Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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A. HAvBED Hospital Bed Definitions and Data Elements
The hospital bed definitions developed as part of the demonstration HAvBED (Hospital Available Beds for Emergencies and Disasters) project were included in this project. In the HAvBED system, "Vacant/Available Beds" refers to beds that are unoccupied and to which patients can be immediately transported. To satisfy vacancy/availability criteria, these beds must include supporting space, equipment, medical material, ancillary and support services, and staff. Such beds must be licensed, physically available, and sufficiently staffed to attend to the patients who occupy them. In the HAvBED project, the term "Current Beds Available" refers to "Vacant/Available Beds". The relationship between the different bed statuses is depicted in Figure 2. Note that the HAvBED "Vacant/Available" classification is close to, but not exactly the same as, the National Incident Management System (NIMS) classification of "Available".
The categories of beds to be reported to the HAvBED project include:
- Adult Intensive Care Unit (ICU): Beds that can support critically ill/injured patients, including ventilator support.
- Medical/Surgical: Also thought of as Adult "Ward" beds.
- Burn: Thought of as Burn ICU beds, either approved by the American Burn Association or self-designated. (These beds are not to be included in other ICU bed counts.)
- Pediatric ICU: Similar to Adult ICU beds, but for patients 17 years and younger.
- Pediatrics: "Ward Medical/Surgical" beds for patients 17 and younger.
- Psychiatric: "Ward" beds on a closed/locked psychiatric unit or ward beds where a patient will be staffed by an attendant.
- Airborne Infection Isolation: Beds with negative airflow, providing respiratory isolation.
(Note: This category may represent available beds included in the counts of other types. In the original HAvBED demonstration, this was called "Negative Pressure/Isolation", but was changed to be consistent with current Centers for Disease Control and Prevention (CDC) terminology.)
- Operating Rooms: An operating room that is equipped, staffed and could be made available for patient care in a short period of time.
Also, the following hospital characteristics used in the demonstration HAvBED project were included in this project:
- Emergency Department (Facility) Status:
- Open—Accepting patients by ambulance.
- Closed—Not accepting patients by ambulance.
- N/A—Not Applicable (Facility does not have an emergency department [ED]).
- Mass Decontamination Facility Availability:
- Available—The institution has chemical/biological/radiological multiple patient decontamination capability.
- Not Available—The institution is unable to provide chemical/biological/ radiological patient decontamination.
- Available:—The number of ventilators that are present in the institution but are currently not in use and could be supported by currently available staff.
As with the original HAvBED project, the Advisory Group requested that, for the purpose of estimating institutional surge capability when dealing with patient dispositions during a large mass casualty incident, the following bed availability estimates should also be reported for each of the bed categories described above:
- 24-hour Beds Available: This value represents an informed estimate of how many vacant (staffed, unoccupied) beds for each bed category above the current number could be made available within 24 hours. This would include specially created institutional surge beds as well as beds made available by discharging/transferring patients.
- 72-hour Beds Available: This value represents an informed estimate of how many vacant (staffed, unoccupied) beds for each bed category above the current number could be made available within 72 hours. This would include specially created institutional surge beds as well as beds made available by discharging/transferring patients.
It should be understood that these numbers represent a "best guess" estimate on the part of facilities and that the actual number of beds available in 24 and 72 hours will vary from these estimates, based upon the demands of the incident as well as the "routine", non-incident-related patient workload.
Such beds could be made available by a number of means including:
- Early discharge of patients.
- Cancellation of elective admissions.
- Transfer of patients to alternative care sites and facilities.
- Creation and opening of institutional surge beds.
Evidence suggests that anywhere from 15 to 25 percent of a hospital's bed capacity could be made available by the early discharge of patients and cancellation of elective admissions. Furthermore, evidence suggests that an additional 5 to 20 percent of a hospital's bed capacity could be made available by transfer of stable patients requiring ward-type care (with the exception of oxygen administration) to a non-hospital alternate care site or facility. (Note that "alternate care site" and "alternate care facility" are used interchangeably in HAvBED.)
Figure 3 summarizes the data elements specified for the HAvBED production system and depicts the HAvBED Web form for manual hospital data entry. The "AHA Survey" numbers are preloaded for each institution from the American Hospital Association (AHA) Annual Hospital Survey data, which may be updated, if necessary.
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B. System-to-System Communication Protocol
One of the main goals of the original demonstration HAvBED system was to demonstrate the utility of amalgamating data from multiple existing computerized bed availability systems. For this purpose, an XML- and Emergency Data Exchange Language (EDXL)-based schema was developed by a group of interested parties to facilitate such data sharing. This protocol is referred to as Hospital Availability Exchange (HAVE) and allows straightforward Web services communication between otherwise incongruent computer systems. The HAVE specification is currently under standards review by the Organization for the Advancement of Structured Information Standards (OASIS). This standardization process is not yet complete, and because of this, the HAvBED schema utilized in HAvBED may vary slightly from the final adopted product due to ongoing minor changes to the proposed standard. The HAvBED data elements, as defined in EDXL, are shown in the HAvBED supportive documentation and discussed in the Web Service Guide, which also gives the full EDXL-HAVE schema. Note that this mode of system-to-system communication is available only to hospital bed availability systems.
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C. Database and Web Development
The high-level system architecture and data flow are shown in Figure 4. The database is comprised of a SQL (Server Query Language) server. This facility database was designed to maintain an historical record of bed availability updates and allows the addition of new institutions to support the concept of creation of alternate care sites (alternate care facilities) and other facilities that could also be tracked by HAvBED. All Web access is through a secure Internet server. All programming in the system was written in C# and Microsoft.NET to produce an ASP.NET application.
A detailed description of the database and Web services programming is provided in the HAvBED documentation.
The hospital database was preloaded with the following information using data from the AHA 2007 Annual Survey Database (2005 data):
- Hospital name.
- Hospital street address, including city, county, State, and zip code.
- Hospital phone number.
- CEO (as initial contact individual, subject to hospital edit).
- Main hospital phone number (as initial contact phone number, subject to edit).
- AHA identification number.
- Hospital geographic coordinates (latitude/longitude).
- Total beds in each HAvBED bed category.
- Trauma center level designation (if any).
The algorithm used for extracting these data is outlined in the HAvBED documentation. It is important to note that some institutions do not report their total beds for each HAvBED category in the AHA survey. Several institutions also left multiple other fields blank, making it impossible for the algorithm to determine whether they should be considered "active" or "inactive" institutions and were therefore left in the database, but were marked "inactive."
We were unable to obtain national listings of NDMS (National Disaster Medical System)-member hospitals or TriCare-affiliated hospitals, so we could not indicate those affiliations in the database. These could be set by the individual hospitals when they review and update their facility data in the HAvBED system or by HHS at the time of system implementation.
As noted below, the HAvBED database supports multiple institution types, including nursing homes. We were unable to locate an appropriate nursing home/extended care facility database for use in initializing the HAvBED database with these institutions.
For improved usability, especially for information retrieval, a GIS mapping component is included in the HAvBED system. This was achieved by integrating the Google Maps utility into HAvBED. This configuration is described in detail in the HAvBED documentation. This functionality permits retrieval and graphic display of information that can be viewed at a regional, state, county, city, or street map level. Specific color-coding of display elements provided rapid visual information of hospital status with mouse-over links to specific facility information.
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D. Interface and Manual Data Entry
As mentioned above, two mechanisms for hospital data entry were developed:
- Automatic" data streaming from preexisting hospital bed availability systems via HAvBED Web services communication.
- A Web-based manual data entry interface for use by those hospitals that are not part of an existing bed availability system and for use by other facility types.
The manual, Web-based data entry screen for a single hospital is shown in Figure 5. The data elements on this screen are identical to the data elements that may be reported via the system-to-system Web services interface.
The Web site is also used to retrieve and display amalgamated data (go to demonstration section, below).
Please note: For purposes of institutional privacy, in this report, all individual hospital data have been altered and do not represent actual hospital conditions.
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E. Enhancements Made to the Sustainable HAvBED System as Compared with the Demonstration System
Through experience with the initial demonstration HAvBED system and based upon input from our Advisory Group, many enhancements were made to the sustainable production HAvBED system. These enhancements include the following:
- Multiple Institutional Classes are now supported:
- Civilian Hospitals.
- Department of Defense (DoD) Hospitals.
- Veterans Administration (VA) Hospitals.
- Mental Health Institutions.
- Nursing Homes.
- Federal Medical Stations.
- Alternate Care Sites (Alternate Care Facilities):
- Basic—capable of providing basic-level care.
- Advanced—capable of providing a higher level of care because of enhanced equipment and/or staff.
- Hospital Vessels (Navy).
- Quarantine Stations.
- Improved user interface, especially with map functions: pan, zoom, etc.
- Improved iconography on maps and navigation tree.
- Ability to mark facilities as inactive or decommissioned.
- Additional facility-specific information.
- Dynamic definition of "Metropolitan Areas" encompassing multiple cities and/or counties.
- Hospital data entry optimized for dial-up Internet connections.
- Automatic geocoding of new facility locations.
- Improved granularity of user permissions:
- Administrator: Can perform any function on the HAvBED site for any geographical entity.
- Bed Data Display: Can only display bed availability & summaries for specified geographical entities. No update capability.
- Bed Data Entry: Can update bed counts for specified geographical entities.
- Data Display National: Can only display bed availability & summaries for any geographical entity. No update capability.
- Web Service User: Automated data feed to update bed counts.
- Facility Data Editor: Can edit contact and location information for an existing facility within specified geographies. Cannot add new facilities.
- Facility Creator: Can add new facilities and edit contact and location information only for those facilities.
- Improved facility searching based upon:
- Facility type (hospital, alternate care site, etc).
- NDMS or TriCare affiliation.
- Trauma center designation level.
- Distance from a designated point (i.e., miles).
- Able to sort institutions based upon (for example):
- Number of available ventilators.
- Number of beds, by category (ICU, medical/surgical, etc.).
- Availability of mass decontamination.
- Emergency department status.
- Data update time.
- Automated system to notify facility contacts of system activation/deactivation and of need to enter updated bed data (via E-mail).
- Data export function in spreadsheet format.
- Improved "Help" function and online documentation.
- Ability to alter dynamically the time window of what is considered a "current" update by facilities.
These features are described in detail, with examples, in the HAvBED User Guide.
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F. HAvBED and the National Incident Management System (NIMS)
Since the development of the demonstration HAvBED system and the establishment of the HAvBED patient bed categories, recommendations for resource typing have been developed as part of the National Incident Management System (NIMS). Resource typing is defined by NIMS as "the categorization and description of resources that are commonly exchanged in disasters via mutual aid, by capacity and/or capability." One hundred twenty Resource Typing Definitions have been developed to date. However, the NIMS "Health and Medical Resources" specification does not deal with hospitals or hospital beds, but rather is directed towards the resources that are part of Disaster Medical Assistance Teams (DMAT) and related groups.
NIMS has established three status conditions for the NIMS-specified Typed Resources:
- Assigned (personnel, teams, equipment, or facilities that have checked in or have been receipted for and are supporting incident operations).
- Available (resources that have been assigned to an incident and are ready for a specific work detail or function).
- Out-of-Service (resources that have been assigned to an incident but are unable to function).
Unfortunately, these status conditions are not consistent with how civilian hospital personnel think about patient bed status. That being said, it should be noted that the HAvBED "Vacant/Available" bed status is very similar but not identical to the NIMS "Available". The bed categories (ICU, medical/surgical, etc.) established by HAvBED have no corresponding delineation under NIMS.
Also relative to NIMS, it should be noted that with the 12 different classes of facilities supported by HAvBED, hospital as well as non-hospital beds are included in the system. In addition, with the specification of its EDXL-HAVE interface, HAvBED establishes the capability of easily interfacing with other computerized bed availability systems.
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G. Demonstration of the HAvBED Production System
The most useful approach for education of the reader about many of the capabilities of the HAvBED production system is to provide a brief virtual tour of its operation. A more complete description is available in the HAvBED User Guide.
Immediately upon accessing the HAvBED secure Web site, the user is presented with the logon screen depicted in Figure 6.
This logon screen allows the system to be password-protected, and, by using predetermined access rights (permissions), limits users to specific sections of the system relevant to their approved access level (e.g. data for a specific hospital, a specific state, a specific region, etc). After logging in, the typical user sees the HAvBED Home Page, shown in Figure 7. (If users only have permission to view or edit data for a single facility, they will instead be taken directly to that facility data, as shown in Figure 9.)
Access to all user functions is from this Home Page. Clicking the "Help" selection on the menu bar on any display takes the user to a context-sensitive help display and to the glossary of HAvBED related terms, a portion of which is shown in Figure 8.
If the user has data entry rights for a single specific institution, clicking on the "View/Edit Bed Availability" selection on the Home Page (Figure 7) would result in the display of data for that specific institution shown in Figure 9.
Selecting the "Show 24- & 72-hour forecast counts" option above the "Bed Category" title includes the data in the display shown in Figure 10.
Selecting "Edit Bed Availability" in the Options box in the upper right corner of the page causes the display of a similar form that allows updating of current bed availability values and other resources (Figure 11). Data for the specific institution could then be updated in the database. Clicking "Save Changes" in the Options box button then updates that hospital's information in the HAvBED system.
On the individual hospital data display, selecting "View Facility Details" in the Options box provides additional information about the institution as shown in Figure 12.
For those users with full administrative privileges, the following display would be shown after logging in (Figure 13). Note that this display provides additional functionality, including the ability to create new facilities, manage users, define metropolitan areas, edit system information, and notify facility contacts via E-mail.
The diagrammatic layout of full administrative user capability is given below (Figure 14).
Selecting the "Summary Report" in the "Reports and Maps" box on the Home Page (Figure 13) allows users to specify a summary report of available beds and other resources in a geographic area (region, state, county, city, or metropolitan area) to which they are allowed access. If a user is allowed bed display access to Federal Region VIII, the following Summary Report would be displayed (Figure 15).
Note the ">=" character in "Current" column. This indicates that one or more hospitals have reported (via the Web services interface) that they have at least one bed (but no specific number given) in each of the bed categories.
A user with access to a specific geographic area (e.g., a region) may also retrieve summary data for any smaller geographic area (e.g., a state, a county, etc.) within that region.
A detailed list by facility can be obtained by selecting "List Facilities in Summary Report" in the Options box (Figure 15). For example, if the Summary Report being viewed was for the State of Colorado, the following display would be presented (Figure 16).
On this display, the list may be sorted by column data values, in ascending or descending order, by clicking on that column header. Detailed data on any facility may be obtained by clicking on the name of that specific institution, taking the user to the institution's data display as demonstrated above (Figure 9).
It is also possible to export data to a spread sheet format for later analysis and study. For example, selecting the "Export My Report" option in the Options box on Figure 15 from a Summary Report of the State of Colorado would produce the spread sheets shown in Figures 17 and 18.
A map of the facilities summarized on the Summary Report or shown on the pages of the facility list may be obtained by making the "View Map" selection in the Options box. In the case of Federal Region VIII, the map shown in Figure 19 would be displayed. On this map, the grey icons represent facilities for which no data had been received. The green icons represent institutions accepting patients; the red icons indicate facilities that are not accepting patients ("on divert").
Maps may also be generated via the "Display Map" selection on the Home Page. For a user who has bed availability retrieval rights for a State (e.g., Colorado), the following data map could be retrieved (Figure 20).
By selecting the "Explain This Page" option under "Help" on the menu bar, the user will see a textual description of the display (Figure 21).
By clicking the "Hybrid" selection on the upper right corner of the map, the facilities and other map features will be superimposed upon the appropriate satellite image as shown in Figure 22.
Note the legend section on the lower part of the display. It specifies the icons that are displayed for the different facility classes and the icon color that indicates the facility status. Full pan and zoom map functionality is available by clicking on the appropriate function pads on the left upper portion of the map. A double left-click on the map will also produce a zoom-in; double right-click yields a zoom-out. Successive zoom-in operations over Denver will show the following (in "Map" display mode) (Figure 23).
Mousing over any facility icon will provide the institution's name. Clicking on the facility icon provides a summary of available beds for that facility (Figure 24).
The full display of bed availability for the facility can be obtained by clicking on the "Click for more detail" selection.
By selecting "Modify My Map" in the Options box, the user is able to selectively display institutions on the map based upon facility class, NDMS- or TriCare-affiliation, Trauma Center Designation Level, or facilities within a user-specified mileage radius from a selected point on the map. The display used to select these options is shown in Figure 25, which is set to retrieve facilities within 50 miles of Colorado Springs, Colorado.
After selecting "Update Report," the resulting map is shown in Figure 26.
The "Modify My Map" function may also be used to construct the map based upon historical bed data at a specific date and time in the past. These capabilities are elucidated in more detail in the HAvBED User Guide. All of this report modification functionality is also available for the textual Summary Reports.
Since many facility bed availability data retrievals of interest may cross city, county or State boundaries (such as the National Capital Region), we have made it possible for users with appropriate permissions dynamically to create "Metropolitan Areas" which facilitate these retrievals both in Summary Reports and Maps. These areas are a preselected collection of counties and/or cities. This capability is fully described in the User Guide.
The sustainable production HAvBED system also provides a full suite of functions to create new facilities; manage user names, user passwords and user permissions; and notify selected facility contacts of HAvBED system activation via E-mail. These capabilities are fully described in the HAvBED User Guide. A sample display used in creating a new facility in the HAvBED system is shown in Figure 27. Note that it allows creation of an institution in any of the 12 classes of facilities.
Both the "Create New Facility" display and the "Edit Facility Details" display (HAvBED documentation) allow a facility to be set to one of three possible statuses:
- Active—an institution or patient care site that is fully functional for the delivery of acute patient care in the designated category and whose status and bed availability number are reported in HAvBED.
- Inactive—an institution or patient care site that does not provide acute patient care, but which could be made an active site through the addition of appropriate personnel, supplies, and equipment. (Inactive facility status and bed availability are not reported in HAvBED.)
- Decommissioned—an institution or patient care site that is no longer physically available and which cannot be made active for the delivery of patient care. Decommissioned facility status and bed availability are not reported in HAvBED.
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