Creating Hospital Surge Capacity Hospital Functions and Reallocation

Creating Hospital Surge Capacity: Hospital Functions and Reallocation of Resources THIRD NATIONAL EMERGENCY MANAGEMENT SUMMIT The Leading Forum on Disaster, Epidemic and Terrorism Planning, Response and Recovery for Healthcare Organizations Renaissance Washington DC Hotel Washington, DC March 4 - 6, 2009 1

Presentation Objectives 2

Presentation Objectives § Identify hospital functions critical to the maintenance and creation of surge capacity § Identify a potential method for closing gaps in medical surge demands § Identify a scalable method able to meet the demands of different types of incidents, adaptable to a variety of hospital sizes and configurations and consistent with CDC, ASPR, OSHA, CMS and The Joint Commission standards and guidelines 3

Introduction 4

Introduction § § Efforts to contain the economic burden of healthcare in the United States have resulted in improved efficiency in hospital operations In part, these efficiencies have been obtained by reducing bed capacity, running near maximum hospital capacity and adjusting resources including staffing ratios Healthcare systems are now being charged with the task of increasing surge capacity to accommodate an influx of patients requiring triage and emergent care with little or no advance warning The purpose of the Hospital Emergency Support Functions Project is to identify staff capabilities and capacity available throughout the hospital that might be reassigned to both clinical and non-clinical services 5

Mandate 6

Mandate Hospitals have been tasked by federal funding mandates and accreditation (The Joint Commission to the numbers of patients) to increase their in-house bed surge capacity, identify and establish plans for additional “alternate care” sites and facilities 7

Background 8

Background § § § Large scale disasters such as hurricane Katrina have drawn attention to the need for medical surge capacity Ironically, it is this surge capacity that was eliminated in order to maximize efficiency Within a hospital environment there are multiple departments with staff that are capable and competent to provide cross coverage to other areas of the hospital where their expertise may be utilized during a large scale surge incident 9 Photo credit: LSU, Jon Best

Challenges 10

Challenges § § § Surge needs associated with a pandemic are among the most challenging given that surge capacity would likely be depleted No clear means have been established to determine staff suitably to care for this increased patient load Need for sustainability of staff for an extended period of time as seen in a pandemic event 11

Challenges § To date, plans nationwide have identified volunteerism and emergency credentialing systems as possible solutions to the staffing issue, however, no evidence has been shown that this approach will appropriately address the staffing needs in a large scale surge incident § Commonly, hospital disaster plans rely on external sources to maintain surge capabilities and create additional capacity § External mechanisms include alternate care sites, patient transfers, volunteerism and special disaster medical assistance teams Emergency Credentialing Program 12

Assumptions 13

Assumptions § § A large-scale surge incident including, but not limited to a pandemic event, will likely dramatically decrease the available workers in all departments of the hospital During a large-scale surge incident certain hospital services will be cancelled Departments within the hospital may be combined to perform functions required by the particular surge incident that extends over multiple operational periods Staff may be reassigned and function competently within their field of expertise with applicable just-in-time training 14

Assumptions § § § External assistance is unlikely to be available to hospitals in national catastrophes such as a pandemic Employee illness, care for family members, and fear of contracting serious illness may drive hospital absenteeism rates to 40% while need for services may increase well above the norm Prudent hospital planning must include internal mechanisms for increasing capacity and maintaining capability 15

Scope 16

Scope § § § The Hospital Emergency Support Functions Project will identify personnel capabilities and capacity available throughout the hospital that may be reassigned to both clinical and non-clinical services during an event that causes a surge of patients and/or as a result of diminished personnel capacity Within each department, staff functions will be identified and categorized in order to create an allinclusive database This database will be utilized during a large scale surge event to identify staff positions that may be reassigned to support the care of patients and maintain the hospital’s functional capability 17

HESF Categories 18

HESF Categories § The Hospital Emergency Support Functions Project identified the following as essential functions of hospitals: – Patient Care – Staff – Facilities – Communications – Safety/Security – Business Continuity 19

HESF Categories To fulfill the essential functions of the hospital, 15 “Hospital Emergency Support Functions” (HESFs) were identified as follows: § Clinical Services § Clinical Support Services § Emergency Family and Staff Support § Nutrition Services § Mortuary Services § Maintenance, Engineering and Energy § Resource Support and Materials Management § Communications and Information Technology § Public Information § Transportation § Safety § Security § Information and Planning § Finance § Human Resources 20

Hospital Functions 21

Hospital Functions Hospital Essential Support Functions Function HESF Number #1 Clinical Services Patient Care #2 Clinical Support Services #3 Emergency Family and Staff Support #4 Nutrition #5 Mortuary Primary Support - Emergency Services - Critical Care - Med/Surg - Labor and Delivery - Maternity - Pediatrics - Psychiatry - Diagnostic Imaging - Epidemiology - Intravenous Therapy - Laboratory - Pharmacy - Respiratory Therapy - Ambulatory Care - Cardiology - Home Care - Obstetrics and Gynecology - Rehabilitation Services - Cath Lab - Echocardiography - EEG - Endoscopy - Interventional Radiology - Peripheral Vascular Lab - Physical Medicine - Radiation Therapy - Sleep Lab - Wound Care - Care Management - Elder Care Program - Children's Psychiatric Services - Employee Wellness - Day Care - Outreach Program - Pastoral Care - Support Services - Psychiatry Services - Wellness Program - Social Services - Cafeteria - Coffee Shop - Food and Nutrition - Kitchen - Pathology None 22

Hospital Functions #6 Maintenance, Engineering, and Energy Facilities #7 Resource Support and Materials Management #8 Communication and Information Technology - Biomedical Engineering - Clinical Engineering - Environmental Services - Laundry/Linen Services - Maintenance - Plant Engineering - Central Processing - Finance Department - Human Resources - Material Management - Purchasing - Receiving - Shipping - Stockroom - Clinical Applications - Help Desk - Information Systems - Interpreter Services - Telecommunications Communications #9 Public Information - Employee Relations - Mailroom - Patient Relations - Public Relations 23 None - Development Office - Foundation - Supply Chain Management - Call Center - Compliance Hot Line - Copy Center - Library Services - Marketing and Communication - Marketing and System Development - Multimedia Services - Information Services - Lobby/Main Desk - Physician Relations

Hospital Functions #10 Transportation Safety/ Security #11 Safety #12 Security #13 Information and Planning Business Continuity #14 Finance - Auxillary - Motor Services - Parking Operations - Patient Escort and Distribution - Garage - Risk Management - Occupationsl Medicine - Safety Officer None - Protective Services - Security None - Administration - Budget and Planning - Facilities Planning and Management - Legal and Risk Services - Community and Gov. Relations - Corporate Compliance - Decision Support - Financial Planning - Plan and Business Development - Strategic Develop. and Marketing - Accounting - Accounts Payable - Budget and Reimbursement - Credit Union - Finance - Payroll - Worker's Compensation - Cashiers - Corporate Finance - Fiscal Servives - Grants and Contracts - Patient Financial Services - Reimbursement 24

Hospital Functions #3 - Employee Assistance Emergency Staff and Family Program Support Staff #15 Human Resources - Float Pool - Hospitalist Service - House Staff Office - Human Resources - Medical Staff Office - Nursing Office - Volunteers 25 - Employee Wellness - Student Services

Compatibility Model 26

Compatibility Model HOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF) HESF Number HESF #1 HESF #2 HESF #3 HICS Branch Director(s) HICS Unit Leader(s) Operations Section Chief Medical Care Branch Director Inpatient Unit Leader, Outpatient Unit Leader, Casualty Care Unit Leader Radiation Therapy, Pathology, Medical Education, Anesthesiology, Volunteer Services Operations Section Chief Medical Care Branch Director Clinical Support Services Unit Leader Volunteer Services, Human Resources Logistics Section Chief Support Branch Director Familcy Care Unit Leader, Employee Health & WB Unit Leader, Primary Departments Supporting Departments Clinical Services Direct patient care: emergency medicine, critical care, emergency anesthesia/surgery; ambulatory and specialty care as resources allow Patient Care Services Transportation, Social Services, Pastoral Care, Volunteer Services Clinical Support Services Laboratory, Radiology, Pharmacy, Respiratory Care, etc. Laboratory, Radiology, Pharmacy Emergency Family and Staff Support Social work; Pastoral care; Critical Incident Stress Management; Interpreter Services; day care, elder care, mental health, temporary sheltering; distribution of essentail supplies Pastoral Care, Social Services Function Name Description 27 HICS Section Chief(s)

Compatibility Model HOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF) HESF Number HESF #4 HESF #5 HESF #6 HESF #7 Function Name Description Primary Departments Supporting Departments HICS Section Chief(s) HICS Branch Director(s) HICS Unit Leader(s) Nutrition Services Coordinate with materials management to secure bulk food, water and ice; mass feeding Food and Nutrition Services Environmental Services, Volunteer Services Logistics Section Chief, Operations Section Chief Service Branch Director (Logs), Infrastructure Branch Director (Ops) Staff Food & Water Unit Leader (Logs), Food Services Unit Leader (Ops) Mortuary Services Expansion of facilities/capacity; postmortem examination & identification; tracking and liaison to families Pathology Environmental Services, Hospital volunteer Services, Pastoral Care, Social Services Operations Section Chief Medical Care Branch Director Casualty Care Unit Leader Maintenance, Engineering & Energy Support or restore essential plant operations, back-up power and water Resource Support & Materials Management Expansion of just-in time inventory; purchasing, leasing, management of MOUs/MOAs; Coordination of donations; logistical resource support and liaisons Plant Engineering, Hospital Maintenance, Facilities Management, Environmental Services Materials Management, Purchasing 28 Safety and Security Operations Section Chief Infrastructure Branch Director Power/Lighting Unit Leader, Water/Sewer Unit Leader, HVAC Unit Leader, Building/Grounds Damage Unit Leader, Medical Gasses Unit Leader, Bedical Devices Unit Leader, Environmental Svs Unit Leader Development Office, Volunteer Services Logistics Section Chief, Finance Section Chief Support Branch Director (Logs) Supply Unit Leader (Logs), Cost Unit Leader (Finance), Procurement Unit Leader (Finance)

Compatibility Model HOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF) HESF Number HESF #8 HESF #9 HESF #10 HESF #11 Function Name Description Primary Departments Supporting Departments HICS Section Chief(s) HICS Branch Director(s) HICS Unit Leader(s) Communications & Information Technology Support or restore information services, telemedicine, telephonics, paging to support internal functions and external connectivity; emergency notification of staff Information Technology, Telecommunicat ions Volunteer Services, Public Relations, Safety and Security. Medical Records Logistics Section Chief Support Branch Director IT/IS Unit Leader Command Staff Public Information Officer N/A Public Information Risk communications to staff and public; Public Relations OEP, HR, Information and Planning, Occupational Health, Safety and Security Transportation Logistical support for internal and external transport of patients; delivery of energy and supplies; securing of transport routes in conjunction with security; facility evacuation Transportation Courier, Materials management Safety and Security Logistics Section Chief Support Branch Director Tranportation Unit Leader Safety Coordinates comprehensive health and safety program to include hazardous material and waster management. Ensure compliance with local, state and federal agencies. Ensures staff safety screening to include PPE, fit testing, etc. Occupational Medicine Patient Care Services, Pharmacy, Facilities Management Command Staff Safety Officer N/A 29

Compatibility Model HOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF) HESF Number HESF #12 HESF #13 HESF #14 HESF #15 Function Name Description Primary Departments Supporting Departments HICS Section Chief(s) HICS Branch Director(s) HICS Unit Leader(s) Security Branch Director Access Control Unit Leader, Crowd Control Unit Leader, Traffic Control Unit Leader, Search Unit Leader, Law Enforcement Interface Unit Leader Security Provides security resources to support logistical, medical, transportation and security services. Coordinates the mobilization of law enforcement. Security Information and Planning Situational awareness; surge enhancements; mobilization, scaling of response, demobilization; resource capabilities; coordination with state emergency response team Safety and security, Admitting Office, Incident Command/EM Manager OEP Planning Section Chief N/A Resource Unit Leader, Documentation Unit Leader, Situation Unit Leader Finance Approval and tracking of expenditures; filing of claims (insurers, government disaster reimbursement, etc. ); emergency payroll policies Finance Human Resources, Risk management Finance/ Adminstration Section Chief N/A Time, Unit Leader, Compensation/Clai mes Unit Leader Human Resources Coordination of alternate/reassigned staff and volunteers; absentee policies; furloughs; coordination with payroll; coordination of crosstraining; credentials verification Human Resources Finance, Medical Records, Occupational Health, Housing Office, Facilities Management Logistics Section Chief Support Branch Director Labor Pool & Credentialing Unit Leader Plant Engineering, Maintenance, Facilities Management, Volunteer Services 30 Operations Section Chief

An Emergency Response: Operational Diagram 31

Operational Diagram 32

Policies for Consideration 33

Policies for Consideration § § Who will authorize the implementation of the Hospital Emergency Support Functions (HESF) in response operations Who coordinates the assessment of staffing needs across all patient care areas In conjunction with ICS/HICS who authorizes the use of support department’s to augment clinical and non-clinical operations Role of Labor Pool Unit Leader 34

Next Steps 35

Next Steps § Gain approval of the HESF process from: – Legal – Human Resources – Senior Administration – Emergency Management Committee § Collaboration with Human Resources and Hospital Information Technology on the modification of the applicable databases to include assignment of “primary” or “secondary” to each work unit identified in the database § Identify appropriate members of HICS/ICS with access to the database 36

Next Steps § § Develop and test process by which identification and reassignment tracking will be accomplished Prepare user’s manual – “Using the HRDB in an Emergency Response” Provide identified members of HICS/ICS with training in the use of the database Design and develop an exercise testing the utility of the database to identify staff for transfer during a medical surge event 37

Questions and Comments 38

Contact Information James L. Paturas, CEM, EMTP, CBCP, FACCP Deputy Director (203) 688 -3224 james. paturas@ynhh. org Yale New Haven Center for Emergency Preparedness and Disaster Response 1 Church Street, 5 th Floor New Haven, CT 06510 www. yalenewhavenhealth. org/emergency 39