jurisdiction
   Red:                Assistance needed outside local jurisdiction or area.
   Black:              Significant assistance needed outside local jurisdiction.
HOSPITAL PREPAREDNESS
  Hospital Connection to Incident
        Command System
       hospitals have internal Incident
 Ensuring
 Command Systems

 Community  planning: connecting hospitals
 to local Emergency Response Structure

 Expanding   hospital capacity to meet surge
 needs
            Reimbursement
Maintaining existing revenue streams is
critical to hospitals during a healthcare surge.
Key concepts surrounding reimbursement
during surge include:
    Advanced planning and collaboration with
     commercial health plan partners
    Acquiring detailed knowledge of the resources
     available to hospitals during surge conditions
    Methods to access additional resources from
     federal and State funded programs
  Establishment of a
Government-Authorized
  Alternate Care Site
What is a Government-Authorized
      Alternate Care Site?
   A location that is not currently providing healthcare
    services
    Will be converted to enable the provision of healthcare
    services to support, at a minimum, inpatient and/or
    outpatient care required after a declared catastrophic
    emergency
   Will help absorb the patient load after all other healthcare
    resources are exhausted

       Types of Government-Authorized Alternate Care Sites
         Mobile Field Hospitals      Arenas
         Schools                     Churches
         Shuttered Hospitals         Stadiums
  What is NOT a Government-
 Authorized Alternate Care Site?
A government-authorized Alternate Care Site is NOT
part of the expansion of an existing healthcare facility,
such as
     extensions of general acute care hospitals
     clinics, or
     long-term care facilities

      Government-Authorized Alternate Care Sites DO NOT include:

     Tents set up for patient care in the parking lot of a hospital and
      under their control
     Sites set up for patient triage by Emergency Medical Services

     Any temporary space set up for patient care under the authority
      of an existing healthcare facility
2009: Current Challenges in Surge
            Capacity
    Gap in needed surge capacity remains
    significant
      2006 Healthcare Surge Initiative

       addressed approximately half of the gap
       in needed beds

 California   hospitals are struggling for
    financial survival. Loss of hospitals would
    increase the gap
      Current Challenges in Surge
            Capacity (cont)
 Unfunded:
     Maintaining surge supplies in operating order
     Refreshing expiring supplies (e.g.
      pharmaceuticals)
     Updating medical equipment
     Training staff to manage, deploy and operate
      surge beds
        Current Challenges in Surge
              Capacity (cont)
 California’s   economic situation is resulting
  in:
     Decreased expenditures for public health,
      with negative impact on the infrastructure to
      respond to public health emergencies
     Layoffs of trained Local Health Department
      staff trained in public health emergency
      preparedness
   Current Challenges (cont)
 Federalfunds are the financial
 support for public health emergency
 response capacity

 From 9-11 to current year, California’s
 federal grants for public health
 emergency preparedness decreased
 25 percent.
Accessing the Standards and
Guidelines for Healthcare Surge
During Emergencies:

http://bepreparedcalifornia.ca.gov/EPO/
CDPHPrograms/PublicHealthPrograms/
    EmergencyPreparednessOffice/
     EPOProgramsServices/Surge/