Florida Department of Health
Best Practice Submission Form
Project Name: Patient Surge-A Hospital and Community Exercise for Alternate Treatment
Contact Name/Title: Gail A. Stewart EMS and Hospital Preparedness Coordinator
CHD/Office: Leon County Health Department Public Health Preparedness
Address: 2965 Municipal Way
City: Tallahassee State: FL Zip: 32304
x181 Suncom: Fax: (850) 487-7954
The Leadership category addresses how your senior leaders guide and sustain your
organization in setting organizational vision, values, and performance expectations; create an
environment that encourages future leaders; and communicates with employees.
Best practices in leadership may encompass:
Developing and maintaining an effective communication process with employees, customers,
community, vendors/business partners and central office.
Supporting and strengthening communities.
Providing a work environment and employee support climate that contributes to the well-being,
satisfaction, and motivation of all employees.
Utilizing evidence-based practice guidelines and initiatives to improve health outcomes.
O Strategic Planning
The Strategic Planning category addresses strategic and action planning; deployment of the
plan; how plans are changed if circumstances require a change; and how accomplishments are
measured and sustained.
Best practices in strategic planning may encompass:
A strategic planning process that use measurable goals and objectives to guide activities which
align with the 10 Essential Public Health Services, Local Public Health Service Standards and
Healthy People 2010, and is communicated to stakeholders.
O Customer and Market Focus
The Customer and Market Focus category addresses how your organization listens to the voice
of the customer and other stakeholders and of the marketplace with a focus on delighting
customers, building loyalties and meeting customer expectations as well as their requirements.
Best practices in customer and market focus may encompass:
A systematic process to ensure client satisfaction and loyalty which includes a process to
measure satisfaction, measure complaints and analyze and utilize data to improve performance.
Developing and maintaining an effective communication process with employees, customers,
community, vendors/business partners and central office.
Linking people to needed personal health services and assures the provision of health care
when otherwise unavailable.
O Measurement, Analysis, and Knowledge Management
The Measurement, Analysis, and Knowledge Management category addresses how you
effectively measure, analyze and review performance and managing organization knowledge to
drive improvements and organizational competitiveness.
Best practices in measurement, analysis, and knowledge management may encompass:
Utilizing DOH standard systems to ensure timely and accurate collection of data.
Utilizing current, appropriate and approved technology to support CHD operations.
O Human Resource Focus
The Human Resource Focus addresses key human resource practices – those directed toward
creating and maintaining a high performance workplace and toward developing employees to
enable them and your organization to adapt to change.
Best practices in human resource focus may encompass:
Utilizing employee education, training, and career development to support the achievement of
the organization’s mission and contribute to high performance.
Assuring a competent workforce by providing employees education and training to improve their
public health core competencies.
Providing work systems that enable employees and organizations to achieve performance
Promoting a workplace environment that supports employee development and high
performance, and enables the organization to adapt to change.
O Process Management
The Process Management category examines key work processes including those that support
production and delivery of products, programs and services.
Best practices on process management may encompass:
Participation on a comprehensive, systematic process to mobilize community partnerships to
identify and improve the community’s health.
A continuous performance improvement process in place.
Utilizing an annual budget planning process that links funding requests to strategic objectives to
performance results; delegates budget management responsibility to the appropriate
management level and provides routine reporting process accurately identifying and monitoring
expenditure and revenue levels.
Utilizing FIRS monthly budget reports to monitor spending and revenue levels and takes
appropriate corrective action when levels fall below or above approved allocations.
Maintaining a core contract congruent with planned revenues and expenditures outlined in the
CHD’s spending plan.
Maintaining standard financial practices that ensure the CHD solvency.
Maintaining a systematic risk management process.
Ensuring readiness and response to natural and manmade public health threats.
O Organizational Performance Results
The Organizational Performance Results category provides a focus that encompasses objective
evaluations and customers’ evaluation of organization’s products, services and programs;
overall financial, budgetary, and market performance; employee and work system results;
leadership system and social responsibility results; and results of all key process and process
Best practices in organizational performance results may encompass:
Products and services
Financial and marker results
Human resource results
Leadership and social responsibility
Has practice/process been recognized by state or national organizations? X Yes O No
If so, whom and when?
Yale New Haven Best Practice Poster Presentation October 2007
In 300 words or less, provide a brief summary of the best practice/project being
proposed including the purpose of the practice/project, populations served and length of
time practice/project has been in existence.
The Alternate Treatment Alternate medical treatment site concept arose after several hospital
exercises overwhelmed already at capacity emergency departments. During hospital drills and
exercises, hospitals had to maintain normal business practices while engaging somewhat
complex, resource intensive exercises. During one simulated disaster, victims arrived and were
escorted indoors to the emergency department causing an extreme bottleneck in care for real
patients as well as simulated matriculation of disaster victims. In order for the hospital to
actually measure capacity to surge when high numbers of patients arrive, each part of the
exercise and daily operations was looked at. Early on it was decided that not all patients who
arrive to the hospital need acute medical care inside an emergency department. It was further
decided that there were resources outside of the emergency department which could and would
support hospital surge.
In planning for the use of the Alternate Treatment Alternate medical treatment site, the most
likely community partners were identified for support. Each community partner and hospital
department were given the surge scenario and asked how much support could be provided. The
Alternate Treatment Alternate medical treatment site logistical lay out and capabilities were
shared. Stakeholder buy in was easier than expected realizing that the most critical patients
would still be delivered to the emergency department for critical care. The Alternate Treatment
Alternate medical treatment site was located away from the main emergency department with
the intent to serve those with minor trauma, behavioral health needs, family reunification and
those in the triage system as being Green or Minor. Past disaster experience indicates that for
every 1000 people in a disaster, 250 die immediately, 750 seek medical care and of those only
250 are admitted or need intensive care. This leaves 500 who need care but may not need to
have that care in an emergency department. This project was implemented in April 2007. To
fully support this project, Leon County will become a Beta Test Alternate medical treatment site
for the Alternate Medical Treatment Alternate medical treatment site concept funded by the
Florida Department of Health. The intent is to replicate what is found at the beta alternate
medical treatment sites and move the concept statewide. This region is fortunate in that the
concept has already been tested so improvement of the process has already started.
What is the issue your practice/project addresses (i.e. community practice, clinical
practice, financial process, internal business process, technology, etc.)? Please provide
This project involves a clinical practice, community practice and involves the
commitment of financial resources and technology.
The project challenges hospital clinical practice with the surge of patients. Most
emergency departments operate with staffing shortages and long waits for patients who
visit. In this exercise using the Alternate Medical Treatment Alternate medical treatment
site concept, clinical staff were brought from departments of the hospital who are not
routinely by the bedside. Nurses from the Nursing Office, Quality Improvement,
Education and Case Management were brought outside of the hospital to manage the
patients who were not critical. This allowed all critical care nurses staffing the
emergency department to focus on the critical patients. The nurses, nervous at first,
blended right into the patient care mode shortly after their arrival to staff the Alternate
medical treatment site. An added benefit for this exercise was that staff from a
neighboring hospital showed up and was on alternate medical treatment site
credentialed and went to work caring for patients. This mutual aid was through a
memorandum of agreement between the hospitals.
This concept could be replicated close to an incident, near a hospital or anywhere that
could efficiently serve a surge of patients. Using volunteer clinicians, medical reserve
corp and memorandums of agreement staffing could evolve. Trailers with medical
supplies (each region was Alternate medical treatment site supplies) can be moved to a
location which would best serve those who were involved in the incident but are not
critical enough to be cared for at the hospital.
What is the target population/audience that your practice/project is addressing? Please
include demographics, population size, target area(s) and/or racial and ethnic health
Tallahassee is the Capital of Florida located in Leon County with a population of
200,000. Tallahassee has two universities, colleges, the seat of State Government and
some industry and agriculture. Statewide, Public Health Preparedness and Response is
divided into seven regions. Leon County is in the North Florida Region with 12 other
primarily rural counties.
Ten hospitals are located in seven of the 13 counties. In Leon County, there are two
hospitals with 968 of the regions total 1,325 licensed but not staffed beds. The small
hospitals in the region have no capacity to surge or to staff for critical patients. In fact,
there is no trauma center designation for any hospital in the North Florida Region.
How did you determine that this issue was important? Please provide data and/or
supporting evidence including target population’s health problems and needs and
methods to obtain baseline data to assess needs for the practice/project.
The need to handle a surge of patients from a disaster into the healthcare system
provided the landscape for this exercise. Traditionally, patients from a disaster enter the
healthcare system through the hospitals emergency departments. Emergency Medical
Services (EMS) triage on the scene of the disaster and provide some care but many
patients self evacuate to the hospital for care. The patients who self evacuate often
times arrive at the hospital before EMS transports the more critical patients. A
bottleneck occurs when patients who are least injured occupy the Emergency
Departments leaving less staff and available beds for those more critical arriving later.
Once it was recognized that hospitals want to do the best for the most and were
constrained by the amount of staff, supplies and available emergency department beds,
a plan to accommodate all arriving patients had to be developed.
The purpose of this exercise was to take concepts from previous disasters and apply
them to a usable solution for handling a surge of patients. The concept of an Alternate
Treatment Alternate medical treatment site at or near the hospital provides a concept
that is plausible.
In disasters there is an 85/15 rule that outlines the expected injury level of patients. The
expectation is that per every 1000 victims of a disaster, 250 will die on the scene, 750
will seek medical care; 188 will be admitted to the hospital, 47 of those will be in
intensive care. This surge on the healthcare system will overwhelm any hospital in the
US today. In a region with no trauma center and many rural hospitals, transfer of this
amount of patients is unrealistic and often not available due to limited resources of
Therefore, in order to handle a surge an alternate plan must be implemented and
exercised to determine exactly how many patients could be realistically cared for as a
result of a disaster.
Who were the community partners and/or internal/external stakeholders involved in the
planning and/or implementation of this practice/project? Please describe their role in the
Tallahassee Police Department
-worked to support hospital with perimeter security
-assisted in setting up and participating with joint information center
Leon County Sheriffs Office
-worked to support hospital with perimeter security
-part of joint information center
Leon County Emergency Medical Services
-triage, treatment and transport of patients from simulated scene to
alternate medical treatment alternate medical treatment site or emergency department
Leon County Emergency Management
-acted as Emergency Management for the hospital
The North Florida Regional Domestic Security Task Force
-fully supported the idea of the alternate medical treatment alternate
medical treatment site
-manned the observation area and did interviews
Tallahassee Memorial Hospital
-provided the spaces
-most of the staffing
-equipment and supplies
Capital Regional Medical Center
-augmented equipment and staffing at Tallahassee Memorial
Tallahassee Memorial Hospital- Emergency Medical Services
-transport of patients from alternate medical treatment alternate
medical treatment site to emergency department
Tallahassee Memorial Hospital- Behavioral Health
-behavioral health for patients and families
Capital Area Chapter of the American Red Cross
-some behavioral health
-provided refreshments and lunch
Lively Technical Center Licensed Practical Nursing Program
-students were patients (60)
North Florida Region Public Health Preparedness
-moulage of patients
Capital District Amateur Radio Emergency Service (ARES)
-Communications with hospitals in the region for patient transfers
-Worked with Emergency Management and hospital Incident
Outline the steps taken to implement your practice/project.
To effectively plan for and execute the exercise to test the use of an Alternate
Treatment Alternate medical treatment site took the commitment of community partners
working with the hospitals. The planning committee was individuals which represented
the response agencies who would participate in the exercise. The individuals on the
planning committee were considered trusted agents and were not to participate in the
actual exercise except to act in roles as evaluators and controllers. The outline for the
exercise was developed with goals and objectives. Once there was agreement the next
step was logistics. In this step, simulated patients were recruited, physical alternate
medical treatment sites were located, equipment and supply deployment planned,
human resources including hospital departments and community partner responders
Student nurses were recruited as patient simulators.
The Capital Area Chapter of the American Red Cross was asked to provide
The selected hospital staff was trained on the concept and what is expected for patient
care in an Alternate Treatment Alternate medical treatment site. Plans were written for
the hospital relating to patient surge and the process to handle such. This concept took
some convincing and with the promotion by the emergency department staff, most felt
that it was an achievable process.
The medical equipment was on trailers and the missing equipment (waiting for money to
purchase) was loaned by a vendor for this exercise. Large tents were erected by the
vendor which if purchased in our region could provide a hospital like environment with
air conditioning, heat, lights and power. These tents can also serve as isolation units by
adding an ante room. The tents provide the feel of a hospital for the non-traditional staff
as portable stretchers and medical equipment were available. The hesitation of doing
patient care outside the traditional hospital quickly vanished.
The day of the exercise, the hospital responded as any other emergency. Simulated call
from the EMS to the hospitals emergency department began the hospital disaster
response. Incident command was set up, the decontamination team responded and
were redirected to become runners and patient transporters. The EMS call included
information about the potential for large amounts of patients which signaled the
Alternate Treatment Alternate medical treatment site response.
What was the estimated cost to implement the practice/project? Please include staff
time, resources, and in-kind contributions.
This exercise requires commitment from the community partners. Those costs are
related to back fill and overtime of the partners in order to participate in the exercise
and to maintain normal operations. It also takes hospital staff redirection from regular
job duties. There is a need for additional medical supplies to support non traditional
emergency department operations.
In this exercise because we used mostly nurses who were administrative rather than
bedside the cost for back fill was not an issue. After 5:00 pm the costs will significantly
change as the nurses will come from areas in which back fill and perhaps overtime will
It is difficult to predict actual costs for human resources. The exercise was conducted as
part of the annual contract with the hospital HRSA so there was some reimbursement
but significantly less than to cover the costs. The exercise did provide the hospital with
the ability to meet the annual accreditation requirements.
What funding sources support this practice/project? Please provide funding sources
such as CHD budget, legislative funding, community contributions, grant funding.
The exercise was supported by a contract between the Florida Department of Health
and the Tallahassee Memorial Hospital and Capital Regional Medical Center. The
contracts are part of the HRSA funding which provides money for hospital exercises.
Exercises of this nature certainly require in kind human resources dollars from each
hospital for back fill. Community partners participating with the hospitals also support
one another by providing personnel to support such an exercise. Public Health
Preparedness personnel were utilized as evaluators, controllers and support for the
Describe plans to sustain the practice/project over time and leverage resources (i.e.
maintenance of funding, staff salaries, and partnerships).
Due to the nature of hospital business, accreditation, regulatory agencies and hospital
life safety requires at least annual full scale exercises for compliance. The hospitals are
able to contract with the Florida Department of Health for federal dollars to help support
exercises. The exercises also test many of the plans which are written and need
validation. The costs of medical staffing and the community partner support far exceed
the dollars available through state and federal resources. In that light, most hospitals
agree that their dollars for back fill and overtime for these exercises will pay off when a
surge of patients arrive to the hospital and can do the best care for the most patients.
Describe the results of your evaluation. Please include baseline information for
comparison, if applicable.
The exercise was the first type ever held in the region.
Exercise Objectives to:
1. utilize ‘disaster triage and treatment area’ outside of ED operations
2. improve community partner coordination for efficiency in patient flow.
3. rapidly deploy staff and manage large numbers of patients in a non traditional
patient care area doing the “best for the most”
4. assess check in and credentialing process through the labor pool.
5. utilize amateur radios (HAM) for alternate communication
6. deploy the regional Joint Information Center to provide timely coordinated release of
7. utilize the Red Cross to participate in family reunification and clergy assistance.
1. Patient Collection points and Triage and Treatment areas established.
2. Rerouting of ambulances and self referred patients was implemented.
3. Perimeter security augmented by law enforcement (result of meetings with stakeholders
over the past 3 years and the final draft of a plan)
4. Emergency Department was closed except to critical patients.
5. Staff was mobilized and in place with overhead pages within 15 minutes, asset typed
prior to exercise. (discussion may be done at time of hire)
6. Neighbor hospital arrived with staff and equipment in “real time.” Clinical and non-
clinical staff credentialed, badged and assigned at the labor pool within 10 minutes of
7. Amateur radios (7) provided redundant communications for the region
8. The Joint Information Center; multi-disciplinary release of information.
9. Behavioral health professionals worked with the Red Cross for reunification.
10. Critical patients in the emergency department had no treatment delay.
• Hospital Incident Command needs web cams to visualize Alternate medical
treatment alternate medical treatment site for more efficiency in planning for
• Staff with clinical credentials in leadership and management positions (non-
clinical) liked working as clinicians and would do it again.
• Community partners visualized alternate treatment alternate medical treatment
site concept and can clearly identify what support they can offer.
• Set up alternate medical treatment site in organized phases –to support incoming
patients while still expanding the alternate medical treatment site
• Family reunification plans were taken from paper to action, worked very wel,
pictures would be helpful especially web basedl.
• Need equipment in mobilization devices or trailers.
• Next step, Regional Exercise with multiple alternate medical treatment sites
Could this practice/project be replicated, and how?
Yes, by planning teams of stakeholders having open discussions then slowly show how
each may be a part of a solution to do the best care for the most patients in a surge
What were the barriers to implementing this practice/project, and what lessons did you
Barriers include community partners having to rethink traditional responses to the past
exercises and how patient matriculation through the healthcare system normally flows.
Patients that are less serious must be directed to the Alternate medical treatment
alternate medical treatment site in order to keep the emergency department resources
open to critical patients.
Patients must trust that although they are being seen at an alternate medical treatment
alternate medical treatment site from the emergency department that the care will be
the same or actually better because of the decrease of bottle necks that often occur in
overwhelmed emergency departments. There needs to be a public education about
what Alternate Treatment Alternate medical treatment sites can provide.
Many think of an alternate treatment alternate medical treatment site as a place. It is
more a concept which can be mobilized with equipment and clinical staff to a location
close to the incident. This “process” rather than a location concept allows to EMS
resources to move critical patients to hospitals while still providing care for the less
critical. This works well with the recognized triage system. Some patients will be
suffering no physical trauma but have sustained mental trauma. This alternate medical
treatment alternate medical treatment site will allow for behavioral health professionals
to work with patients outside of the emergency department and provide rapid
Technology was addressed with the Alternate medical treatment site for patient
registration, patient transfers and patient discharges. A wireless secure system would
be very helpful for patient tracking. Patients move quickly in and out of the Alternate
medical treatment site and in order to facilitate moving the patient seamlessly through
the system, a web based system would be more efficient than paper. This would also
with identification of the dead by downloaded pictures and would facilitate reunification
of family members.
Pain medications and palliative care is a challenge because security of medications and
the vendor contracts only allow for limited supply. This is an in process discussion for
Fatality management is a part that is also being worked on.