State Expert Panel on Inpatient Surge Capacity

x

Guidelines for Managing

Inpatient and Outpatient

Surge Capacity

Recommendations of the State Expert Panel on Inpatient and Outpatient Surge Capacity

November 2005

Table of Contents

Introduction ……………………………………………………………………….Intro-1

1. Types of Incidents ……………………………………………………………Page 1-1

2. Increasing Availability of Existing Inpatient Beds …………………………Page 2-1

3. Field Triage …………………………………………………………………….Page 3-1

4. Opening/Creating Areas or Wings for Inpatient Surge Capacity ………………Page 4-1

Classification of Surge Capacity Beds by Triage Colors ……………..…….Page 4-2

Application of Color-Coded Surge Beds to the Level of Incident……...... Page 4-3

Example of Surge Capacity Matrix ………………...……………………… Page 4-4

Surge Capacity Matrix …………………………….………………………Page 4-5

Cohorting Surge Patients …………………………………………………. Page 4-6

Summary of Surge Capacity Beds …………………………..…………… Page 4-7

St. Camillus Hospital Surge Capacity Support Area Matrix …………… Page 4-8

5. Inpatient Units for Special Considerations …………………………………...Page 5-1

6. Criteria for an Inpatient Surge Capacity Bed ………………………………… Page 6-1

7. State Stockpile of Inpatient Surge Capacity Beds …………………………… Page 7-1

8. Patient Care Staffing for Inpatient Surge Capacity Areas ……………………. Page 8-1

Staffing Strategies………………………………………………………… Page 8-1

Assignment of Staff to Color-Coded Beds ………………………………..Page 8-2

Job Action Sheets ………………………………………………………… Page 8-3

Managing the Continuum of Care After the Initial Surge of Inpatients …Page 8-3

Transition Matrix …………………………………………………………Page 8-4

Secondary Surge …………………………………………………………. Page 8-4

Discharge Planning and Case Management …………………….. Page 8-5

9. Ancillary Care Staffing for Inpatient Surge Capacity Areas ……………Page 9-1

Ancillary Support Matrix ……………………………………… Page 9-2

10. Staff Support Considerations ………………………………………………. Page 10-1

11. Equipment and Supplies …………………………………………………….. Page 11-1

Equipment Location Matrix ……………………………………………… Page 11-2

Equipment Source Matrix ……………………………………………… Page 11-2

Critical Supply Inventory ………………………………………………. Page 11-3

Supply Source Matrix …………………………………………………… Page 11-5

12. Triage Center …………………………………………………………………. Page 12-1

Criteria for Triage Center ………………………………………………. Page 12-1

Decontamination ………………………………………………………… Page 12-1

13. Outpatient Surge Capacity …………………………………………………… Page 13-1

Alternative Treatment Site Matrix ……………………………………….. Page 13-2

14. Exercise ………………………………………………………………………. Page 14-1

15. Off-Site Alternative Inpatient Treatment Centers ……………………………. Page 15-1

16. Risk Communications ……………………………………………………… Page 16-1

17. Business Continuity Plan …………………………………………………… Page 17-1

18. Guidelines for Completing Your Hospital Surge Capacity Plan ……………. Page 18-1

Appendices

Appendix A: Map of HRSA Hospital Disaster Preparedness Regions …………Appendix A-1

Appendix B: START Triage Algorithm …………………………………………Appendix B-1

Appendix C: JumpSTART Triage Algorithm …………………………………Appendix C-1

Appendix D: Example of Hospital Surge Capacity ………………………….. Appendix D-1

Appendix E: Prioritization of Patient Care Tasks ……………………………. Appendix E-1

Appendix F: Job Action Sheets ………………………………………………..Appendix F-1

Appendix G: Medications in ChemPacks …………………………………….Appendix G-1

Appendix H: Accessing the ChemPacks ………………………………………Appendix H-1

Appendix I: Rationing Supplies …………………………………………………Appendix I-1

Appendix J: Access to Personal Protective Equipment ………………………….Appendix J-1

Appendix K: Strategic National Stockpile List of Assets ……………………….Appendix K-1

Appendix L: Template Memorandum of Understanding ………………………Appendix L-1

Worksheets

Worksheet 1: Incident Level Matrix ……………………………………………Worksheet 1-1

Worksheet 2: Surge Capacity Matrix …………………………………………..Worksheet 2-1

Worksheet 3: Surge Capacity Summary ………………………………………..Worksheet 3-1

Worksheet 4: Surge Support Area Matrix ………………………………………Worksheet 4-1

Worksheet 5: Staffing Ratios for Surge Capacity Matrix …………………….Worksheet 5-1

Worksheet 6: Transition Matrix ……………………………………………….Worksheet 6-1

Worksheet 7: Ancillary Support Matrix ……………………………………….Worksheet 7-1

Worksheet 8: Equipment Location Matrix ……………………………………..Worksheet 8-1

Worksheet 9: Equipment Source Matrix ………………………………………..Worksheet 9-1

Worksheet 10: Critical Supply Inventory Matrix…………………………….Worksheet 10-1

Worksheet 11: Critical Supply Source Matrix ……………………………….Worksheet 11-1

Worksheet 12: Alternative Treatment Site Matrix ……………………………Worksheet 12-1

Introduction

This document provides guidelines and recommendations for hospitals to manage a surge of inpatients and outpatients in a mass casualty incident. The National Bioterrorism Hospital Preparedness Program of the Health Resources and Services Administration (HRSA) has granted funds to help hospitals better manage a surge of inpatients, based on a minimum capability of hospitals being able to treat 500 adult and pediatric patients per 1,000,000 population. For the State of Wisconsin this translates to being able to care for a minimum surge of 2,683 additional inpatients.

Presently, there are 12,922 staffed beds for the 128 medical/surgical hospitals in the state. Initially, it was felt that surge capacity could be achieved by establishing Alternative Treatment Facilities, that is, other sites, apart from the hospital, such as community centers, schools and other such large buildings that could be converted into use as inpatient facilities. The many logistical, clinical, legal and financial issues involved with the implementation of the Alternative Treatment Centers are myriad.

128 hospitals participated in an exercise in May 2004 to measure their ability to increase inpatient bed capacity. The results of the exercise demonstrated that:

• Hospitals were able to “empty” existing beds by early discharge and other strategies so that there were approximately 7,000 available inpatient beds[1]
• Hospitals were able to open and/or convert other areas or wings of their facilities to care for inpatients so that there were approximately 17,700 additional inpatient beds available[2]

The State Expert Panel on Inpatient and Outpatient Surge Capacity was convened to make recommendations, based on the surge capacity goals, presented to hospitals by HRSA, and the options that are available to hospitals to achieve this goal. This Panel was composed of Inpatient Nursing and Emergency Department managers.

These Guidelines then are based on the results of the May 2004 exercise and the recommendations of the Expert Panel. The strategy recommended for Wisconsin hospitals is to both “empty” existing inpatient beds to the extent possible (to deal with the initial surge of inpatients) and to open other areas for inpatient care.

Based on the results of the May 2004 Exercise, the following matrices represent the surge capacity potential for Wisconsin Hospitals by region (see Appendix A: Map of HRSA Hospital Disaster Preparedness Regions).

Intro-1

Region / Staffed Beds / Available Beds[3] / Surge Beds[4]
1 / 1,211 / 808 / 2,198
2 / 1,184 / 641 / 1,710
3 / 1,028 / 588 / 1,828
4 / 694 / 452 / 1,016
5 / 2,381 / 1,066 / 2,629
6 / 991 / 651 / 1,337
7 / 5,433 / 2,757 / 6,985
State Total / 12,922 / 6,963 / 17,703

Note: It is important to recognize that the above number of “17,703 additional inpatient beds” does not mean that hospitals have actual beds that can be deployed. The matrix below displays the actual “available surge beds” to accommodate a surge of inpatients.

Region / Surge Beds / Available Surge Beds[5] / Surge Beds Needed[6]
1 / 2,198 / 1,171 / 1,027
2 / 1,710 / 552 / 1,158
3 / 1,828 / 612 / 1,216
4 / 1,016 / 448 / 568
5 / 2,629 / 1,284 / 1,345
6 / 1,337 / 370 / 967
7 / 6,985 / 2,199 / 4,786
State Total / 17,703 / 9,230 / 11,067
Surge Cots / (2,600)[7]
Surge Beds Needed / 8,473

Since any mass casualty incident will be local in nature, it is the responsibility of each hospital to have the ability to implement this Inpatient and Outpatient Surge Capacity Plan. How long the hospital will need to manage this surge of patients will depend, of course, on the intensity and geographical footprint of the area affected.

Intro-2

These Guidelines provide hospitals with a plan to manage a potential surge of approximately 11,830 patients[8]. This surge of patients could result from an extremely traumatic incident such as a grandstand or building collapse. However, a pandemic flu incident could begin to push even these limits. Each flu season finds many hospitals at full bed capacity with their resources pushed to the limit.

In the event of a catastrophic mass casualty incident such as a nuclear explosion or a “Hurricane Katrina Incident”, even this mass casualty surge capacity may not provide sufficient inpatient and outpatient treatment capacity and thus overwhelm the capacity of the healthcare system to manage a catastrophic event.

Intro-3

1.Types of Incidents

There are two major types of mass casualty incidents that may occur:

Traumatic incidents may be caused by multiple vehicle accidents, building collapse, explosions, chemical spills, airplane crash, etc. Hospitals will be alerted as to the time of the incident and the Estimated Time of Arrival of the casualties. These incidents are usually time-limited as to their duration. In most cases, within 24 hours from the inception of the incident, the total surge of patients will have arrived at the hospital. Soon thereafter, patients will have been stabilized and treated and the discharge of the first of these patients will occur. Within days, the hospital can expect to return to near normal operations. Except for explosive events, where there may be large numbers of burn patients, it is expected that, in most traumatic incidents, hospitals will be able to manage those in need of long-term hospitalization.

Biological incidents may be caused deliberately by such agents as anthrax or smallpox or indeliberately by pandemic flu or by other infectious disease outbreaks. In these incidents, the identification of the incident will occur over time and the surge of patients will occur slowly at first and may then peak considerably at a certain time due to the incubation period. The duration of these incidents cannot be determined and may last for weeks and even months, such as in the case of pandemic flu, which can come in several waves over long periods of time.

TheseGuidelines will address surge capacity for both types of incidents. These Guidelines will apply similarly to both types of incidents with a few special considerations for biological incidents.

1-1

2.Increasing Availability of Existing Inpatient Beds

There are various strategies to increase existing inpatient bed capacity such as early discharge of patients, cancellation of elective admission, etc.

In a traumatic incident it is recommended that this strategy be used only as a secondary strategy with the opening of surge capacity areas as the first strategy. This is due to the fact that staff will be occupied with the surge of patients and will not have time initially to begin the implementation of the strategies to make occupied beds available. It is expected that patients in a traumatic incident will arrive faster than occupied beds can be “emptied” or made available. In addition, the in-house and outside “traffic”, created by these “emptying” strategies, may add to the congestion, caused by the incoming surge of patients and the family members, media and general public that will arrive at the hospitals along with these victims.

This “emptying” strategy will prove more effective and more clinically appropriate as the “surge patients” are treated and then moved to more appropriate beds, which will be made available through early discharge and other such “emptying” strategies. The goal is to return to “normal” operations and bed configurations as soon as possible.

2-1

3.Field Triage

Before a hospital can begin to establish its inpatient surge capacity plan, the staff responsible for the implementation of this plan must be familiar with the triage protocols that will take place in the field. This process involves triaging (“sorting”) patients by their severity of injury, based on a color-code system, which is widely used by EMS and First Responders and their hospital partners.

TheWisconsin EMS Emergency Preparedness Plan (WEEPP) has recommended the use of START (Simple Triage and Rapid Treatment) as the triage protocols for adult patients and JumpSTART as the triage protocols for pediatric patients (see Appendix B: START Triage Algorithm and Appendix C: JumpSTART Triage Algorithm).

START and JumpSTART uses the following color codes to triage (“sort”) patients:

• GREEN designates patients that are ambulatory and thus their injuries may be of a minor nature. It is anticipated that GREEN patients, in a mass casualty incident, will not be transported to hospitals, but rather will receive initial treatment in the field and/or be transported to alternative outpatient treatment centers (see Section 13).

• YELLOW designates patients that do not need immediate care and thus are triaged for “delayed” treatment.

• RED designates patients that are in need of immediate care.

• BLACK designates patients that either have died or whose injuries are so severe that they are expected to die and thus are designated as “Expectant”. In a mass casualty incident, the number of BLACK patients may increase due to the limited resources and will be brought to the hospital for palliative care. The triage principle that will be used in the field and in the hospital is “Do the greatest good for the greatest number.”

2-1

4.Opening/Creating Areas or Wings for Inpatient Surge Capacity

The May 2004 Exercise demonstrated that hospitals were very creative in the identification of wings, areas and spaces that could be opened and/or converted for use as inpatient treatment areas. These potential treatment areas included such areas or spaces as:

• Waiting Rooms
• Wings previously used as inpatient areas that can be reopened
• Conference Rooms
• Physical Therapy Gyms

Appendix D: Example of Hospital Surge Capacity provides an example of the type of data, produced by the May 2004 exercise, which is available for each of the 128 medical/surgical hospitals in the State of Wisconsin.

Obviously, there is a hierarchy among these rooms as to which would best and first be used as inpatient surge capacity treatment areas. These Guidelines are intended to provide hospitals with recommendations on how to determine which areas and rooms can best be used for which patients.

It is important for the hospital to consider other areas that will be also be affected by the surge of inpatients so that not all space is targeted for inpatient care. For example, a surge of patients will also bring a surge of family members and visitors. Spaces need to be identified to accommodate the needs of these people. For example, the cafeteria usually is a large area that could accommodate inpatient surge beds. However, this space will be necessary for food services for staff and visitors. Family members and visitors will also need spaces to congregate and relax. Patients from distant areas will be accompanied by family and friends, who may stay at the hospital for long periods of time.

This selection of areas to be used for surge capacity can best take place when the hospital has an understanding of the intensity of the incident and the resulting number of surge patients that it may receive. Collaboration and the establishment of alert protocols with EMS and other First Responders and the Emergency Operations Center (EOC) will provide hospitals with the necessary information to implement the appropriate number of inpatient surge beds.

The following Incident Level Matrix was developed by the Expert Panel to help hospitals tier their plans for the implementation of inpatient surge capacity beds, based on the number of patients expected:

4-1

INCIDENT LEVEL MATRIX
Incident Level / Number of Patients Expected
I / 1 – 10
II / 11 – 25
III / 26 – 50
IV / 51 – 100
V / >100

Each hospital is expected to build their inpatient surge capacity plan, based on the number of staffed beds they have available. A rural Critical Access Hospital with 20 staffed beds will have a plan that is different than that of a metropolitan hospital with 300 beds.

Commentary: The Expert Panel agreed that a disaster code at most hospitals, calls for a response from everyone at the hospital. Consideration is to be given to calling a Disaster Code by the Level of Incident so that only the appropriate resources are deployed, based on the different levels of incident. For example, only ED staff and certain others may need to respond to a Level I incident, while everyone responds to a Level V.

Classification of Surge Capacity Beds by Triage Colors

The following guidelines are written to help hospitals initially triage or “sort” their surge capacity beds and identify which beds can best be used for which type of patient. Thus, if a hospital is told that it should expect to receive 10 RED patients and 15 YELLOW patients, the hospital will have pre-identified in this plan which rooms can best serve the needs of these patients.

Thus, the inpatient surge capacity rooms should initially be designated by the following triage color codes:

• RED rooms are to be designated for the care of patients in need of immediate care. These RED surge capacity rooms are rooms, which need to be similar to ED rooms with the required gases and equipment. Examples of such rooms are PACU and ICU rooms or, if necessary, a medical/surgical room.

• YELLOW rooms are to be designated for the care of patients, whose treatment can be delayed. These are medical/surgical rooms or areas or other rooms that are in close proximity to existing medical/surgical rooms and also in close proximity to ancillary services and supplies.

• BLACK rooms are to be designated for the palliative or comfort care of patients and may be rooms that are more distant from the core acute care service areas because these patients will be provided only with minimal services.

4-2

IMPORTANT: As in the field, all these patients will need to be constantly retriaged. The color designation may change several times for these patients.

Application of Color-Coded Surge Beds According to the Level of Incident

The initial alert from the field will give the hospital information regarding the number of color-coded patients that are expected to be transported to the hospital. This will enable the hospital to determine which areas or rooms it will use to care for RED, YELLOW and BLACK patients.

Level I: It is expected that at this Level most hospitals[9] will be able to handle the surge of inpatients with its existing inpatient staffed bed capacity without the need to deploy any inpatient surge capacity beds.

Level II: The first consideration for the hospital is how many RED patients will be coming to the hospital. According to the Incident Level Matrix, Level II will involve 11- 25 patients. RED patients should ideally be placed in ED rooms. If there are more RED patients than there are ED rooms, then there must be the deployment of areas that can be designated as RED surge capacity rooms, where these RED patients can receive immediate treatment. In this case, these rooms are more treatment areas than they are inpatient rooms.

Level III, IV and V: The hospital is to have pre-identified inpatient surge capacity areas for RED, YELLOW and BLACK patients. The Surge Capacity Matrix (see Worksheet 2) should also enable the hospital to identify the maximum number of RED, YELLOW and BLACK patients that the hospital can manage.

However, even if hospitals have identified only a certain number of RED rooms, e.g. 10 RED rooms, if 15 RED patients are transported to the hospital[10], then the hospital will have to tap into the next level of YELLOW rooms and “do the best they can to meet the needs of their patients, given the limited resources.”