Public Health Emergency Preparedness

Chapter 4. Staffing

For purposes of this report, we assume that current community standards of care will be maintained at a surge facility, even though this may not be possible due to current nursing and ancillary health-care provider work force shortages. To determine the staffing needed to maintain this standard of care, we first considered the skill sets that would be needed at a surge facility. We then examined State and Federal regulations for guidance on the staffing types and ratios that would match these skill sets. While these regulations offer guidance, they lack specificity. We therefore considered the staffing ratios currently used at Boston area community hospitals and skilled nursing facilities, as we expect the patients served at a surge facility will fall in this range of patient acuity and care needs. The sections below explore the skills that would be needed at a surge facility by staffing type, regulatory requirements for hospital staff, staff-patient ratios, numbers of staff needed (based on community hospital and skilled nursing facility staffing), and available sources of staff for a surge facility.

4.1 Skills Needed by Staff Type

It will be important to identify particular skills of each staff type that would be considered essential based on the type of patients hospitalized. For example, under Scenario 2 good infection control skills would be essential for all staff—not only for the nursing staff, but also for housekeeping, dietary, social services, laundry, etc. It would be necessary for those responsible for recruiting staff to identify the needs of the anticipated patients and the corresponding skills that would be required. Nursing departments frequently use a skills checklist during the hiring process to identify the potential employee's level of expertise in various patient care areas. New or potential hires are asked to rate their experience with particular patient types or procedures as proficient (2 or more years experience), moderate  (1-2 years experience), limited (intermittent experience), or no practice (theory only). Such a checklist would be useful in a surge situation to identify skill levels and as an aid to assigning staff to particular units or areas to ensure a good mix of skill levels  For example, many nurses do not know (or are not experienced in) how to insert an intravenous line. When recruiting or selecting nursing staff, it would be helpful to have at least some, not necessarily all, of the nurses capable of performing this task. 

Many of the tasks that nurses perform can be done by other types of staff—both inside and outside the nursing department. Some tasks would require some training, while others would require little or no training. In a surge situation, it would make sense to reassign as many RN tasks as possible and safe to others capable of handling them. The goal would be to maximize use of the RNs' specialized assessment and judgment skills, while using ancillary staff to provide hands-on care, treatment, and patient information gathering. The table in Appendix C illustrates the process that could be employed to identify RN skills that could be delegated to other staff types. Only those skills potentially applicable for other staff types are included. Knowledge of the training curriculum used with these other staff types would be essential. Tasks could be coded as "able" for those skills/tasks that the various staff types would be expected to know, "potential" for tasks that they could do depending on training and experience and "with training" for tasks that they could be trained to do. For example, nurse aides are taught how to take vital signs (temperature, pulse, respirations, and blood pressure) and could likely be trained to do certain dressings and treatments. 

This information, used in combination with the suggested staffing types and numbers may provide alternative approaches when the identified staffing types and numbers are not available. 

Recommendation: Skilled nursing facility staff levels/ratios may be acceptable for stable surge facility patients. Nurse-extenders could also have expanded roles.

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4.2  Federal and State Regulations on Staffing

We conducted a preliminary review of Federal and State regulations:

1. To understand current staffing requirements.
2. To identify regulations for which some type of waiver in a declared emergency would be required.

After discussion with the Massachusetts Department of Public Health, we understand that at least some of these regulations could be waived or relaxed in a major mass casualty incident and thus do not consider these regulations to constitute absolute requirements. The same may not be equally true in other States, in which emergency waiver authority may not be as extensive as it is in Massachusetts. 

We examined regulations governing hospital staffing and nursing facility staffing, as the medically stable patients relocated to a surge facility in an emergency are likely to have a acuity levels and needs somewhere between those of patients at a skilled nursing facility and a community hospital.

4.2.1 Federal Regulations on Staffing

Hospital Staffing

The Code of Federal Regulations conditions of participation for hospitals participating in the Medicare program, contains regulations covering various services offered. Based on our assumed patient population and their needs, we reviewed the regulations on staffing. Most regulations are not specific, requiring only that staff is qualified and sufficient to meet the needs of the patients. Requirements for the following services were reviewed:³²

• Medical Staff. The medical staff must be composed of doctors of medicine or osteopathy.
• Nursing Services. "The director of nursing services must be a licensed registered nurse. He or she is responsible for... determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.  There must be adequate numbers of registered nurses, licensed nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient."
• Medical Records. "Must be appropriate to the scope and complexity of services performed. The hospital must employ adequate personnel to ensure prompt completion, filing and retrieval of records."
• Pharmaceutical Services. "A full-time, part-time, or consulting pharmacist must be responsible for... all the activities of the pharmacy service. The pharmaceutical service must have an adequate number of personnel to ensure quality pharmaceutical services, including emergency services."
• Radiology Services. A qualified full-time, part-time, or consulting radiologist must supervise the ionizing radiology services. A radiologist is a doctor of medicine or osteopathy who is qualified by education and experience in radiology.
• Laboratory Services. The hospital must maintain or have available (either directly or through a contractual agreement) adequate laboratory services to meet the needs of its patients. 
• Food and Dietetic Services. The hospital must have a full-time employee who serves as director of the food and dietetic service and there must be a qualified dietitian full-time, part-time, or on a consultant basis and administrative and technical personnel competent in their respective duties.

Long-term Care Staffing

Federal requirements for staffing in long-term care facilities are similar to those for hospitals with additional provisions for ensuring that services not available on site are available contractually, e.g., laboratory, radiology, and pharmacy.

• Nursing. Long-term care regulations are specific that there must be a registered nurse in the facility for 8 consecutive hours 7 days a week and that there must be "sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident..."³³
• Dietary. The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis. If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietitian.³⁴ A qualified dietitian is qualified based on either registration by the Commission on Dietetic Registration of the American Dietetic Association or education, training, or experience in identification of dietary needs and planning and implementation of dietary programs.³⁵ Federal regulations now allow the use of paid feeding assistants provided the individual has completed a State approved training course and works under the supervision of a registered nurse or licensed practical nurse.³⁶
• Social Services. A facility with more than 120 beds must employ a qualified social worker full-time. A qualified social worker would have a bachelor's degree in social work or in a human services field, including but not limited to sociology, special education, rehabilitation counseling and psychology, and 1 year of supervised social work experience in a health-care setting working directly with individuals.³⁷

4.2.2 Massachusetts Regulations on Hospital and Long-term Care Facility Nurse Staffing

Hospital Nurse Staffing

Like the Federal regulations, Massachusetts regulations on nursing coverage are not specific to the number of hours required per patient per day or to any specific ratio of nurses to patients. They require only that there be a sufficient number of registered nurses on duty at all times to plan, supervise, evaluate, and perform nursing care. The regulations do state that each hospital shall establish a nursing service under the direction of a registered nurse, currently registered by the Board of Registration, who holds a baccalaureate degree in nursing and who has had at least 4 years experience in nursing practice, at least two of which were in an administrative or a supervisory capacity.³⁸ There must be adequate supervisory coverage for all nursing units during each shift, and units must be staffed with at least one registered nurse at all times. The only exception to the required unit coverage allows a licensed practical nurse to cover a unit provided it adjoins a unit covered by a registered nurse such that the registered nurse can be readily available to go from one nursing unit to another when skilled nursing services are needed.³⁹

The only provision in the regulations concerning numbers of nursing staff assigned by unit states that, "The number of registered nurses, licensed practical nurses, and unlicensed nursing personnel assigned to each nursing unit shall be consistent with the types of nursing care needed by the patients and the capabilities of the staff."⁴⁰

Long-term Regulations on Nurse Staffing

Similar to Massachusetts' hospital regulations, the regulations for long-term care facilities require "appropriate, adequate, and sufficient nursing services to meet the needs of patients or residents and to assure that preventive measures, treatments, medications, diets, restorative services, activities, and related services are carried out, recorded, and reviewed."⁴¹ Long-term care facility regulations are less than hospital regulations in that, although the director of nursing and supervisor must be registered nurses, charge nurses may be registered nurses or licensed practical nurses.  Regulations are more specific regarding staffing ratios. Facilities are identified by level (I-IV) with staffing ratios specific to the level. Level I facilities (Intensive Nursing and Rehab Care Facility) must provide 2.6 hours of nursing care per day; at least 0.6 hours shall be provided by licensed nursing personnel and 2.0 hours by ancillary nursing personnel. Level II facilities (Skilled Nursing Care Facilities) must provide 2.0 hours of nursing care per patient per day; at least 0.6 hours must be provided by licensed nursing personnel and 1.4 hours by ancillary nursing personnel. Level III (Supportive Nursing Care Facilities) and Level IV (Resident Care Facilities) are not applicable for the population identified for this study, as skilled nursing is required only periodically. 

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4.3 Staff Types Needed in a Surge Situation

Clinical experts offered guidance about the staff types needed for a surge facility, which are grouped here in four major categories:

• Physicians and physician extenders—includes nurse practitioners and physician assistants, medics/paramedics.
• Nursing—licensed nurses (RNs and LPNs) and nurse aides or patient care assistants/technicians, medics/paramedics.
• Allied health—laboratory, x-ray, pharmacy, therapy and medical records.
• All others—laundry, housekeeping, food service, central supply, security, etc.

Staff types are also ranked according to how critically they would be needed for the two scenarios. Three ranks were identified:

1. Staff needed on site on a 24 hours a day, 7 days a week (O).
2. Staff needed on site for some portion of the day and available on an on-call basis when not on site (D).
3. Staff needed to be available only occasionally either on-site or for telephone consultation (A).

For example, staff responsible for direct patient care is ranked as being needed on a 24-hour basis, while those providing specialized services might only be available as needed or on call. In a surge situation, we would expect that one staff person might assume multiple roles, at least on for a limited time. If the newly opened hospital were to remain in service for longer than some predetermined length of time, this assumption of multiple roles would have to be replaced by recruiting appropriately qualified individuals. In addition, patients' conditions could deteriorate while at the surge facility, requiring their return to the tertiary care hospital (since the surge facility would not house an ICU, OR, or ED.) Also, during off-hours, those in the building may be required to cover for departments other than their own.  For example, on the night shift, the person in charge of security may be responsible for delivering drugs and supplies to the nursing units.

Selection of staff types and availability of ranks are based on discussions with experts in the fields of emergency medicine and a review of available emergency and disaster management plans. Table 4 illustrates the staff types proposed and their availability.

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4.4 Typical Staffing Ratios at Community Hospitals and Skilled Nursing Facilities

In an effort to determine the numbers of staff that would be needed to care for the patient population identified while maintaining community standards of care, we examined staffing levels in Boston area community hospitals of 200-300 beds and at local long-term care facilities, to better understand the staffing currently viewed as acceptable. The two functioning community hospitals that we used as community models are licensed for 150 and 236 beds. The long-term care facility we used as a model has a sub-acute or transitional care unit (29 beds) along with several long-term units (92 beds). The sub-acute or transitional care units were included because they care for patients who may be much like those served by a surge facility under Scenario 1, i.e., needing short-term skilled nursing and rehabilitation services until ready to return home. This section of the report describes the staffing of such facilities, which constitutes an acceptable range for staffing a surge facility

4.4.1 Physician Staffing

Physician staffing in community hospitals is typically variable, with each patient having one attending physician assigned to their care and each patient usually being seen at least once a day. Most community hospitals have at least one physician in house 24 hours a day, 7 days a week as well as an internist functioning as a hospitalist or house doctor who is available for admissions and in-house emergencies or urgencies. Community hospitals typically use non-physician practitioners (NP, PA) to perform some of the routine rounding on stable patients. The surge facility will require at least one physician in house 24 hours a day and a variable number during working hours depending on census, acuity, and the availability of non-physician practitioners. 

Patients in long-term care facilities are seen by their physician on admission and as needed but usually at least one time per week and even more commonly every second or third day.  There are no physicians in the building on a 24-hour basis. Nurses contact physicians with questions regarding their patients and physicians either come to the facility to examine and treat the patient, have the patient transferred to a hospital emergency room, or give the nurse orders over the phone. Nurse practitioners, under the supervision of a physician, may also see patients. Regulations regarding the scope of nurse practitioner practice are specific to each State. We assume that most patient needs at a surge facility would similarly be met by nurses (RNs and advance practice nurses) and that on-site physician presence would be minimal, although probably greater than at a nursing facility.

4.4.2 Nurse Staffing

We examined staffing at current sub-acute/transitional units and long-term care units to better understand the range of staffing possible and because some staff types apply to the entire facility, not just the sub-acute/transitional care unit (e.g., housekeeping, laundry, dietary). Staffing may be estimated using ratios of nurses or nurse aides to patients or using hours per patient per day. These ratios may apply to all nursing staff, for nurses by licensure type (RN, LPN, nurse aide, or patient care assistant) or by licensed vs. non-licensed staff.  Hospitals consider staffing in terms of "nurses" per patient, not distinguishing between registered nurses and licensed practical nurses. The two community hospitals we used as models apply the following nurse to patient ratios for medical/surgical units:

• Model Hospital A (150 beds) reported ratios of 1:5 on all shifts for general surgical, telemetry, and medical/surgical units (all days including weekends and holidays with an occasional one additional patient on the night shift).
• Model Hospital B (236 beds) reported 1:4-5 on days and evenings, 1:7 on nights with 1-2 personal care attendants (PCA) (nurse aides) per shift per unit.  Units range in size from 20-36 beds. Staffing is the same on weekdays, weekends, and holidays.

In contrast, a local long-term care (LTC) facility reported the following ratios for nurses and nurse aides:

• Sub acute/transitional care unit. 1 nurse: 14-15 patients on all shifts, all days of the week. Nurse aide ratios are 1 aide for 5-6 patients on day shift, 1: 7-8 on evening shift, and 1:14-15 on night shift.
• Long-term care units. 1 nurse for 18-19 patients on the day shift and 1 nurse for 36-37 patients on the evening and night shifts. Nurse aide ratios on long-term care units ranged from 1:7-9 on day and evening shifts to 1:18-19 on night shifts.

Table 5 summarizes staffing for these facilities we examined; these staffing estimates could be used to create ranges on which staffing for a surge facility might be based.

4.4.3 Allied Health Staffing

Hospital Allied Health Staffing

Allied health staffing at the two model community hospitals provides limited guidance as both of these facilities are teaching hospitals with intensive care units, emergency departments, surgical services, and maternity, nursery, and pediatric units—none of which the surge hospital is envisioned as providing. Descriptions of allied health staffing in the long-term care facility may provide a more realistic picture of staffing needs in the surge situation.

Long-term Care Allied Health Staffing

A review of staffing for allied health positions at long-term care (LTC) facilities revealed that many services are contracted out (pharmacy, laboratory, x-ray, respiratory therapy) while others that are used infrequently, e.g., speech therapy, may be shared with several other facilities. Modifications to usual staffing responsibilities were made because of the higher demand for services that nursing facility vendors were not able to meet. For example, nurse aides at the facility we contacted have been taught how to take EKGs and draw blood because the laboratories that service the facility do not come to draw bloods as frequently as is needed on the sub-acute/transitional care unit. The use of contracted services, common in the LTC environment, and noted earlier as a reasonable approach in a surge situation, makes a review of LTC staffing and services a fairly reliable model for what will likely be required in the surge situation. Table 6 summarizes allied health staff use in the LTC facility.

4.4.4 All Other Types of Staff

Other Hospital Staff

As noted in the previous section, because the model community hospitals used in this study provided many more services (with associated staff types and numbers) than anticipated for the surge hospital, we have opted to rely more heavily on staffing information from the nursing facility setting as it is likely more applicable to the surge situation under study. We anticipate no ICU, OR, or ED, for example, leaving surge facility patients who resemble skilled nursing facility patients rather than community hospital patients. Table 6 provides information on other staff types used by the nursing facility we reviewed, terms of hours per day.

Other Nursing Facility Staff

Certain staff types are not used in the particular nursing facility setting we contacted, or alternatively are contracted out (e.g., Biomedical engineering, morgue workers). Table 7 illustrates the staffing levels observed for all other types of staff in nursing facilities we contacted. The long-term care facility includes a 29-bed sub acute/transitional care unit and 92 long-terms care beds. Allied health staff is used without assignment to any particular unit, thus no differentiation is made between sub acute/transitional care and long-term care.

4.4.5 Numbers of Staff Needed in a Surge Hospital Situation

To estimate the numbers of staff needed under the two scenarios, we relied on information provided by two community hospital and nursing facility staff, and the opinions of experts in the field of hospital administration, medicine, health-care human resources, and emergency management. In an emergency situation, staffing levels would be based on the judgment of those in charge and the number of available qualified people. Staffing would probably not be as high as is currently reported by the 'model' community hospitals. The nurse staffing levels reported at nursing facilities may be more useful, to illustrate the numbers of patients that can be cared for with adequate supplemental ancillary help (i.e., nurse aides). The next table shows a range of staffing levels by staff type, using community hospital levels as an ideal and nursing facility staffing as a suggested minimum. 

For purposes of this report, we're assuming that the patients under the two mass casualty scenarios are equally acute and that staffing levels will vary depending on:

 

1. The expertise that will be required to care for the two groups.
2. A presumption that the institution of precaution procedures in the infectious population (Scenario 2) would necessitate higher direct care staffing levels because of the additional time required to care for patients on precautions.
3. The availability of ancillary staff (e.g., EKG technician, phlebotomist), which will affect the number of nursing staff required. 

Fewer ancillary staff would necessitate more nursing staff to accomplish tasks normally the responsibility of ancillary staff. We did not assume that the Federal Emergency Management Agency (FEMA) would deploy any Disaster Medical Assistance Teams (DMATs) to assist in staffing the surge facility, although that may be a likely scenario based on historical precedent, if the mass casualty incident is localized to one geographic area or region. 

Table 8 contains a suggested range of staff needed for each scenario.  Estimates of staffing needs are included for those types identified as needed on a daily basis for each scenario.

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4.5 Staff Organization

In a mass casualty situation in which a shuttered hospital is reopened, staff will be functioning in an unfamiliar environment and likely working with strangers. Staff confusion and stress surrounding work and personal situations will undoubtedly be high. Using a standardized organizational system that clarifies individual and team responsibilities, chain of command, and communication pathways will facilitate maximum staff efficiency in a difficult situation.

It is not clear who will 'own' the surge facility or will have ultimate authority and responsibility for it. Several alternatives are possible and should be considered by State planners. At least two possibilities are:

 

1. Temporarily transferring control/responsibility of the surge facility to one of the major health systems or hospitals in the area
2. Conferring temporary control/responsibility on a State, county or city health department. 

If alternative (b) is considered, it would be highly advisable to enlist the assistance of local hospital leaders and administrators with experience in running a hospital. In either case, a command and control structure will need to be implemented in advance so that all parties are prepared to act if a mass casualty occurs.

Hospital Emergency Incident Command System (HEICS)

The Hospital Emergency Incident Command System (HEICS) is "an emergency management system which employs a logical management structure, defined responsibilities, clear reporting channels, and a common nomenclature to help unify hospitals with other emergency responders."⁴² It was released as a generic disaster response plan modeled after the FIRESCOPE management system, which was developed in the early 1970s out of a partnership between Federal, State, and local fire agencies. HEICS has been distributed throughout the United States and Canada and across the globe. HEICS is "becoming a standard for health-care disaster response and offers the following features:

• Predictable chain of command.
• Flexible organizational chart allows flexible response to specific emergencies.
• Prioritized response checklists.
• Accountability of position function.
• Improved documentation for improved accountability and cost recovery.
• Common language to promote communication and facilitate outside assistance.
• Generic approach to command and control that is designed to function with positions instead of relying on key individuals.
• Cost effective emergency planning within health-care organizations."⁴³

HEICS features a flexible management organizational chart (Appendix B), which allows for a customized hospital response to the crisis at hand. The system may be activated on a limited basis and expanded as more personnel become available or are required. In early phases, staff may assume more than one role, and as more staff becomes available, these multiple roles are handed off to other qualified staff. The organizational chart consists of four major area section chiefs reporting to the incident commander. Each of the section chiefs (logistics, planning, finance, and operations) has a number of supporting staff. Each position has an accompanying Job Action Sheet describing whom the person reports to, the mission, and immediate, intermediate, and extended tasks. This organizational structure provides a platform for common terminology to enhance communication and improve documentation. HEICS materials are offered without charge to interested hospitals. 

In a surge hospital situation, the HEICS system provides a standardized organizational plan that may be familiar to recruited staff. Based on a disaster response, many of the tasks listed on job actions sheets are not appropriate, however, because of the structure provided it appears to be an appropriate tool to help organize staff to function in an unfamiliar and confusing environment. The job action sheets outline job responsibilities, identify who reports to whom, and prioritizes tasks.

Key Positions and Responsibilities

HEICS specifies a variety of roles and responsibilities for incident command, many of which are applicable for the situation of reopening a shuttered hospital for surge capacity expansion.

• Incident Commander. The incident commander assumes overall leadership. He/she is assisted by several advisors/coordinators who deal with the news media, other agencies, security and safety, and physician assignment. The four major section chiefs are assigned by the incident commander. Each chief designates directors and unit leaders to sub-functions. Figure 1 illustrates a typical organizational chart adapted for this particular surge hospital situation, (i.e., no emergency department, no critical care, no surgical service, no maternity/nursery, no pediatrics).
• Logistics Section Chief. The logistics section chief focuses on operations associated with the physical environment and ensuring adequate levels of food, shelter and supplies. He/she is responsible for power; utilities; sanitation; water; trash; communication systems (telephone, intercom, paging system); transportation of supplies, patients, and staff; and meals for patients and staff.
• Planning Section Chief. The planning section is responsible for compiling information about the current situation and developing long-range planning. He/she is to keep staff up to date regarding the current disaster situation inside the hospital and in the surrounding area, maintain an inventory of available staff and volunteers, organize and coordinate medical and nursing staff, track patient census by location and status, and anticipate needs.
• Finance Section Chief. The finance section is to monitor the utilization of financial assets. He/she is responsible for the accounting and documentation of all resource expenditures, providing cost analysis data, maintaining personnel time records, negotiating and/or issuing contracts to purchase or obtain resources and receiving and investigating all accident/incident claims resulting from an employee action on hospital property.
• Operations Section Chief. This is a large section covering the overall delivery of medical care, ancillary services, and staff support. This group is responsible for triage; patient admissions and discharges; planning for short- and long-term staffing and medical resource needs; morgue services; overseeing laboratory, radiology, and pharmacy services; and the social and psychological needs of the staff, patients, and families. This group would also be responsible for sheltering and feeding of staff and volunteer dependents.

Recommendation: Planners should establish an incident command structure, familiar to all who will be called upon to serve.

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4.6 Staffing Based on the Modular Emergency Medical System Acute Center

The discussion above describes the numbers and types of staff needed in a surge hospital situation based on information provided by community hospital and nursing facility staff and the opinions of experts in the field of hospital administration, medicine, health care, human resources, and emergency management. A range of needed staffing numbers was determined by using the community hospital ratios as an ideal and the nursing facility staffing as a suggested minimum. Another model for determining staffing numbers for a surge facility is that provided under the Modular Emergency Medical System (MEMS), which is based on the Incident Command System described in the previous section.

The MEMS was designed as a template to assist communities to rapidly increase their medical capacity to deal with casualties from a large-scale biological weapons incident.⁴⁴ The concept came out of a series of workshops conducted in 1998 by the Domestic Preparedness Biological Weapons Improved Response Program (BW IPP) under the auspices of the Department of Defense Domestic Preparedness Program. MEMS focuses on managing an incident in which the number of casualties significantly overwhelms a community's existing medical capabilities and involves an outbreak of a disease. Management of the system is based on the Incident Command System, which is commonly used by the emergency response community. The system establishes a framework for expanding patient care through the use of two modules—Neighborhood Emergency Help Centers (NEHCs) and Acute Care Centers ACCs)—which may be linked to an area hospital or to a community emergency management office. NEHCs are temporary outpatient care centers that deal with noncritical and psychosomatic complaints, keeping these patients away from hospital emergency departments. NEHCs provide basic medical evaluation and limited treatment but are seen primarily as distributors of prophylactic medications and self-help information. ACCs are designed to provide inpatient treatment for patients with a bioterrorism-related illness. ACCs provide basic agent-specific and ongoing support care therapy (i.e., antibiotic therapy, hydration, bronchodilators, and pain management), while hospitals focus on the treatment of critically ill patients.⁴⁵

The remainder of this section focuses on the ACC and its applicability to this project.

The maximum capacity of an ACC is 1,000 beds, organized in increments of 250 bed pods and 50-bed nursing subunits. It is modeled after the Incident Command System with the following main components along with their respective responsibilities.

• ACC Administrator—responsible for command and control functions of the entire center.
• Communications Section—coordinate with the area's Emergency Operations Center, maintains an activity log that documents all activities including bed status reports, operational problems and similar items.
• Security/Safety Section—responsible for assigning security staff, identification procedures, and environmental health and sanitation.
• Community Liaison Section—responsible for responding to community concerns, preparing information for the media and outside agencies.
• Functional Units
  • Records/Planning Section—responsible for all the paperwork generated within the ACC, maintaining staff logs, patient registration, treatment and disposition records. A Patient Care Coordinator, within this section, maintains a control register identifying patients admitted to the ACC. The PCC's role is similar to a nursing supervisor as he/she is aware of nursing staff and bed availability. He/she directs admitted patients to the appropriate unit. If staffing permits, a Labor Pool Leader may be added to assist with staff assignments.
  • Medical Operations Section—consists of the nursing subunits, pharmacy services, family services (optional) and temporary morgue.
  • Supply Logistics Section—responsible for obtaining and maintaining the facility, equipment and supplies as well has contracts for services, supplies and equipment. Section includes the Materials/Supply, Food Service, Resource Transportation, Housekeeping and Maintenance functional units.
  • Finance Section—if needed and if staffing permits, a finance director is assigned responsibility for providing monies for procuring special equipment or supplies, contracting with vendors, timekeeping, cost analysis, collection of insurance information from patients and any other financial aspects of the incident.

The ACC is physically set up so that one 250-bed pod, composed of 5 50-bed nursing subunits is completed before beginning the physical setup of the next 250-bed pod. Patients are admitted when the first 50-bed nursing subunit is completely set up and staffed. When the nursing subunit is at 70-80 percent capacity, another subunit is opened. When the first 250 beds reach 50-60 percent capacity the next pod should be ready for receipt of patients. Suggested staffing per 12-hour shift for a 50-bed subunit is as follows:

1 physician 6 RNs or a mix of RNs and LPNs 2 medical clerks/unit secretaries 1 case manager 2 housekeepers

1 physician's assistant or nurse practitioner 4 nursing assistants/nursing support technicians 1 respiratory therapist 1 social worker 2 patient transporters

The minimum number of staff providing direct patient care per 12-hour shift is 12, which includes the physician, the physician extenders, nurses and nursing assistants. If staffing permits, each nursing subunit should have a unit leader (either physician or RN). Staffing in non-direct-care areas for the maximum capacity ACC is estimated at approximately 50 with some variability depending on the number of, for example, security guards needed, and available volunteers.⁴⁶ ACC developers caution that precise numbers of each type of staff will be dependent on the type of disaster and resulting illnesses. The ACC report recommends staffing for other departments as shown in Table 9.

The ACC suggested staffing numbers are fairly close to what we had proposed based on expert opinion, taking into consideration the different bed configurations—the 50-bed ACC subunit as compared to the FTE's for the 200-300 bed surge hospital. Our staffing estimates include additional staff types designated as needed depending on patients needs, e.g., an infectious disease specialist, and a radiologist as well as some staff types to cover operations that the ACC does not include in its scope of work, for example, food preparation.

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