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Surge Capacity and Health System Preparedness: Facilities and Equipment: Transcript of Web Conference (continued)
Cindy DiBiasi: So how do you specifically handle the issues
that you have just raised about pediatric surge capacity?
Dr. David Markinson: We have to find that same parallel that we
just talked about. All surge planning
must include children so we must address pediatrics, period. But then, and I think people have done a reasonably good job at starting to look at
pediatrics as part of traditional surge or part of the population where we haven't
gone and we need to get very quickly is a uniquely pediatric event. This means that the emergency operations
plans must include pediatric as part of any event, uniquely pediatric
event. Providers must be trained. We must have equipment and pharmaceuticals,
drills and exercises and we know if peds are out of proportion to their normal
number in the population, it is going to require adult providers, adult units
and adult equipment. So we must have the
training, the protocol, the procedures and plans to allow that to happen.
Lastly, because of that family unit
concept, we also have to think about if there is a charge for pediatric
providers. While they said for many
years that all of us that take care of adults must think of children, the flip
is also true. We are going to keep the
family together, children's hospitals, pediatric providers must be prepared to
Cindy DiBiasi: So are there Federal and
State resources available for use in the event of a public health emergency
that is focused on pediatrics?
Dr. David Markinson: In general, almost all surge capacity as
well as emergency operations plans take into account Federal and State
resources. If I am the hospital director
and I am setting out my plans, I would say, "Here is how long I will have to,
best case scenario, worst case scenario, handle it on my own." And then I sort
of expect certain Federal and State resources.
At the Federal level, this may be the Strategic National Stockpile, the
National Disaster Medical Service, DMAT team.
Unfortunately, the assumption that I made for the adult population do
not apply to children. For example, the
DMATs do not have a requirement for pediatric-trained providers and they do not
have a requirement for pediatric equipment.
Some of them may do this on their own, but you cannot assume when you
get a DMAT you are going to have pediatric.
You can't build that into your planning.
The Strategic National Stockpile
originally had almost no pediatric considerations. I have to say that they have done an
exceptional job of moving forward to get better, but their hands are tied. They are only allowed to stock equipment and pharmaceuticals for its FDA indications.
So if it is not indicated for children, they can't stock it. We know at least half the stuff we use in hospital standard care is not approved for children. We use good medical sense. Unfortunately, the Strategic National Stockpile can't. As a result, when the
hospitals or counties or localities make their plans, they cannot assume that
for pediatric resources will arrive, even from the State level.
Things like State stockpiles are often
based on the list of the National Stockpile, same problems exist. Things like the Medical Reserve Corps, which is the local medical physician volunteers and other health care providers,
again, no requirement for pediatric training, no necessity of pediatric
providers so you may get lucky and find help, but you may not. So as hospitals plan, they must assume that none of these Federal and State resources have pediatric capability and for
their pediatric surge, pediatric planning, they have to survive on their
Cindy DiBiasi: David, you have been talking about special
considerations when it comes to children.
Does the same hold true for the decontamination of a child?
Dr. David Markinson: Decontamination is a good example of where
unique anatomy, physiology, equipment and mental health needs come in. The general premise of decontamination, as I
am sure you heard, we heard it a little bit earlier, is for gross removal of clothing
and then most commonly water to actually do further decontamination. Taking it just at the simplistic level
because of the time allotted, think about it. The first thing we do is we ask
people to disrobe and then we, after they are done, get them dressed. How many stockpiles have Pampers or other
diapers? How many stockpiled gowns in
the size of a child? We may have tons of
hospital gowns for adults or other things we can throw over an adult, but what
are we going to do for a baby?
In addition, think about the typical
decontamination shower or other model.
Building a [unclear] or getting them undressed. That alone can cause hypothermia. We then are spraying them down and how many
of our decontaminations are set up to provide hot or warm water as a constant
flow for the mass numbers that we have?
So we can be inducing significant hypothermia in the children.
In addition, most of these things run
off a fire hose or main line from the hospital. The pressure of the water
itself, if not regulated down, may actually knock the child over, cause injury
or cause injury to the skin.
Also, what about the child just going
through the process? It may be hard
enough under times of panic to convince an adult, take off your clothes, walk
down this through the shower and do the following things: how are you going to get a toddler to do
that, a school-aged child? What if the
child doesn't even walk? So we need to
account for chaperoning the children through the process and preferentially
chaperoning them with people they know and trust and the non-ambulatory. Then the mental health, which comes into
that. How do we get children to comply
and how to do we not make the process more detrimental than the health?
Cindy DiBiasi: Well, you talked about the problems. Now are there solutions? Are there ongoing efforts to bridge any of
Dr. David Markinson: There are some very good efforts. The first step was really identifying where
the gaps were and where attention needed to be focused. This was done by the National Advisory Committee
on Children and Terrorism. This was a
legislated activity of an advisory committee by the Secretary of Health and
Human Services that completed about a year ago, a report to the secretary with
specific guidelines of what to do for children across the entire agency, the
Health and Human Services Agency, as well as some comments from interaction
with other agencies such as the Department of Education and Homeland
While some of these have been taken on,
again, fulfilling all of these guidelines and recommendations would be helpful,
but also for the people at the State, the county, the locality or the local
municipality. While these were done from
the Secretary of Health and Human Service across all Federal agencies, size may
change, the government agency news may change, but these guidelines would
easily be applicable to a county government, a State government or a
In addition, the specific elements of
what you need to do came out of an AHRQ-funded conference that we hosted about
a year ago, Pediatric Disaster and
Terrorism Preparedness: A National
Consensus Guideline. We recognize
that the literature, while there, was limited on what kids need so we brought
together the best experts from across all the disciplines of the government
agencies and looked at the evidence.
Where there was evidence, recommendations were there and in the absence
there was consensus. As you look here,
you have a list of all the topics.
Unfortunately, time will not allow me to go through each one of these,
but you have specific recommendations and they are very specific. They talk about numbers of equipment, numbers
of providers, actual dosages, and treatment protocols across all the range of
things you see here.
This was one point in time and we knew
when we did this that there would be new threats, net technologies out there
and new questions that came up. So using this evidence-based consensus model
and a wide range of experts in pediatrics, the people have to implement these
in terms of emergency preparedness, public health and the government agencies
involved, we kept this group together and have actually added to it to create
something called the Pediatric Expert Advisory Panel. This is a multi-disciplinary group, both
governmental and non-governmental. It is
an ongoing program and what it does is give us an ability to rapidly add on as
new threats or technology and then disseminate the findings on our Web site
through an info brief which summarizes the findings and through conferences and
An example of one of the items that
came up was earlier this year. The Food
and Drug Administration (FDA) approved something called the Pediatric Dosage
Atropin. Mark One, many of you may know,
is the treatment of choice for adults exposed to chemical nerve agents of a
specific type. Unfortunately, while this
was touted as a pediatric equivalent, it is not. It is only half of Mark One. It includes atropin and not the paradoxin the
In addition, the original guidelines
for treatment said Mark One is acceptable in appropriate dosages down to any
age after bonafide exposure. This data
was reviewed. The data about the new
device was reviewed and a recommendation came out to continue using the Mark
One as a preferred treatment for all children of any age and not to stock and
not to use the pediatric atropine. An
info brief came out that explained all the key points that went into that
decision, what the future recommendations are and why they were made. That was distributed recently by mail and it
is now on the Web site.
Cindy DiBiasi: Well, let's talk about where people can get
more information because obviously there is some incredibly valuable
information in your report.
Dr. David Markinson: The general report, The Pediatric Disaster Conference Consensus Guidelines, are
available on our Web site. In addition,
on the Web site are these info briefs, the ones we talked about. In addition, this Pediatric Expert Advisory
Panel is ongoing. You can send in
questions from the Web site and the panel will address them and we release
these info briefs. The info briefs are
mailed and you can also be asked to be on the mailing list. They are mailed to all government leaders and
emergency preparedness at the State and local level, government agencies and
all members of the group and professional organizations. So the Web site, I believe the address is
being typed up as we speak. This is
where you can get all the information about the Pediatric Preparedness Program,
all our resources, talks and presentations we have given plus it gives you an
avenue to ask us questions about ongoing issues.
Cindy DiBiasi: Great.
Thank you, David. We will be back
to ask you some more questions. In a
moment, we are going to be opening up the discussion for questions from our
listening audience but first I would like to turn to David Gruber from the New
Jersey Department of Health and Senior Services.
David, how has New Jersey approached surge
capacity within the State?
David Gruber: Good afternoon, Cindy,
and I think because I represent New Jersey I feel comfortable in
drawing from a Bruce Springsteen line and that is, "One step up and two steps
back." I think if you look at how we
address surge capacity, we took with our initial funding, one step forward and
used a band-aid approach to some of the critical issues that needed to be
immediately addressed. However, we
realized that we needed an overall strategic plan to make it the most effective
program, so we took a few steps back and developed that strategic plan.
When we developed the strategic plan,
we decided that we weren't going to go hospital-centric; we were going to go
system-centric. We would look at the
systems versus the facility. To do that,
we had to figure out what the threat was and how we were going to address the
issue. So we looked at two separate
scenarios. One was an acute event and
the other was a chronic event. The
classic acute event could be an explosive event or a chemical attack that would
really hurt the health system, hurt it bad, hurt it hard and hurt it
quick. That we would place that against
a chronic event in which would be a slow-moving attack, it would require
long-term effects, it would have long-term effects and long-term care
So to do this and to make this happen
and to apply all the assets that the State of New Jersey had, we created what we
call the Health Emergency Preparedness and Response Triangle. We recognized that to be most effective, we
would have to ensure that public health, health care delivery systems and the
emergency management system were all linked together and were all addressing
Cindy DiBiasi: Now earlier in this broadcast, Sumner spoke
about the surge capacity benchmarks that are included in the HRSA program. How does New Jersey address these
David Gruber: Well, we made sure that we didn't look at
the benchmarks by themselves but looked at the benchmarks as they applied to
our program. So we reviewed our focus
and our focus was primarily on situational awareness, knowing what was going on
throughout the State at all times with the health system. Also we looked at tempo control; being able
to use time to our benefit, not time as an enemy. We looked at passive and active architectures
so that we would both push information out to our communities and pull
information back. I talked about
systems, but we also looked at redundancy knowing that the primary system
frequently fails exactly when you need it so we made sure we had backups. Then we had targeted capabilities that we
will discuss a little bit later.
So instead of applying the benchmarks,
what we did was we applied the benchmarks to our strategy and our programs and
used them to evaluate our programs.
Additionally, we created what we call the Health and, excuse me, the
Emergency Preparedness and Response Health System Network. The benchmarks were used as measures of this
network; they were not drivers of this network.
They were measures of the strategy, not drivers of the strategy.
Finally, what we did was we created a
division within the Department of Health that looked at all the issues that the
benchmarks would address and that is listed on the next slide you see.
Cindy DiBiasi: How has emergency preparedness funding been
used in New
Jersey to enhance surge capacity?
David Gruber: What we did was design programs and then
figure out how we were going to fund the programs as opposed to seeing a
funding source and then seeing how we would spend the money of that funding source. We are very fortunate in New Jersey that the governor and
commissioner are exceptionally knowledgeable and dedicated to the program so in
addition to large amounts of CDC and HRSA funding and a little bit of ODP
funding for health, we have what we call Med Prep funding, which is State
bioterrorism funds. That is to the tune
of approximately $12 million and has been given to us over the past few
years. To put that in perspective, that
is about number nine or so, if you look at HRSA grants, as far as amounts of
But we took that money, and as I
mentioned, we applied it to programs and if we move to the next slide we can
see we put a roadmap out there and it was a three-year road map in which we
concentrated on developing an infrastructure first, looking at our command and
control and communications next and then exercising the system as the final
We also tried to focus on the big
programs and the big money programs upfront under the assumption that
eventually money is going to end and funds will draw down. So if our big investments are paid for
upfront, we feel we would have long-term programs.
Cindy DiBiasi: Well, tell us about some of the programs
that have been put into place to address surge capacity in New Jersey.
David Gruber: I would like to focus specifically on two
programs. The first one is our Medical
Coordination Centers. This is in support
of our regional concept. In New Jersey, we have five public
health regions and we are in the process of standing up a medical coordination
center in each of these regions. These
medical coordination centers are responsible on a daily basis for the
collection of information and giving us the status of the health system as a
whole as part of our desire to maintain that situational awareness. During an event, they would be used to guide
the resources, personnel and response during a mass-casualty event. What we are looking at is not looking at an
individual facility responding, going back to one of our original slides, but
looking at the system as a whole responding.
The second thing I would like to talk
about is our strategic State stockpile.
About two years back, we recognized that there are some challenges to
the Strategic National Stockpile System and its ability to get pharmaceuticals
and medical supplies to us in twelve hours.
So we felt that we should create a State stockpile that would bridge the
gap between an event and when the national stockpile might arrive. We also recognize that there are some cities in New
Jersey that weren't selected as MMRS cities,
yet we felt deserved the attention that an MMRS city might have and were
susceptible to pharmaceutical shortages during a mass-casualty incident.
The last thing that we recognized, as
Dr. Markinson had mentioned, there are parts of the Strategic National
Stockpile that don't cover specialized care such as pediatric care. So we have developed our own State stockpile
and have applied both HRSA money and also our State money to that.
One other thing I would like to address
and that is our information technology initiatives. We have quite a few software packages that
will be integrated into our medical coordination centers that provide us both
on a daily basis and also during an event, information regarding the health
care system. Some of those are listed up on the slide. The first being diversion which tells us the
status of emergency rooms and other critical areas of a hospital. Our HRMIS Hospital Capacity System will give
us information on bed status but not just generalized bed status but pediatric
beds, intensive care unit (ICU) beds, etc.
We are looking at emergency medical
services (EMS) and decontamination
trailer tracking by using on our
vehicles GPS [Global Positioning System].
We are also looking at some project tracking software consistent with
the HRSA and CDC grants. Our Strategic
State Stockpile will have an inventory system so using GIS mapping and
point-and-click we will know, real time, what the inventory is in our State
stockpile. A professional health care
registry that many of the users are familiar with at the national basis, excuse
me, with the national initiative that was just announced and we will have it at
our State level. We started that.
And finally credentialing so we know
who can do what where, when and how.
Cindy DiBiasi: David, have you run into any challenges with
respect to surge capacity?
David Gruber: I think the challenges are more general
challenges and obviously every State has things that are particular to them, New Jersey being in that
situation. We have some national
assets. For example, we are a major rail
corridor and road corridor and many of you who have paid tolls on the New Jersey turnpike recognize
that. Major ports and airports and also
sandwiched between Philadelphia and New York City and I think that it
is important to realize that we, we are obviously not just a State, we are
treaters of overflow from New York City and Philadelphia should they have major
We have some national industries that
are critical. Agriculture is a major
part of New Jersey and we have to protect that. Atlantic City
is a target, as mentioned before, and we do have nuclear power plants. Additionally, New Jersey has significant
petrochemical industry along with pharmaceuticals; agriculture is a big part as
Cindy DiBiasi: And I assume you have a Web site, an E-mail address, that if
people want more information to learn about New Jersey's approach, where can
they get that?
David Gruber: Should I be, I would be happy to send
anybody any information they would like and it would be david.gruber@doh.State.nj.us.
Cindy DiBiasi: David, thank you. In a moment, we will open up the lines for
questions from the listening audience, but first let me tell you how to
communicate with us. There are two ways
you can send in your questions. The
first is by telephone and we do encourage that because we would like to hear
from you. If you are already listening
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As you are formulating your questions
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The center supports and conducts research to improve the access,
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I would like to take a quick moment to thank Dr. Sally Phillips, who is
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Prevention and Clinical Partnerships and she has been instrumental in helping
to produce this series.
It is our hope for today's conference
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Alternatively, you could E-mail your
comments to the AHRQ User Liaison Program at https://info.ahrq.gov. Well now let's go to questions from the
audience and on the phone from New York we have Rick
Rick Morrissey: How are you?
Cindy DiBiasi: Fine, Rick, how are you?
Rick Morrissey: Yes, my question deals with the portion of
the presentation on national bioterrorism and hospital preparedness program
presented by Lt. Commander Sumner Bosler, in his presentation he spoke of
critical benchmark number 2.3. That
referenced the staff to bed ratios, yet I did not hear anything that indicated
what an appropriate staff to bed ratio would be. Can we get that information or an area where
we can get information to determine that requirement?
Lt. Commander Sumner Bosler: Well, specifically we actually left the
ratios; we put examples into the HRSA continuation application this year just
as examples for States or localities to plan out individually on their
own. We didn't want to get into, since
we are not a regulating agency, into establishing ratios that may not be
appropriate for certain localities.
Cindy DiBiasi: Does that answer your question?
Rick Morrissey: Actually it didn't but it does give us an
idea of where to go to start looking for something to determine a formulation
in determining the needs.
Lt. Commander Sumner Bosler: In the application we reference the old SBC
com acute care con ops and that shows ratios or actually does fairly extensive
planning for minimal care areas; not really hospital-centric but more off-site
care. It depends on the level of
planning that you are looking towards whether you are doing inpatient or
off-site care and the level of care, minimal versus acute care. So it really depends on what you are looking
for and what you are planning for. You
can contact me via the phone number that was left on my answer slide and that
way we can discuss this at greater length if you are looking for more
Rick Morrissey: Well I appreciate the phone number. I will contact you to access and get some
more information. Thank you very
Cindy DiBiasi: We will be giving the phone number in just a
minute. Let me just go back to this next
question. This is for David Markinson
and the caller wants to know, "How can we determine what items are in the SNS,
the Strategic National Stockpile, relating to the care of children?"
David Markinson: Again, the issue of the
specific contents of the SNS you can imagine are pretty confidential or
somewhat confidential what the specific numbers are. Many of the prophylactic agents have now been
included in a formulation that you can get into kits. Probably your best source of information is
your local public health department and Office of Emergency Management who has
a responsibility for actually distributing and handing out or implementing the
SNS should it arrive and when it would arrive.
I would address questions to them about what specific items would not be
covered that you would have to provide equipment for locally.
In general, this would be mostly
antibiotics that you see commonly published on the CDC Web site or other AHRQ
or any other guidelines. If you look at
antibiotics and you note that the following wording, "Not indicated for
children." I can guarantee you that is not in the SNS because they are bound by
FDA rules. So while I will not be able
to go into the exact contents, any medication, pharmaceutical or antidote that
is not indicated for children by the FDA will not be in the stockpile. Same thing with equipment.
Cindy DiBiasi: David Gruber, "Please
describe the type of health system integration software used for credentialing
during a mass casualty."
David Gruber: That is a good
question. As far as credentialing, right
now we are looking at an identification system that the health department will
start and then the State as a whole will look at to apply to possibly police,
fire, etc. so that the State as a whole has a credentialing system and
On that identification system, we will
have bar coding and the electronic capability to put credentials on the back of
the card so that cards can be read at an event or at a facility should someone
go to a facility. It is in its early
stages so I would love to tell you more, but we haven't moved beyond that part.
Cindy DiBiasi: OK. A
couple of follow-ups here. The phone
number for Sumner Bosler is (301) 443-1095.
That is (301) 443-1095. While we
are giving out contact information, someone has called in and asked for Bettina
Stopford's E-mail contact information again so Bettina if you could give us
Bettina Stopford: Sure. It
Cindy DiBiasi: OK.
And a question for you Bettina.
How do you feel about portable isolation to support surge capacity
needs? Is there any interesting equipment
Bettina Stopford: You know there is, and I guess I am lucky in my
travels to get to go to some vendor fairs and there is some interesting things
out there but it is really important to take a look at it, not just in your
facility only but in a community-based effort to see what are some cost
effective things that you can do to increase isolation. But there is some vendor-type stuff out there
for portable use. There are tents that
have filtration in it. There is any
number, a plethora of things that you can use.
It is a matter of finding out what exactly is applicable to your area.
Cindy DiBiasi: OK.
David Gruber, "Regarding the State stockpile, did you include
psychotropic medication for both adults and children?"
David Gruber: Yes.
The way we determined what was going to be in the stockpile was part of
our overall State advisory committee and we got together a group of experts
within the State and asked them to identify what was appropriate. We also have a pediatric component of our
advisory committee and they are providing the input for children for the State
Cindy DiBiasi: I have got a question on a decontamination
unit and now that I think maybe Sumner and Bettina might want to talk about
it. "Considering a surge using all
hospitals, should have a decon unit and a trained decon team?"
Bettina Stopford: I would say yes, absolutely. Now I think that you have to look at it in
the regional area too and the only way you are going to be able to determine
what your specific needs are for numbers is to make sure that you are embedded
in the community base hazard vulnerability assessment. How many people are likely to potentially be
exposed? The primary exposure could be
from an industrial accident primarily so this is why it is very important for
health care facilities and EMS, etc., to be embedded in community planning that
would determine your numbers.
This past year, all States have had to
participate, if they want, (unclear) funding, in a Homeland Security assessment
strategy where they determine some of their top tens or credible threats and
that related to the number, the impact number of people that they thought would
be potentially contaminated or exposed. That gives you some real, sort of
credible threat data if you would work with your State and regional plan people
to determine how many people potentially impact our hospital or our community,
your EMS, so that is what you build your planning off of. But I think that JCAHO requires a certain
amount of decontamination capability although they don't go into numbers; there
is sort of an intent there to have some more capacity than most people have now
which is usually one or two.
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