The Hospital Response

Real Time Experience at AMCH

Sarah Elmendorf, MD

Rebecca O’Donnell MT,CIC

IntroductionIntroduction

Hope for the best, plan for the worstHope for the best, plan for the worstEvolving plan, never completed!Evolving plan, never completed!Current approachCurrent approach--not all the answersnot all the answers4 initial measures 4 initial measures (J healthcare management 2004 49 (40 227(J healthcare management 2004 49 (40 227--235))235))

–– hospital staff educationhospital staff education–– information technologyinformation technology–– disease surveillance improvementdisease surveillance improvement–– additional equipment and staffadditional equipment and staff

Regional effortsRegional efforts

ApproachApproach

Assess a single patients entry into AMCH Assess a single patients entry into AMCH systemsystem

–– Real timeReal time

Identify current strengths and weaknessesIdentify current strengths and weaknesses–– Table topTable top

Respond to weaknessesRespond to weaknesses–– Additional needs assessment/planning at department Additional needs assessment/planning at department

and division leveland division level

Assess surge capacityAssess surge capacity

Key AssumptionsKey Assumptions

SARS planning applied to Avian Flu SARS planning applied to Avian Flu PreparednessPreparednessOverall threat is smallOverall threat is small

Science 2004 304:968Science 2004 304:968--969 969 BUTBUTHigh case fatality rateHigh case fatality rateWho (5/05): Who (5/05): Avian flu making ominous changesAvian flu making ominous changesPotential global health impact could be Potential global health impact could be catastrophiccatastrophic

ArrivalArrival

ChallengesChallengesSafe entry into the Safe entry into the systemsystemPreparedness for Preparedness for the unknown

StrategiesStrategiesEducation of triage Education of triage staffstaffSignage Signage

the unknown

ArrivalArrival

ChallengesChallengesDiagnosis unknownDiagnosis unknown–– Distinguish from other Distinguish from other

respiratory infectionsrespiratory infections

Changes in case Changes in case definitions

StrategiesStrategiesRespiratory etiquetteRespiratory etiquetteAnyone who presents Anyone who presents with a cough is with a cough is immediately maskedimmediately maskedTriage alertTriage alertRecognize risk factorsRecognize risk factors–– Travel, exposure to Travel, exposure to

poultry, exposure to poultry, exposure to other cases

definitions

other cases

ArrivalArrival

ChallengesChallengesSign interpretation Sign interpretation

StrategiesStrategiesEnglish and Spanish English and Spanish signssignsSigns with picturesSigns with pictures--don’t reinvent, use!don’t reinvent, use!

Are you confident infection is not being spread?

ArrivalArrival

Visual AlertsVisual Alerts

ArrivalArrival

ChallengesChallengesSurge Capacity Surge Capacity

StrategiesStrategiesInflux of patients Influx of patients will require regional will require regional collaboration and collaboration and coordination coordination

Triage Triage

ChallengesChallengesTriage staff unsure Triage staff unsure of current events of current events and case definitionsand case definitions

StrategiesStrategiesCommunication Communication –– ICP rep on ED QIT ICP rep on ED QIT –– IC roundsIC rounds

AlertsAlerts–– Central locationCentral location

EducationEducationTest the systemTest the system

TriageTriage

ChallengesChallengesEnforcement of Enforcement of respiratory etiquetterespiratory etiquette–– Legal issuesLegal issues–– Security issues

StrategiesStrategiesSegregate patient from Segregate patient from main waiting areamain waiting areaSeparate waiting Separate waiting areas/family areas/family conference roomconference roomDevelopment of Development of respiratory etiquette respiratory etiquette bags

Security issues

bags

Are you prepared to enforce policy?

Triage Triage

Isolation Isolation

ChallengesChallengesExtended Extended PrecautionsPrecautions

Visitors and FamilyVisitors and Family

StrategiesStrategiesContact/Airborne Contact/Airborne signs for doorframesigns for doorframeStickers for chartStickers for chartCommunicationCommunication–– Notify infection Notify infection

controlcontrol

Visitor/family Visitor/family screening, PPE, screening, PPE, check in logscheck in logs

Isolation Isolation

ChallengesChallengesCorrect use and Correct use and removal of personal removal of personal protective protective equipment (PPE)equipment (PPE)Compliance with Compliance with PPEPPEAvailability of PPEAvailability of PPE

StrategiesStrategiesContact /Airborne Contact /Airborne signsignPPE removal signPPE removal signPPE observer PPE observer PPE cartPPE cartEducation sessionsEducation sessions

IsolationIsolation

IsolationIsolation

ChallengesChallengesDisinfection of Disinfection of environment and environment and equipment

StrategiesStrategiesDedicate where Dedicate where possiblepossibleEmpty room of Empty room of unnecessary unnecessary suppliessuppliesDisinfect! Disinfect! Disinfect! Disinfect! Disinfect!

equipment

Disinfect!

Are you prepared for extended precautions?

Patient MovementPatient Movement

ChallengesChallengesContain diseaseContain diseaseCommunication

StrategiesStrategiesMask patient Mask patient Identify most direct Identify most direct routerouteSecurity Security participation and participation and traffic controltraffic controlICP involvement ICP involvement Use of PPE duringUse of PPE duringtransport

Communication

transport

CommunicationCommunicationChallengesChallenges

Multiple disciplinary Multiple disciplinary involvement

StrategiesStrategiesPrepared policiesPrepared policies--located on Intranet sitelocated on Intranet site-- NotificationNotification-- Patient placementPatient placement-- Patient managementPatient management-- Identification of patientIdentification of patient-- Hand hygieneHand hygiene-- PPEPPE-- Environment and equipment Environment and equipment

disinfectiondisinfection-- Laboratory specimensLaboratory specimens-- Linen and wasteLinen and waste-- Interdepartmental transferInterdepartmental transfer-- Visitors

involvement

Visitors

CommunicationCommunication

ChallengesChallengesInternal/External Internal/External communicationcommunication

Laboratory Laboratory notification

StrategiesStrategiesCounty notification County notification Testing the system Testing the system with other with other communicable communicable diseasesdiseases

Stickers for lab Stickers for lab specimensspecimensEducationEducationIntranet site

notification

Intranet site

Communication Scheme Communication Scheme EDInternal Medical/Nursing Staff

Epidemiology

Laboratory

Public Relations

County Health Departments

Radiology

NYSDOH Regional Epidemiology

NYSDOH Wadsworth Laboratory

Pt Care Unit

Medical Director/Administration Multiple

specialties

External

Communication: a critical but time consuming element

Medical EvaluationMedical Evaluation

Medical EvaluationMedical Evaluation

ChallengesChallengesMedical staff fit Medical staff fit testing/compliancetesting/compliance

StrategiesStrategiesPowered air Powered air purifying respirator purifying respirator (PAPR)(PAPR)Fit testing critical Fit testing critical medical staffmedical staffAll sizes/types of All sizes/types of NN--95 respirators 95 respirators available on units available on units

Medical EvaluationMedical Evaluation

ChallengesChallenges

MultiMulti--specialty specialty involvement/ educationinvolvement/ education

Movement of patientsMovement of patients

StrategiesStrategiesEmergency Preparedness Emergency Preparedness Readiness SiteReadiness SiteStreamline clinical Streamline clinical managementmanagement

Maintain precautionsMaintain precautionsIntubate/extubate in Intubate/extubate in negative pressure roomnegative pressure roomLimit movement of patient Limit movement of patient

DiagnosisDiagnosis

ChallengesChallengesWhat specimens to What specimens to collect?collect?

Avian flu/other Avian flu/other respiratory infectionsrespiratory infections

StrategiesStrategiesIntranet siteIntranet site–– Identify specimens Identify specimens

neededneeded–– Current case definition Current case definition

with symptoms/risk with symptoms/risk factors/travel factors/travel

Maintaining precautionsMaintaining precautions

TreatmentTreatment

ChallengesChallengesOptions limited

StrategiesStrategiesPharmacy preparednessPharmacy preparednessVaccination campaignVaccination campaignIncreased stock of Increased stock of antiviral medicationantiviral medicationKnowledge of most Knowledge of most current current recommendations

Options limited

recommendations

Potential for SurgePotential for Surge

ChallengesChallengesOverwhelming Overwhelming resources of health resources of health care system care system –– PPE PPE –– EquipmentEquipment–– Staff

StrategiesStrategiesEarly recognitionEarly recognitionEarly treatmentEarly treatmentEarly isolationEarly isolationStocked PPEStocked PPENegative pressure Negative pressure unitsunitsPatient diversion

Staff

Patient diversion

Potential for SurgePotential for Surge

ChallengesChallengesOverwhelming Overwhelming resources of health resources of health care system care system –– PPE PPE –– EquipmentEquipment–– Staff

StrategiesStrategiesTeam approachTeam approachOn the spot On the spot tracking and tracking and references, Palm references, Palm Pilots Pilots

Staff

Potential for SurgePotential for Surge

ChallengesChallengesMultiple hospital Multiple hospital Collaboration

StrategiesStrategiesRegional Resource Regional Resource CenterCenterHEOCCHEOCCAlbany County Albany County Community Advisory Community Advisory GroupGroupAlbany County Albany County Communicable Disease Communicable Disease Workgroup

Collaboration

Workgroup