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Mass Medical CareDuring an Influenza Pandemic:

Establishing Influenza Care Centers

PRESENTATION AND WORKBOOK

NACCHO Advanced Practice Center (APC)

Road Shows Albuquerque, New Mexico

August 11-12, 2009

APC Toolkit

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Toolkit Sections

1. Concept of Operations2. Command and Control 3. Communications4. Staffing and Training5. Clinical Standards,

Protocols and Operations

6. Infection Control

7. Fatalities and Morgue8. Facilities9. Equipment and

Supplies10. Security11. Transportation

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Toolkit Tools

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Today’s Objectives• Present highlights of the toolkit.• Focus on your local area

requirements for mass medical care.• Use the workbook to start

your planning.

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What Are Expectations or Requirements?• In California:

– Hospitals surge to care for seriously ill or injured.

– Public health activates ACS/ICCs to care for moderately acute ill or injured patients, thereby taking the load off hospitals.

– (Originally, hospitals were expected to set up and run the ACS...).

• What are State-wide expectations or requirements for ACS activation?

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What’s the Status of Current Planning ?• Healthcare Surge Plan (area-wide)?• Hospital surge plans?• Mass dispensing site (s) operational plan?• Alternate Care Site (ACS) operational plan?

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ACS Planning Resources• APC Toolkit – based on SCC’s ICC.

http://www.sccgov.org/portal/site/phd/agencychp?path=%2Fv7%2FPublic%20Health%20Department%20(DEP)%2FAdvanced%20Practice%20Center%20(APC)

• CA Dept Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume 2 http://bepreparedcalifornia.ca.gov/NR/rdonlyres/640A3732-2667-4F61-B044-413478888816/0/volume2_ACS_FINAL.pdf

• CA Government-Authorized Alternate Care Site Operational Tools Manual. http://bepreparedcalifornia.ca.gov/NR/rdonlyres/C2AD6528-F781-4D8C-B900-828A1C2C6F0C/0/Operational_ACS_Ops_Tool_FINAL.pdf

• Seattle-King County APC Video http://www.kingcounty.gov/healthservices/health/preparedness/%7e/media/health/publichealth/documents/hccoalition/AltCareVideo.ashx

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Elements of Planning: Interconnected Decisions

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Influenza Care Centers (ICC)• For pandemic planning, Santa Clara

County established the concept of Influenza Care Centers (ICC).

• ICCs are alternative care sites designed to address the needs of moderateacuity patients in a pandemic.

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ICC Pandemic Planning Assumptions:

• Local hospital capacity will not meet hospitalization demand:– Bed capacity limits (adult and pediatric acute

care, adult critical care, pediatric & neonatal critical care).

– Ventilator limits (all ventilators, including disposable, mass casualty ventilators).

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ICC Pandemic Planning Assumptions:• Illness, hospitalizations, fatalities

– 25-35% popn clinically ill

– 13-22% require hospitalization

– 2.5-5.0% fatalities

• 12 months w/illness, hospitalizations, fatalities evenly distributed each quarter.

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-4000

-2000

0

2000

Week

No. o

f Bed

s

Avail Hosp beds 920 229 -461 -1,150 -1,841 -2,301 -2,301 -1,841 -1,150 -461 229 920Avail ICU beds 204 76 -51 -205 -358 -486 -538 -486 -358 -205 -51 76

1 2 3 4 5 6 7 8 9 10 11 12

0

5000

10000

15000

20000

Week

Case

s

Deaths 56 225 394 563 731 844 844 731 563 394 225 56Hospitalizations 256 1,023 1,790 2,556 3,324 3,835 3,835 3,324 2,556 1,790 1,023 256Illnesses 1,125 4,500 7,875 11,250 14,625 16,875 16,875 14,625 11,250 7,875 4,500 1,125

1 2 3 4 5 6 7 8 9 10 11 12

Surge and Capacity Challenges

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Estimate # Patients, Sample – Albuquerque, New Mexico

• Estimated (Albuquerque) population 600,000

• 600,000 x .25 = 150,000 = # clinically ill

• 150,000 (# clinically ill) x .22 = 33,000 = # require hospitalization

• 33,000 (# require hospitalization) / 4 = 8,250 pts / quarter = (12-week pandemic “wave”)

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Estimate # Beds for Flu Patients Sample – Albuquerque, New Mexico• # of local area (Albuquerque) hospital beds

– University of New Mexico Hospital - 431– Heart Hospital of New Mexico - 55– Presbyterian Hospital - 453– The Children's Center at Presbyterian Hospital - 81– Lovelace Women's Hospital - 185– Kaseman Presbyterian Hospital – 252– Specialty Hospital of Albuquerque - 82– Kindred Hospital-Albuquerque – 61

• Total = 1,519 beds

• In hospital surge, 50% for flu patients = 760 beds(total includes ICU beds).

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Estimate # of ACS Patients, Sample – Albuquerque, New Mexico

ACS Patients – 12 Week Pandemic Albuquerque, New Mexico Example

Week # Hospitalizations Percentage Used

1 82.5 1.0 %

2 371.25 4.5 %

3 660 8.0 %

4 825 10 %

5 990 12 %

6 1196.25 14.5 %

7 1196.25 14.5 %

8 990 12 %

9 825 10 %

10 660 8.0 %

11 371.25 4.5 %

12 82.5 1.0 %

8,250 100%

Cumulative hospitalizations weeks 1-7, would be 5322 patients with a total of 60 available beds. An ACS is needed to care for 4 ,562 patients during peak weeks 5, 6, and 7.

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Workbook – Estimate # Patients• Estimated population: ________

• _____ x .25 = ______ = # clinically ill

• _______ (# clinically ill) x .22 = ________ = # require hospitalization

• _______ (# require hospitalization) / 4 = ______ pts / quarter = (12-week pandemic “wave”)

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Workbook: Estimate # Patients• # of local area hospital beds __________

• In hospital surge, 50% for flu patients

• = _________ beds

(total includes ICU beds).

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Workbook: Estimate # ACS/ICC Patients

• # beds available for flu patients _______________

• # patients / quarter = __________• Figure % of pts/qtr for each week. (Use

%’s shown).• Identify peak weeks.• Subtract # beds available from the

#hospitalized (cumulative – add the weeks up to and including the peak week).

• This is the number to plan for at the ACS/ICC.

ACS Patients – 12 Week Pandemic

# Patients /Quarter = 12 Weeks __________

Week # Hospitalizations Percentage Used

1 1.0 %

2 4.5 %

3 8.0 %

4 10 %

5 12 %

6 14.5 %

7 14.5 %

8 12 %

9 10 %

10 8.0 %

11 4.5 %

12 1.0 %

100%

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Toolkit Sections

1. Concept of Operations2. Command and Control 3. Communications4. Staffing and Training5. Clinical Standards,

Protocols and Operations

6. Infection Control

7. Fatalities and Morgue8. Facilities9. Equipment and

Supplies10. Security11. Transportation

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1. Concept of OperationsStep 1 – Describe the ICC, Objectives

– Standard of Care– Level of Care

Step 2 – Operational PeriodsStep 3 – ActivationStep 4 – De-activation

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ICC ObjectivesPrimary objectives for the establishment of an ICC

include, but are not limited to, the following: • Decompression of acute care hospital inpatient

beds (receiving site for hospital discharge patients who are not able to be cared for at home)

• Used instead of acute care hospital inpatient beds (inpatient care for moderate-acuity patients and palliative care)

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Standard of Care• Standard of care during a healthcare surge is the utilization

of skills, diligence and reasonable exercise of judgment in furtherance of optimizing population outcomes that a reasonably prudent person or entity with comparable training, experience or capacity would have used under the circumstances. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes*.

– California Department of Public Health (CA DPH)

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Pandemic Levels of Care

At Home CareAt Home Care Isolation Oral Hydration Oral Antibiotics

Influenza Care CentersInfluenza Care Centers • Intermediate Care• IV & Oral Hydration• Oxygen• Nursing Services• MD on call

Hospital AdmissionsHospital Admissions Critical Care Ventilators Ancillary Services

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Level of Care Planning Decisions

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Workbook: Level of Care Planning Decisions

• Estimated # patients_______

• Level of Care at hospital (s) _________________

• Level of Care at the ACS/ICC ________________

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Operational Periods• Define and describe the Operational Periods in

terms of a likely pandemic cycle and daily operation.

• It is anticipated that an ICC will be operational from eight to fourteen weeks for the first wave of a pandemic influenza event and then for an additional eight to twelve weeks during the second wave.

• Operational periods = 12 hours.

• Staffing

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ACS Activation• Follows area’s event/emergency activation

procedures per NIMs.• Authority to activate/operational policy:• The Health Officer will notify the local officials of the intent to activate and

then coordinate implementation through the Medical-Health Branch of the

Operational Area Emergency Operations Center. Positions in the ICC are

filled according to National Incident Management System (NIMS). Once

ICCs have been activated, only patients routed to ICCs or those triaged on-

site for admission will be accepted. Patients that are admitted to an acute

care hospital at the time the ICC is activated will remain in the acute care

facility and will not be transferred to an ICC.

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Workbook: Activation• Describe how emergency operations are

activated per NIMS.

• Who has authority to activate the ACS?

• What patients are admitted upon activation?

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Deactivation

• Authority to de-activate.• NIMS position to oversee deactivation.• Exit strategy in catastrophic failure:

– Facility fire– Civil unrest, gun fire– Government, societal failure

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Workbook: Deactivation• Who has authority to deactivate the ACS?

• Which NIMS position oversees deactivation?

• Describe catastrophic failures that might occur:

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2. Command/Control • ICC organization• Hospital Incident Command (HICS)• Planning with:

– Hospital representatives– Emergency management

representatives– Fire and Law enforcement– Inventory managers

USE TOOL #2

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• Step 1 – Describe relationship of ICC to Public Health

• Step 2 – Describe relationship between ICC to the EOC – Medical Health Branch

• Step 3 – Prepare organizational charts

2. Command/Control USE TOOL #2

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ICC Organizational ChartGeneral Staff

ICC Division Manager

Safety Officer

Operations Section Chief

Finance/Admin Section Chief

(See below)

Medical Care Branch Director

(See below)

Infrastructure Branch Director

(See below)

Security Branch Director

(See below)

Logistics Section Chief

(See below)

Planning Section Chief

(See below)

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Workbook – ICC Organization Chart

• The ACS/ICC is a field operation of __________________.

• The ACS/ICC Incident Commander reports to ____________.

• Logistics and support is provided by: __________________________

USE TOOL #2 and TOOL #5

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3. Communications • Step 1 – Determine ICC needs.• Step 2 – Describe methods.• Step 3 – Consider communications:

– Within the ICC– Between the ICC and other ICCs– Between the ICC and hospitals/healthcare

providers– Between the ICC and the EOC

USE TOOL #3TOOL #18

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3. Communications • Wireless Laptop

Computer • (5) Portable 800 MHz

radios (EMS Frequencies)

• Access to existing landline fax machines

• Access to existing landline phones

• Access to internet-accessible computers

• Access to a television with cable or satellite service

• Access to a radio• Handheld Patient

Tracking Devices• Wireless router

USE TOOL #3TOOL #18

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4. Staffing and Training • Step 1 – Determine staff ratios.• Step 2 – Describe functional roles.

(Tool 4 – Functional Roles Matrix)

• Step 3 – Determine training requirements for categories of positions.

• Step 4 – Identify types of support staff needed.

USE TOOLS #4 and #5

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4. Staffing and Training

• Local public health agency employees will not be sufficient for staffing the ICCs. The broader health care community, city governments, and community volunteers must provide human resources to ensure adequate staffing of the ICCs.

USE TOOLS #4 and #5

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4. Staffing and Training• The recommended staffing patterns are based on

the following scenario for Santa Clara:

• Total number of patients per ICC = 450

• 12-hour shifts for all staff

• Patient population includes 50% patients on IV fluids (n=225) and 60% on Oxygen via nasal cannula (n=270)

• Each ICC is divided into sections (treatment units) of up to 40 patients each.

USE TOOLS #4 and #5

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4. Staffing the ICC Position Staff-Patient Ratio ICC (450 patients) ICC Treatment Unit

(40 patients; 10-12 units)

Medical Doctors

1 : 50-60

8-9

<1

Registered Nurses 1 : 15-20 23-30 2-3

Respiratory Therapists

1 : 20-30 15-23 2

Caregivers (Health Technicians)

1 : 5 90 8-9

Clerical 1 : 20 23 2

Social Workers 1 : 60 8 <1

Pharmacists 1 : 60 8 <1

USE TOOLS #4 and #5

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Workbook: Staffing• Number of patients (beds) in the ICC = (#)• Using staffing ratio chart, determine

staffing ratios to be used.• Review and revise Tool #5 Job Action

Sheets• Identify community support for staffing.

USE TOOLS #4 and #5

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ACS Staffing RatiosPosition Staff-Pt

RatioICC (450)

Santa Clara(Toolkit

Example SCC needs twelve 450 bed ICCs )

ICC (100) (22% of SCC

ICC)

(Any town, USA

Example)

ICC (___)= ___ % of SCC ICC

(450)

Staff Ratio as % of SCC’s Staff-Patient

Ratio Medical Doctors 1: 50-60 8-9 per ICC 1-2

Registered Nurses 1: 15-20 23-30 per ICC 5-7

Respiratory Therapists 1: 20-30 15-23 per ICC 3-5

Care Givers (Health Technicians)

1: 5 90 per ICC 20

Clerical 1: 20 23 per ICC 5

Social Workers 1: 60 8 per ICC 2

Pharmacists 1: 60 8 per ICC 2

Workbook: Staffing USE TOOLS #4 and #5

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4. Training • ICC Orientation – Just in Time

Training• Pre-event Clinical Operations

Training – Public Health Clinical ICC Staff

• Pre-event Clinical Skills Training 

USE TOOLS #4 and #5

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5. Clinical Standards, Protocols and Operations• Standing Orders

• General• Admitting• Asthma• Heart Failure• Diabetes• Pregnancy• Palliative Care

• Clinical Triage

• Oxygen Delivery Alternatives

• Insulin and Blood Glucose Monitoring Sheet

• Pharmacy Order Form

• Patient disposition log

• ICC Intake Assessment Form

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Elements of Planning: Interconnected Decisions

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5. Clinical Standards, Protocols and Operations• Step 1 – Develop triage guidelines.• Step 2 – Describe admissions/intake process.• Step 3 – Describe pt./bed tracking.• Step 4 – Define documentation and patient charting.• Step 5 – Describe daily evaluation.• Step 6 – Describe pharmacy formulation protocols.• Step 7 – Describe discharge criteria/procedures.• Step 8 – Develop visiting rules/regulations.• Step 9 – ID housekeeping/environmental services.

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5. Clinical Protocols & Patient Care Tools

Tool 6 – Oxygen Delivery Alternatives Tool 7 – Clinical Triage Guidelines during Pandemic Critical Resources State Tool 8 – Influenza Care Center Intake Assessment Tool 9 – General Standard Orders Tool 10 – Standing Orders for Asthma Tool 11 – Standing Orders for Heart Failure Tool 12 – Standing Orders for Diabetes Tool 13 – Standing Orders for Pregnancy Tool 14 – Standing Orders for Palliative Care Tool 15 – Admitting Orders Tool 16 – Consent to Treatment Form Tool 17 – Medication Tracking Sheet-Family Tool 18 – EMSystem Tool 19 – EMTrack Tool 20 – Patient Disposition Log Tool 21 – Daily Patient Assessment Flow Tool 22 – Change Orders Tool 23 – Insulin and Blood Glucose Monitoring Tool 24 – Pharmacy Order Form Tool 25 – Medication Administration Record Tool 26 – Visitor Guidelines and ICC Etiquette Tool 27 – Patient Discharge Form

USE ALL THESE TOOLS

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5. Patient Care• Triage guidelines and admission• Admission/intake process

– Standardized Orders– Admission protocols

• Bed and patient tracking• Medical records/patient charts• Daily evaluation and treatment• Transfer dispositions

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5. Patient Care• Pharmacy protocols• Discharge protocols• Family care giving guidelines• Visitor guidelines• Environmental services

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Workbook: Clinical Protocols and Patient Care• Convene a workgroup: physicians, RNs,

EMS• Determine patient care “flow”• Review protocols

– Santa Clara County in the APC Toolkit

– New York Medical College, School of Public Health

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8. Facilities• Step 1 - Determine criteria for facility

selection.• Step 2 – List recommended facilities.• Step 3 – Diagram ICC layout.• Step 4 – ID other required facility areas

needed.• Step 5: Conduct a site visit; coordinate with

facility operators.

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Facility Criteria USE TOOL#28 and #29

1. Location and size 2. Infrastructure and equipment capacity:

a. Communications b. Unimpeded wireless connectivity c. Electrical power with back-up generator capability d. Climate control e. Adequate parking and loading ramps f. Sufficient material handling equipment (MHE) –fork lift pallet jacks

3. Patient care requirements: a. Separate rooms with large floor space for patient care b. Billeting for personnel (and possibly family members) c. Bathrooms with shower capabilities for patients d. Kitchens and food service for staff and patients; Potable water; Refrigeration; Ice

making capabilities 4. Available services:

a. Laundry facilities b. Waste removal (to include bio-hazard)

5. Security: a. Perimeter security b. Capable of being secured and secure storage for controlled substances

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SCC’s ICC Facility Requirements

Substantial square footage with

large open areas. Sites geographically distributed

around the county. Hotels: surge support.

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ACS Ward Layout USE TOOL#28 and #29

70’

50’

5’ aisles in each direction

5’ access aisle along one side

Table Table

Drug Cabinets Supply

Shelves

Patient Cart

Supply Cart Nursing

Station

Bay 1 Bay 2 Bay 3

Bay 5 Bay 4

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ACS Bay Layout USE TOOL#28 and #29

Bin

Chair

Bin

Chair

Bin

Chair

Bin

Chair

Bin

Chair

Bin

Chair

Bin

Chair

Bin

Chair

O2 Tank & Stand

20’

20’

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Workbook – Facilities • List facilities that may be used as an

ACS/ICC in your area:

USE TOOL#28 and #29

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6. Infection Control• Step 1 – Determine necessary PPE for ICC

staff.• Step 2 – Determine necessary PPE for ICC

visitors.• Step 3 – Describing environmental cleaning

procedure(s).• Step 4 – Develop procedures for disposal of

biohazard waste.

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7. Fatalities - Morgue• Step 1 – ID operational area for temporary

morgue.

• Step 2 – ID required equipment/supplies.

• Step 3 – Determine type of staffing.

• Step 4 – Describe how bodies are transferred.

• Step 5 – Describe personal property procedure.

• (See Mass Fatality Toolkit)

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9. Equipment & Supplies • Step 1 – Develop inventory list, consider local

resources & scope of ACS/ICC care.

• Step 2 – Determine storage and maintenance.

• Step 3 – Describe process for implementing: ordering and moving supplies.

USE TOOL#3

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Equipment & Supplies• Warehouse Storage

– Electrical items – on shelves, plugged in, temperature controlled area

– Maintenance items (i.e. Glucometer) need periodic inspection, stored in bulk containers, temperature controlled.

– Pharmaceuticals, temperature controled or in refrigerator.

– Stack-limited items, heavy/bulky, palletized, stored on pallet racks, 10’ wide aisles.

– Bulk items, smaller, lighter, easily damaged, stored in bulk containers, stacked densely, w/o aisles.

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10. Security• Step 1 - Describe role of Security at ICC.

• Step 2 – Describe Access Control.

• Step 3 – Describe Crowd Control.

• Step 4 – Describe Traffic Control.

• Step 5 – Describe role of Law Enforcement Interface

• Step 6 – ID sources of security personnel.

USE TOOL#28 and #29

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Access Control • Staff, visitors, support, media, officials.• Anticipate theft of pharmaceuticals, medical

supplies.• Anticipate individuals who try to

surreptitiously remove a patient or bring a patient in to the ICC.

• Anticipate media attempting entry.• Badging, log-in and out.

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Crowd Control/Traffic Control• High volumes of ill

people.• Highly emotional

people.• Neighborhood

concerns.• Protestors, provide

escorts.

• Patient parking• Staff parking.• Patient

loading/unloading.• Ambulance• Delivery• Media area.

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11.Transportation• Step 1 – Describe policy for transporting

patients to the ICC.• Step 2 – Describe policy for transporting from

the ICC to hospital.• Step 3 – Describe how transportation

requirement will be met.• Step 4 – Describe communications for

transportation operations.• Planning with OEM Logistics

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ContactsOlivia NunezSanta Clara CountyPublic Health Preparedness976 Lenzen AvenueSan Jose, CA 95126(408) 792-5266 sccphd.org/APC 

Laurie FriedmanSYA Group, Inc.1126 Broadway, Suite 4Burlingame, CA 94010650-373-7747Laurie@syagroup.com

Rocio Luna, MPHDirector, PH Preparedness and Data

ManagementSanta Clara County Public Health

Department976 Lenzen AvenueSan Jose, CA 95126Main Line (408) 792-5040

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