Public Health Emergency Preparedness

Chapter 6. Alternative Care Sites

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By Stephen Cantrill, M.D., Lead Author,^a Carl Bonnett, M.D.,^b Dan Hanfling, M.D.,^c Peter Pons, M.D.^d

^a Associate Director, Department of Emergency Medicine, Denver Health Medical Center
^b Emergency Medical Services Fellow, Department of Emergency Medicine, Denver Health Medical Center
^c Director, Emergency Management and Disaster Medicine, Inova Health System
^d Professor of Emergency Medicine, Department of Surgery, University of Colorado Health Sciences Center

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This chapter discusses the issues surrounding non-Federal, non-hospital-based alternative care sites (ACSs). It describes different types of ACSs as well as critical issues and decisions that will need to be made regarding these sites during mass casualty event. Potential barriers are addressed, and examples of case studies are included.

 

Alternative Care Sites (ACS) Issues and Recommendations At A Glance Major Challenges to Successful ACS Planning and Establishment Lack of regional and State planning with clear delineation of responsibilities and authority The requirement that multiple groups work together who traditionally have not done so, including health care providers with conflicting institutional allegiances, hospitals, emergency managers, regional planners, and local and State health departments Lack of financial inducements to create, drill, and execute the plan Issues regarding professional licensing; verification; and supervision, both intra-and interstate Funding and compensation issues Recommendations for ACS Planners Ensure that all communities have an integrated mass casualty event (MCE) plan in place to provide for expansion of health care services into ACSs when existing health care providers and institutions become overwhelmed. Constitute a planning and implementation committee comprised of, at a minimum, emergency managers, planners, public health departments, health care providers and institutions, local and regional government representatives, and appropriate private partners. Ensure that a concept of operations (CONOPS) document is prepared to define in advance the anticipated role that the ACS facility will serve. Identify and assess potential sites for implementation of an ACS prior to an incident. Whenever possible, put in place agreements to permit such use. Obtain, stockpile, and store supplies, equipment, and pharmaceuticals sufficient to meet the anticipated role for the ACS as defined in the CONOPS in a fashion that will permit rapid deployment to a selected site. Prepare a plan for personnel staffing sufficient to meet the anticipated role for the ACS as defined in the CONOPS. Anticipate and plan for operational and logistic support of the ACS. Plan for the needs of pediatric patients.

Background

The impact of an MCE of any significant magnitude likely will overwhelm—and indeed may render inoperable—hospitals and other traditional venues for health care services. This situation will necessitate the establishment of ACSs for the provision of care that normally would be provided in an inpatient facility, including acute, subacute, and chronic care.

The concept of providing medical care in a nonhospital ACS has been demonstrated throughout history: during the Civil War, the aftermath of the San Francisco earthquake of 1906, the influenza pandemic of 1918-1919, and more recently the aftermath of Hurricane Katrina. During the Cold War in the 1950s and 1960s, this concept was developed and formalized by the U.S. Civil Defense Agency in cooperation with the Department of Health, Education and Welfare as "Packaged Disaster Hospitals" (PDHs). These PDHs consisted of modularized, predeployed units for 50, 100, or 200 beds. In 1972, Congress discontinued its support funding for the PDH concept. The 2,500 deployed units were declared to be surplus and were discarded over the next decade. More than three decades later, however, we find ourselves in the interesting position of rediscovering, resurrecting, and refining the concept of ACSs.

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ACSs in the Context of an MCE

The focus on catastrophic bioterrorism over the past decade has resulted in some key efforts in the development of the concept of ACSs. The most widely recognized effort has been the development of the Acute Care Center (ACC) and Neighborhood Emergency Health Center (NEHC) concepts by the U.S. Army Soldier and Biological Chemical Command (SBCCOM).

NEHC and ACC Concepts Under the auspices of the Department of Defense and the Domestic Preparedness Program, the Biological Weapons Improved Response Program developed the Modular Emergency Medical System (MEMS) to provide systematic, coordinated, and effective medical response in the event of a large-scale biological terrorism incident. MEMS strategy established a framework for which outside medical resources could be used to enhance local response efforts in two types of expandable patient care modules: the NEHC and the ACC. The NEHC is designed to function as a high-volume casualty reception center, performing victim triage and dispensing medicines and information. The ACC is designed and equipped to treat patients who need inpatient treatment but do not require mechanical ventilation and those who are likely to die from an illness resulting from an agent of bioterrorism. Sources: Acute Care Centers: A Mass Casualty Care Strategy for Biological Terrorism Incidents (December 2001), and Neighborhood Emergency Help Centers: A Mass Casualty Care Strategy for Biological Terrorism Incidents (May 2001). Both documents prepared in response to the Nunn-Lugar Domestic Preparedness Program by the Department of Defense. Go to: http://www.nnemmrs.org/resources/surge_capacity_guidance/index.html.

The innovative body of work surrounding the development of the ACC and NEHC concepts has addressed several key issues related to the delivery of care outside of established hospitals, including:

• The level and scope of care to be delivered
• The physical plant required for the establishment of such facilities
• Staffing requirements for delivery of such care
• Medical equipment and supplies requirements
• The incident management system required to integrate such facilities with the overall delivery of health care in the context of a disaster.

In the aftermath of the September 11, 2001, attacks, more concerted focus was placed on the definition and development of public health and medical surge capacity. A distinction was drawn between health care facility surge capacity and community surge capacity, with the understanding that community surge capacity strategies were focused on the creation of out-of-hospital solutions to the delivery of health care, closely mirroring the ACC concept.

This understanding led to the emergence of a new definition of ACS, one that included a location for the delivery of medical care that occurs outside the acute hospital setting for patients who, under normal circumstances, would be treated as inpatients. In addition, the ACS has come to be viewed as a site to provide event-specific management of unique considerations that might arise in the context of catastrophic MCEs, including the delivery of chronic care; the distribution of vaccines or medical countermeasures; or the quarantine, cohorting, or sequestration of potentially infected patients in the context of an easily transmissible infectious disease.

Surge Capacity

Further conceptual development of surge capacity was conducted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and focused on the establishment of "surge hospitals." The JCAHO identified three types of surge hospitals:

• Facilities of opportunity, which are defined as nonmedical buildings which, because of their size or proximity to a medical center, can be adapted into surge hospitals
• Mobile medical facilities, which are mobile surge hospitals based on tractor-trailer platforms with surgical and intensive care capabilities
• Portable facilities, which are mobile medical facilities that can be set up quickly and are fully equipped, self-contained, turnkey systems usually stored in a container system and based on military medical contingency planning.
  

All three types of contingencies were used and deployed in the aftermath of Hurricane Katrina.

Planners may download the guide, Surge Hospitals: Providing Safe Care in Emergencies, from http://www.jointcommission.org.

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Challenges to Successful ACS Planning and Implementation

While recent experiences with Hurricanes Katrina and Rita clearly demonstrate the need for ACSs to provide medical care at the time of an MCE, there are multiple impediments to successful ACS planning and establishment. The most significant challenges include:

• Lack of regional and State planning with clear delineation of responsibilities and authority
• The requirement that multiple groups work together who traditionally have not done so, including health care providers with conflicting institutional allegiances, hospitals, emergency managers, regional planners, and local and State health departments
• Lack of inducements to create, drill, and execute the plan
• Issues regarding health professional licensing; verification; and supervision, both intra- and interstate
• Funding issues.

Key Issues in ACS Planning

To respond effectively to an MCE, advance planning is critical. Community planners (from municipal agencies, including public safety, public health, and emergency management as well as representatives from local health care organizations or institutions) must conceive of a plan for how the ACSs would deliver wide-ranging medical services to the population in need. This planning must be done with existing health care facilities (hospitals, outpatient clinics, and multispecialty group offices) and home care entities. Planners must delineate the specific medical functions and treatment objectives that the ACS facility would need to accomplish.

This approach assumes that an organized mechanism exists for triage of patients into high-acuity, moderate-acuity, low-acuity, and expectant/expired categories, so that patient needs are matched with available medical resources. The division of patients also must identify those patients for whom no manner of medical intervention is likely to result in a positive outcome and are therefore candidates for palliative care. Such planning also assumes that the most severely ill or injured high-acuity patients can receive medical care commensurate only with what would be expected within the setting of a hospital facility or an ACS that is outfitted to serve as an acute care hospital, which is unlikely.

The biggest challenge, however, is the fact that most communities will not be able to procure the amount and complexity of resources or the level of staffing required to extend hospital facilities into designated ACSs. For this reason, most ACSs will be located in "buildings of convenience." It is imperative for planners to establish clear operational definitions of what can and cannot be accomplished in the setting of an ACS.

Getting Started with an ACS What To Do? The most important step in attempting to overcome the challenges to successful ACS planning and implementation is to begin the planning process. How To Do It? A single individual or group must recognize that planning for ACS is a mandatory part of all hazards preparedness and identify or establish an administrative structure to begin the planning process. Who Should Be Involved? Participants in this process should include emergency managers, community planners, public health (local and State), public safety, emergency medical services (EMS), area health care facilities, and health care providers.

The development of ACS plans will not be accomplished in a vacuum. Key planning issues to consider include the following:

• Local health care and emergency management systems all should be involved not only in the ACS planning process but in the commitment of financial support as well.
• Any regional health care alliance that is formed to plan for response to disasters must integrate ACSs into their operating plans. As such, these facilities must fit within the broader spectrum of medical and health care incident management. Community planners must identify the logistical support necessary for establishing such ACSs.
• Community planners should identify and create protocol-driven patient management objectives, based on assumptions about the types of patients that would be treated in such ACS facilities.

Different Uses of an ACS ACS facilities ultimately may be developed to serve different purposes depending on the circumstances requiring their use. An ACS might be designed to serve as one of the following: A primary triage point, helping decide which patients require hospitalization, can be managed at home, might benefit from observational care and minimal interventions available at the ACS, or require palliative care which also might be available at an ACS. Such a facility might be reasonably expected to cohort a group of patients who were exposed to certain infectious agents but do not need more than continued observation and minimal, if any, medical intervention. A community-focused ambulatory care clinic that serves as a point of distribution for medications, vaccinations, or other medical interventions that must be delivered to a wide population. A low-acuity patient care site to permit the offloading of stable patients from hospitals to enhance their internal patient care capability or as primary sites for the care of stable low-acuity patients.

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Key Issues in ACS Establishment and Operation

The successful establishment and operation of an ACS is, by its very nature, a complex undertaking, with a variety of issues to be addressed. As is the case with all aspects of preparedness, these issues are best vetted and investigated well before an event that necessitates their implementation. Several of the points discussed below also will apply to the situation where a locale is not setting up its own ACS but rather is operating in a supportive role of a Federal Medical Station (FMS) ACS.

FMSs are designed to provide surge medical capacity (equipment, material, pharmaceuticals) to communities overwhelmed by mass casualties.  They can provide rapidly deployable health and medical care to those patients who have nonacute medical, mental health, or other health-related needs that cannot be accommodated or provided for in a general shelter population. They also provide health and medical care for patients with needs such as:

• Conditions that require observation, assessment, or maintenance.
• Chronic conditions which require assistance with the activities of daily living but do not require hospitalization.
• Medications and vital sign monitoring, particularly for patients who are unable to do so at home.

"Ownership," Command, and Control of the ACS

The single most important issue for the successful establishment of an ACS is the determination of ownership, command, and control of the ACS. These issues should be decided at a local or regional (as opposed to institutional) level and must involve the identification of the individual(s) with the authority to decide whether, when, and where an ACS should be opened and the authority to operate the site.

The most effective way to make such decisions is to use and build on the organizational and governance structure that is already functioning in the region or State. The administrative structure for operation of an ACS should follow the basic concepts of the hospital incident command system discussed earlier in this guide and reviewed below.

The Hospital Emergency Incident Command System (HEICS) was developed in the early 1990s to provide an emergency management system for hospitals for use during a medical disaster, but the concept has been adapted to other areas of emergency response as well and certainly lends itself to providing structure and organization to the operation of an ACS. Indeed, many ACSs that were set up during Hurricanes Katrina and Rita used the basic concepts of HEICS, which were then altered to fit the unique aspects of the ACS. HEICS, now known as HICS, provides an emergency management system that provides a logical, flexible management structure with a clear chain of command and is compliant with the National Incident Management System.

Hospital Incident Command System* Management Structure The Incident Command Section provides overall coordination of the response and is the central communication point. The Operations Section is responsible for clinical duties including triage and treatment and directs all patient care resources. The Logistics Section is responsible for providing facilities; services, including food service and communications; and materials. The Planning Section determines and provides for the achievement of each medical objective and manages human resources. Finance and Administration is responsible for maintaining accounting records, issuing purchase orders, and stressing facility wide documentation. *Hospital Incident Command System is the new name for the revised Hospital Emergency Incident Command System. Planners are encouraged to view the updates posted at http://www.emsa.ca.gov.

 

Recommended Approaches to the ACS Planning Process Ensure that all communities (local and regional) have an integrated MCE plan in place to provide for expansion of health care services to ACSs when health care providers and institutions are overwhelmed. Convene a planning and implementation committee comprised, at a minimum, of emergency managers, planners, public health departments, health care providers and institutions, local and regional government representatives, and appropriate private partners. Ensure that a concept of operations (CONOPS) document is prepared to define in advance the anticipated role that the ACS facility will serve. Identify and assess potential sites for implementation of an ACS prior to an incident. Whenever possible, put in place agreements to permit such use. Obtain, stockpile, and store supplies and equipment sufficient to meet the anticipated role for the ACS as defined in the CONOPS in a fashion that will permit rapid deployment to a selected site. Prepare a plan for obtaining or stockpiling pharmaceuticals sufficient to meet the anticipated role for the ACS as defined in the CONOPS. Prepare a plan for personnel staffing sufficient to meet the anticipated role for the ACS as defined in the CONOPS. Anticipate and plan for operational and logistic support of the ACS, including, at a minimum: communications, internal and external with redundancy, security, transport of patients to and from the ACS, mechanisms for documentation of services, food services, resupply, staff rotation and rest, laundry services, and storage capacity.

Any ACS should be operationally integrated into a community-wide, unified command. It also should be integrated into the local Health Alert Network, which will allow for consistent approaches of care to the various medical problems that will be encountered (e.g., pandemic influenza, acute radiation syndrome).

Health Alert Network (HAN) The HAN is a nationwide program that establishes the communications, information, distance learning, and organizational infrastructure for a new level of defense against health threats. The HAN will link local health departments to one another and to other organizations critical for preparedness and response. The Centers for Disease Control and Prevention (CDC) is leading HAN development, working in partnership with other health organizations. Currently, HAN is providing health information and the infrastructure to support the dissemination of that information at the State and local levels. Go to: http://www2a.cdc.gov/han/Index.asp.

Decision To Establish and Open an ACS

This usually will be collaboration among local emergency managers, regional planners, health care workers responsible for operating the facility, county and State health officials, and any institutions that will participate in the staffing or logistical support of the ACS.

Scope of Care To Be Delivered and Patient Population To Be Served

Although the target patient population and scope of care to be delivered at an ACS may be event specific, some general guidelines are outlined in Table 6.1. Depending on the specific situation, the ACS may be used to:

• Provide delivery of ambulatory or chronic care
• Offload less ill patients from nearby hospitals, thereby increasing the hospitals'; surge capacity
• Provide primary victim care at a standard appropriate for the austere situation
• Provide quarantine, sequestration, or cohorting of "exposed" patients
• Provide palliative care.

One of the key decision points in the delivery of out-of-hospital care at an ACS is the ability to provide oxygen and respiratory therapy, particularly the ability to provide mechanical ventilation. The logistics and expense of sustaining oxygen delivery systems in an ACS setting, however, is extremely complex and prohibitively expensive. The exception to this may be the use of nursing homes and long-term care facilities in the role of alternative care facilities, given their existing medical gas supply.

Tentative sites are best identified in advance, and the mechanism of approval for use as an ACS should be investigated. As a rule, permission to use municipal buildings will be easier to obtain, and it will be easier to get MOUs to use existing staff members. Possible structures of opportunity are outlined in Table 6.2. Each will have advantages and disadvantages, depending on the type of MCE.

Although site selection is usually a local function, State partners should be asked early in the planning process whether potential shelters or ACSs have been designated at a State or regional level. If the ACS must supply ambulatory patient care, it may help to locate it near a victim shelter to support victims with chronic medical needs in that shelter. A list of requirements for an ACS has been converted to a matrix tool to assist with ACS site selection (in the table at the end of this chapter).

ACS Selection Tool The selection of a potential building to use as an ACS is an imprecise science and may vary based on the nature of the event. Using a consensus process, a group of hospital engineers, facility personnel, and health care providers developed and refined a list of infrastructure requirements for ACSs based on some initial work by the Department of Defense. These characteristics were then converted into a matrix tool to assist in site selection with each characteristic being assigned a relative weight from 0 to 5 (see the table at the end of this chapter). The values for each structure under consideration then can be added up giving a relative rank order of the suitability of each building. This tool is most appropriately used in advance of any event, so a list of potential buildings for use as ACSs can be developed and maintained. The tool is available at https://www.ahrq.gov/research/altsites.htm.

Supplies and Equipment

Another issue that requires advance planning is the availability of supplies for the adequate operation of an ACS. Routine supply chains will be stressed or not operational during an MCE of any magnitude or duration. Although the degree of need for certain supplies may be event specific (e.g., increased need for masks during a pandemic), the need for many basic supplies can be accurately forecasted. This is especially true for basic durable medical equipment (cots, IV poles, wheelchairs, etc.). These supplies may be stored as portable caches, which then may be transported to the ACS for use.

Caches can vary from a bare minimum cache ("Level I") for institutional augmentation to the very complete cache ("Level III") as defined for the ACC by the Soldier and Biological Chemical Command (SBCCOM). Certain supplies have a limited shelf life and therefore will require product rotation or replacement. As noted above, the ability to supply supplemental oxygen to patients in the ACS is problematic, with no simple solution. Some potential partial solutions to this problem are offered below.

The Challenge of Supplemental Oxygen The use of an ACS for patients who require supplemental oxygen is highly problematic from a logistical point of view. Options to supply supplemental oxygen run from a home fill unit (10L/min maximum, less than $1,000) to deployable oxygen generation or liquid oxygen storage and distribution system (multiple patients, high technology, upwards of $480,000). Given the variables of cost, general availability, ease of use and sustainability, the most promising options for supplying supplemental oxygen would be either a bank of 10L/min home fill units or a rack of eight interconnected "H" oxygen cylinders, each supplying 7,000 liters of oxygen for a cost of approximately $13,000. Even this rack setup is severely limited, however, as the eight "H" cylinders could supply only 50 patients at 2 liters of oxygen per minute for 8 hours. This would necessitate three refills per 24-hour period and would require the rapid installation of a rudimentary gas distribution system. Support for ventilated patients would increase the rate of oxygen consumption significantly, further complicating this issue, and most likely would not be possible. Sources: Agency for Healthcare Research and Quality (AHRQ). Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency. Available at: https://www.ahrq.gov/research/altsites.htm. Accessed July 21, 2006. Anthony Rizzo, USAF, MC, SFS, Chief, Operations Division NORAD-USNORTHCOM/SG. Deployable Oxygen Solutions for FEMA briefing. Available at: https://www.ahrq.gov/research/altsites/alttool3.htm. (Appendix A). Accessed July 21, 2006.

Caches of supplies should be stored in a modular fashion in units supporting 50-100 patients, allowing an ACS to be set up in stages.

Experience with the FMS for victims of Hurricane Katrina demonstrated the need for wheelchairs, walkers, and canes in an ACS. Local or regional resources are not likely to be sufficient to deal with this requirement. Questions also were raised about the appropriateness of using cots in an ACS, which require staff members to bend over constantly and are inadequate for dealing with obese patients. This problem may be solved by purchasing oversized cots.

Expensive diagnostic and monitoring equipment (e.g., portable x-ray machines, ultrasounds, cardiac monitors), in most cases, will be beyond the scope of an ACS. Advances in point-of-care clinical laboratory testing, however, may allow some basic laboratory tests to be performed at an ACS.

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