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Surge Capacity and Health System Preparedness

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Transcript of Web-assisted Audioconference

This Web-Assisted Audioconference, broadcast on May 17, 2005, has been designed to help policymakers, program administrators, health systems, health care providers, and other preparedness decisionmakers by providing information about the latest research, tools, and models available in this topic area.

Cindy DiBiasi: Good afternoon. Welcome to our program, "Mass Casualty Care: Overlooked Community Resources." Today's 90-minute event will focus on the potential for using existing, but unused, facilities beyond our hospitals to provide care in a large-scale public health emergency.

My name is Cindy DiBiasi, and I'll be your moderator for today's program. This Web conference has been designed to help policymakers, program administrators, health systems, health care providers, and other preparedness decisionmakers by providing information about the latest research, tools, and models available in this topic area.

It's sponsored by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, often referred to by the acronym AHRQ, or "ark." Before we begin, let me introduce you to an interesting interactive feature of this Web conference, and I'm going to ask for your feedback throughout the Web conference by polling the audience.

So please join me now as we practice using this feature. Let's take a poll to see who we've got joining us in the audience. To participate, click on the polling tab in the lower right-hand side of your screen and answer the following question.

"I'm participating in this Web conference from region of the United States." And for the Northeast, select "a"; for the Northwest, select "b"; for the Southwest, select "c"; for the Southeast, select "d"; for the Midwest, select "e"; for Mid-Atlantic, select "f"; and for outside of the United States select, "g."

And while we wait to get the poll results to see where you're from, and we're seeing that we have participation from all over the United States and outside of the United States as well. Now, we have one more followup question for our audience. Please answer the following question.

"I most closely represent the following organization." If you represent State or local government, select "a"; if you most closely represent nursing homes or assisted living facilities, select "b"; for health care systems, select "c"; researchers, "d"; private sector, "e"; for clinicians, select "f"; and for all others, "g."

Before I introduce our panelists for today's discussion, I'd like to give you some background on why we're holding this event. The reason for today's discussion is clear and compelling—the events of September 11th, 2001, and subsequent anthrax attacks have emphasized the need for U.S. health care organizations and public health agencies to be prepared to respond to acts of bioterrorism and other public health emergencies.

Many States, health care organizations, and systems have developed preparedness plans that include enhancing surge capacity to respond to such events.

Much has been accomplished in the past several years to improve health system preparedness. However, it is possible that a mass casualty event could compromise at least, in the short term, the ability of local or regional health systems to deliver services.

Under these circumstances, it may be necessary to draw from resources in the community other than existing hospitals for providing critically important care. The United States Department of Health and Human Services developed a strategic plan to strengthen our Nation's emergency preparedness system to respond to a bioterrorist attack or other mass casualty event.

Many HHS agencies, such as the Office of Public Emergency Preparedness, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality, have played important roles in preparedness efforts.

AHRQ objectives to address the HHS strategic network for emergency preparedness are to develop and assess alternative approaches to develop health care surge capacity, models that address training and information needs, alternative uses of information technology and electronic communication networks, and protocols and technologies to enhance interoperability among health care systems.

I'm excited to be able to announce a just-released and much-anticipated report from AHRQ. This report, "Altered Standards of Care in Mass Casualty Events," includes the recommendations of a 39-member panel of experts in bioethics, emergency medicine, emergency management, health administration, health law and policy, and public health to examine this issue.

Altered Standards of Care in Mass Casualty Events can be found online at Printed copies may be ordered by calling 1-800-358-9295, or by sending an E-mail to

I'll begin by introducing today's panelists, and in the studio with me I have Dr. Lucy Savitz, Senior Health Services Researcher, Quality Outcomes and Safety Research Program at RTI International; Mrs. Andrea Hassol, Senior Associate Health Division, Abt Associates, Inc.; and Dr. Debra Berg, Medical Director of the Bioterrorism Hospital Preparedness Program, New York City Department of Health and Mental Hygiene.

I'd also like to introduce Dr. Richard Zane, Vice Chair, Department of Emergency Medicine and Medical Director for Bio-defense and Emergency Preparedness at Harvard Medical School, and Dr. Zane is joining us from his office in Boston. Welcome, everyone.

Before we begin our discussion today, I will explain how the program will work. First, we'll talk with each of our four panelists and then open up the lines to take your questions. You'll be given instructions on how to send in questions to us later in the program. Although we don't think you'll have any technical problems, I'll give you a few tips on dealing with them just in case.

If you have Web-related technical difficulties or if it appears that the slides are not advancing in synch with the audio, you may need to restart your browser and log on again. If you are on the phone, dial "Star 1" to be connected to an operator.

If you have trouble with the audio stream or an uncomfortable lag time between the streamed audio and the video, you can access the audio through your phone by dialing 1-888-809-8967. The password is "68782."

And if technical problems cause you to miss part of this conference, at the end of our 90 minutes today, we'll let you know how to access an archive of this Web conference at a later time. So now I think we're ready to discuss today's topic.

Let's begin with Dr. Lucy Savitz, who is a Senior Health Services Researcher in the Quality Outcomes and Safety Research Program at RTI International. Lucy is here today to talk about a research project she's working on that was designed to explore the special needs and potential role of nursing homes in preparedness planning. Well, thanks for being with us, Lucy.

Lucy Savitz: Thank you very much.

Cindy DiBiasi: If we could just start by getting an overview of your project.

Lucy Savitz: Sure. Thank you very much. I get this question a lot. Why consider nursing homes? And when we think about nursing homes, it's important to understand that the previous focus on preparedness planning has been on hospitals and first responders. We also know that we have a burgeoning elderly population in the United States and they're particularly vulnerable during a time of disaster.

And lastly, and I think in some ways most importantly, there are nearly 17,000 nursing homes in the United States; we have very little understanding of the extent to which they've done preparedness planning and have been included in local and regional planning efforts.

Cindy DiBiasi: Now, there are nursing homes in nearly every community, but they usually have not been considered historically when it comes to surge capacity plans, right?

Lucy Savitz: Exactly. Exactly. And in our study, we're looking at a couple of key factors. So first and foremost, we're looking at the extent to which there are disaster plans in place and they've done specialized training.

What we see is that nursing homes do have disaster plans and there's core competency related to power outages, sewer outages, and electrical outages, which would be important core competencies in a time of disaster; however, they've not really been tailored to bioterrorism events. There are also special needs that nursing homes have.

One example is those nursing homes that have Alzheimer's patients. For those patients, in drills, there have been instances where patients have been harmed because normal observation has not taken place. Interesting, too, is the issue of flows and the role that nursing homes can play in surge capacity.

What we're trying to understand here, if anybody's worked in a nursing home or in a hospital, discharges from hospitals back to nursing homes are fairly slow and arduous processes. So understanding how quickly nursing homes could receive their patients.

And in most cases they intend to receive only their patients. We know from studies of other community disasters, notably one in Los Angeles County, where it was observed that over 52 percent of the responding nursing homes actually received disaster-related admissions.

In rural areas, nursing homes may be the only health care facility located there, and we know in almost any lines we use in bioterrorism preparedness, there are conflicts in State and local regulations that are important to observe.

Cindy DiBiasi: How did you go about looking at these issues?

Lucy Savitz: Well, we really did a two-stage study. Next slide, please. In our qualitative case studies, we are drilling down in six States where our partner-integrated delivery systems are located, and there we do focus groups with administrators and medical directors and disaster coordinators in nursing homes.

We also have a long-term care survey tool that was developed by Dr. David Dosa at Brown University, where we are validating basically that tool.

Could they answer these questions? Doing in depth discussions and looking at disaster plans. An interesting piece that we've added onto this is an atlas, where we have maps of all 50 States and then further "drill down" in our case study States.

On the next slide you'll see the six States where we are doing "drill down": so Intermountain Health Care System in California, Utah; Providence Health Care in California, Oregon, and Washington; UNC Health Care in North Carolina; and lastly UPMC Health System in Pennsylvania.

Cindy DiBiasi: So what have you learned so far?

Lucy Savitz: Well, preliminary findings, and I emphasize these are preliminary, it's still ongoing, we're starting to see that, you know, actually these nursing homes do have disaster plans in place, and there's a lack, as I've already mentioned, in terms of tailoring to bioterrorism events.

We are observing that nursing homes have not been typically included in disaster preparedness planning at the local level, even though State plans often refer to nursing homes as a potential stakeholder in those planning processes.

We know that there are special needs the nursing homes have in terms of risk communication with family members, in terms of some nursing homes having both patient populations that require extra comforting in a chaotic time, and then lastly that locally there are some nursing homes that would have the potential to offer surge capacity extensions, either storing materials and supplies, possibly having staff that could assist in vaccination programs, and lastly in some cases taking admissions, community-dwelling elderly who are in need or low-level admissions from hospitals that they could move out to the nursing home facilities on a temporary basis.

Cindy DiBiasi: Tell us more about the atlas. What's its purpose, and how does it contribute to preparedness planning?

Lucy Savitz: Right. Well, as they say, a picture speaks a thousand words, and I think you see this in this map. This first map is a map of North Carolina, and basically, we're overlaying six layers of data here. So obviously, normally you'd be looking at six different tables that were not integrated.

Here we're putting all of that information together in one place. And there will be a State map for every State in the United States that shows the rural-urban continuum, the location of hospitals and nursing homes, HRSA BT planning areas, county borders, and road networks.

On the next map, Elizabeth Rude at RTI is working very closely with myself and others on our team to generate these comparative maps where we're looking at the degree to which there's concordance and various geographic-based planning areas like the MMRS, like the HRSA BT areas, like the emergency management areas and emergency medical service areas.

We believe that these maps don't necessarily answer questions but stimulate important discussions that could occur at local and regional levels. The last map really shows you, I think, the power of maps, and you can see in this next map, if we could have the next slide, please, the purple areas are those areas where there's no hospital but there's a nursing home facility.

So a State or local planner could look at a map like this and understand where they might look to reach out to a particular nursing home if it's colocated nearby a threat.

Cindy DiBiasi: Now, Lucy, what does "drill down" mean?

Lucy Savitz: Drill down? When we look at these maps, what we're trying to do is to look at varying layers of information. I should point out that when we put these kinds of maps together, we are assembling data from multiple data sources that haven't historically been viewed in the same way.

And so bringing data from the Centers for Medicaid and Medicare Services, from the Census Bureau, and a lot of these bioterrorism planning areas are dynamic; they're changing all the time.

So we've had to get on the phones and talk to people in the States in the various regions to understand how HRSA BT areas are being reconfigured, how MMRS areas are being reconfigured, and what the corollary is across the States.

Cindy DiBiasi: So what do you think? What are the major opportunities here for improving advanced planning and preparedness?

Lucy Savitz: I think there are a couple of things that we see here that are really promising. One is that we can use these kinds of tools, the survey tool that we're producing and the atlas, to really assist and stimulate discussions around planning and proper resource decisionmaking; to help perhaps entice people into including nursing home administrators in the planning process; to understand locally—and I say locally—understand the special needs and contributions of nursing homes, because we know nursing homes are very diverse in their capacities; to help nursing homes think about updating their disaster plans to include bioterrorism; and lastly, to perhaps create incentives for developing targeted training for the staff working in nursing homes.

Cindy DiBiasi: Well, thank you, Lucy. And just a reminder for our audience, you'll be able to ask Lucy questions about her project following the other panelists' presentations. I'd now like to turn to Andrea Hassol and Richard Zane. Andrea is a Senior Associate at Abt Associates, and her colleague, Richard, is an emergency room physician and instructor at Harvard Medical School, and Richard is joining us from his office in Massachusetts. Hi, Richard, can you hear me?

Richard Zane: I certainly can. Thank you, Cindy.

Cindy DiBiasi: Great. Andrea and Richard are currently finishing a project that's addressing the expansion of surge capacity through the use of former hospitals.

Now I understand that this project looks at what might be involved in converting former hospital buildings into temporary shelters for patients with nonurgent care needs, and we're glad to have you both with us. And Andrea, as you begin, could you tell us exactly what is a shuttered hospital?

Andrea Hassol: Absolutely. Thank you, Cindy. Our first question was, is it feasible to use a shuttered hospital for surge capacity? Rich and I are located in the Boston area, where there are a lot of hospitals that have closed in recent years, and took a look at several of them. There are some that have been completely stripped.

They have nothing left right down to the plumbing fixtures and the utilities don't work. Clearly such a place would not be useful.

But there are others that have maintained a modest daytime mission, usually a medical mission, like a walk-in clinic or elder daycare or something of that sort, Where the building still has its fire and safety licenses, still has its utilities, doesn't have inpatients, so the inpatient wings are largely vacant. And those kinds of places do have potential to serve as a temporary hospital, if you will, during a surge capacity situation.

Cindy DiBiasi: Now, Andrea, your research examines the use of shuttered hospitals in a surge event, is that right?

Andrea Hassol: Yes.

Cindy DiBiasi: Okay. So how did you go about looking at the research questions?

Andrea Hassol: All right. We thought of this in two different kinds of scenarios. The first would be a massive casualty event with trauma victims, where you would need to have hundreds, perhaps thousands of patients needing immediate services.

The major tertiary medical centers are able to clear about 25 percent of their beds almost immediately by delaying admissions, by discharging patients to hospitals and rehab and home as quickly as possible.

If that 25 percent were not enough and you had more hundreds of patients who needed tertiary medical care, the concept would be that you move out of the tertiary medical centers anyone who's well enough to be moved out.

Now, if your rehab and nursing homes are full, where do you move them to? That's what a surge facility might be able to do. The second situation would be in an infectious disease or epidemic kind of situation where what you need to create is essentially an isolation hospital.

It's unlikely that any existing hospital would want to step up and become the smallpox hospital or the avian flu hospital. But it would be better to keep those patients to the extent that they can be well-cared for, to keep them in a separate facility and kind of provide their necessary services in that isolated location. That might be an appropriate use of a shuttered facility as well.

Cindy DiBiasi: Well, Richard, let me ask you a question. As someone who does much of his work in the emergency department, can you tell us what sorts of services could be offered by former hospitals there?

Richard Zane: Certainly. As Andrea mentioned, hospitals would be able to create probably 25 percent capacity with little notice. What we have found is there is almost no sustainability in this capacity. So hospitals would have to offload quite significantly to create or maintain that capacity.

When we looked at these shuttered hospitals, we primarily looked at being able to provide lower-acuity inpatient medical and postsurgical care for relatively stable patients. We will be able to do things like monitoring routine nursing services, medications, and wound care and provide things like a pharmacy and some basic laboratory studies either on site or having them placed in another facility.

Cindy DiBiasi: Well, Richard, what are some of the barriers to using shuttered hospitals in a mass casualty event?

Richard Zane: Well, the biggest barrier is that you can't truly count on a shuttered hospital as being an asset in a mass casualty event or disaster unless you prospectively have done your homework and determine that you do have a shuttered hospital in your area and you know exactly what it takes or what it would take to open this hospital.

So the most important message is that you may have a shuttered hospital in your area and you may be able to use it in an acute situation, but importantly, you have to do that ahead of time. So you have to look at the hospital, see exactly what is and what is not available, and make plans for how you would indeed go about opening that hospital.

And in our project, we've created tools that will allow States or cities to go into these hospitals and do a pretty critical evaluation of whether or not they will be available or useful.

And a "no" answer is very useful. Not as useful as a "yes," but knowing that this is not an asset is also a useful question to answer. Cindy?

Cindy DiBiasi: Well, thank you, Richard and Andrea. And we will be getting back to both of you so the audience will have the opportunity to ask you more questions. And before I move on to our next presenter, I'd like to take a quick minute to poll the audience about the subject Andrea and Richard discussed.

Yeah, I'd like to know how many folks on the phone know the location of shuttered hospitals in their area. Please answer the following yes/no question, and Andrea, while we're waiting for that?

Andrea Hassol: I'd like to mention Rich went through some of the things that could be done at a shuttered facility like this that you've brought up to speed with a lot of advance planning. There are also things that probably could not be done with a shuttered facility that's been reopened for this purpose.

It probably wouldn't be possible to have surgery or intensive care on site. The equipment and staff and special training that's necessary just couldn't be assembled at the drop of a hat. You probably couldn't do things like complex chemotherapy or dialysis or acute psychiatric and detox kinds of services.

Probably obstetrics and pediatrics wouldn't be appropriate. So we're talking about medically fairly stable medical and postsurgical patients but not the kind of specialty services that most hospitals also offer. It's a limited kind of set of services that we're talking about.

Cindy DiBiasi: Okay. And let's ask the audience the next question, which is, "Do you know what organization or local group would be responsible for getting shuttered hospitals in open and utilized in a mass casualty event?"

Andrea Hassol: And I guess the last point I'd like to make is one that Rich made, and that's that you can't wait for the mass casualty event, because it's essentially too late. There's an awful lot of planning that needs to happen before the event.

There are State regulations and Federal regulations that may need to be waived. There are a lot of issues about who would be responsible and liability and medical records and patient transportation that all need to be considered and worked through before there's an event that requires the opening of a shuttered facility.

Cindy DiBiasi: And Andrea, we're just getting the results back from the first question, and the question was, "How many people know the location of the shuttered hospitals in your area?" And it was 56 percent no and 44 percent yes. So most of them don't know, but does that number surprise you, that it would be that split?

Andrea Hassol: Well, it could be that some communities don't have closed hospitals; they just have not had the situation that caused the community hospital near a major city to close.

Cindy DiBiasi: So some of that 44 percent, there may be no hospitals they know about?

Andrea Hassol: Right. And for others, the status of that closed facility may be unclear. The ownership status may be unclear. A facility may be on the way to becoming assisted living or condos or something else. So it could be that the status of any closed facility is in flux. And it's not clear whether it would be available for an emergency.

Cindy DiBiasi: Now, we have a wider gap in the answer to the next question, and that question is, "Do you know what organization or local group would be responsible for getting shuttered hospitals opened and utilized in a mass casualty event?"

And 41 percent of the participants said yes, they would know, and 69 percent said they would not know, 59, rather. Yeah, I guess that doesn't add up to 100 percent, does it?

Andrea Hassol: Well, I guess that doesn't surprise me too much, because it's not clear to us who would be responsible, even in a situation like Massachusetts, where we looked at this in some depth.

Would it be a health department that would be ultimately responsible? Would the surge facility be operated as a satellite from some other hospital system? Who would ultimately be the medical director?

Who would be responsible for, you know, the liability issues? Those are really the remaining questions that need to be addressed, that we have not answered completely with our study, but they're very important questions for any community to consider.

Cindy DiBiasi: And Andrea, as I said, we're going to come back to you and let the audience ask you some more questions directly. But first, let's turn now to Dr. Debra Berg, the Medical Director of the Bioterrorism Hospital Preparedness Program, who joins us from the New York City Department of Health and Mental Hygiene.

Good afternoon, Debra. I understand that you're working on a primary care emergency planning project. Can you describe a little bit about what you and your colleagues are doing in New York?

Debra Berg: Thank you, Cindy. Simply stated, the purpose of the project was to define the role of primary care centers in large-scale emergencies. Primary care centers are often located in geographically centered parts of the residential areas and serve as a main source of health care to the neighborhoods and as a gateway to acute care facilities.

And yet after September 11th and the anthrax investigations, we found out most of the funding to New York City was being targeted to hospitals, and we realized that there was a gap by not including primary care centers. And we did so then to provide an integrated response.

We developed a project that had several steps and included a needs assessment of primary care centers followed by a gap analysis, creating a series of interventions, two tabletop exercises, and a post assessment.

Cindy DiBiasi: You began the project with a needs assessment. What did you find?

Debra Berg: The result from the needs assessment was interesting. And not unlike what Lucy Savitz found with her assessment of nursing homes which is that Primary care centers deal with emergencies on a regular basis: the disruptive patient, transferring an acutely ill patient, dealing with a computer server failure.

They have written evacuation plans, plans for a bomb threat or fire safety. On the other hand, when it came to having preparedness plans for a bioevent or for dealing with a citywide emergency, those plans were extremely variable from primary care centers and relatively undefined.

Cindy DiBiasi: So in your view, how could primary care centers be better prepared for a large-scale emergency?

Debra Berg: We developed a series of interventions. And to be honest with you, the interventions were not much different than what we would do with hospitals.

We worked with primary care centers so that they could form an emergency management planning team and from there an incident management system to assign roles and tasks for their staff during an emergency. They conducted a hazard vulnerability analysis, which created a lot of surprises for the primary care center.

Being located near a popular building like the Empire State Building or a subway or a shopping area made them realize that they were at risk for certain types of incidences that they hadn't thought about before.

They also received a series of emergency preparedness talks, and those talks were given to certain individuals within the center to take back to their other employees. And lastly, they participated in two tabletop exercises to help put everything together at the end of the project.

Cindy DiBiasi: Debra, what lessons could other primary care centers learn from the work that you did?

Debra Berg: The lessons that primary care centers can learn is that, first of all, undoubtedly it's a time-consuming process, and I have to give them a lot of credit for the time that they put into building the emergency management plan. However, there was a lot of buy-in and a lot of interest to get started.

And there are a lot of advantages that came from primary care centers working with the Department of Health, and that included becoming a part of the health alert network.

They were able to participate in a panel discussion with the Office of Emergency Management, with our emergency medical services, the local and State Health Department, and the Greater New York Hospital Association.

The tabletop exercises were another example where primary care centers were able to work directly with public agencies and also the Division of Mental Hygiene, who came to provide some very practical advice and assistance during the tabletop exercise, which worked through a smallpox outbreak.

Cindy DiBiasi: So based on your observations, what role can primary care centers play in an emergency?

Debra Berg: Well, you know, what we found that was really interesting is that primary care centers can play several roles during a single emergency, and it really depends on their geographic location and the type of emergency.

We learned that primary care centers certainly will play the role of an information hub and that will help steer individuals away from the hospital to the primary care center, primary care centers who work with community-based organizations, so that the distribution of information may be shared.

Primary care centers also feel responsible for at least starting mental health counseling, triage, or referring individuals to mental health facilities.

Obviously, primary care centers will care for patients whose illnesses are non-event-related but in addition serve as a surge capacity enhancement for local hospitals. Next slide. Lastly, primary care centers may triage event-related patients; they may be able to supply some of their resources or staff to area hospitals or other primary care centers; and most recently, we've been educating individuals from primary care centers about our Medical Reserve Corps, because they become a rich source to participate in our points of distribution around the city if there should be a mass antibiotic distribution plan undertaken.

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