March 28 2012 10 am Noon

March 28, 2012 (10 am – Noon)

Purpose To introduce local Health Officers, Public Health Directors, LEMSA Administrator, and LEMSA Medical Director and other staff to the Altered Standard of Care Pre-Planning Guide.

Altered Standard of Care Pre-Planning Guide WHAT IS IT?

Altered Standard of Care Pre-Planning Guide The Altered Standard of Care Pre-Planning Guide is designed as a tool to assist local emergency planners with modifying the current EMS delivery system in response to a catastrophic incident.

Altered Standard of Care Pre-Planning Guide • Developed with HPP Year 8 grant funds • Based upon best practices and source documents including: – Santa Clara County Altered Standards Tool, – San Francisco County Altered EMS Protocols, – CDC and NHTSA guidelines

Altered Standard of Care Pre-Planning Guide • Designed as an all-hazards tool for any type of disaster, including: – – Severe flooding Earthquakes Pandemic Outbreak Other catastrophic incidents

EXERCISE SCENARIO Pandemic Outbreak (Week 6) *Worldwide, National, and State data is based upon actual response information from the H 1 N 1 outbreak

WORLD WIDE IMPACT

Worldwide Impact • In early February, confirmed reports from the U. S. Centers for Disease Control revealed a novel strain of the influenza virus.

Worldwide Impact The World Health Organization declared a global pandemic alert as more than 214 countries and overseas territories or communities worldwide have reported laboratory confirmed cases of the novel virus.

Worldwide Impact As of last week, most developed countries reported widespread infection, including at least 18, 449 deaths.

Worldwide Impact Community Mitigation measures include school closures, cancellation of mass gatherings, isolation and quarantine, and other social distancing measures.

Worldwide Impact • Health care systems experiencing significant stress; reporting regional surges in hospital, emergency department, and outpatient visits. • Some countries reporting hospital bed, equipment and medication shortages.

NATIONAL IMPACT

National Impact CDC is reporting that the most impacted populations include: – Children and young adults – Persons with underlying chronic medical conditions (e. g. chronic lung disease, heart disease, immunosuppression, neurological and neurodevelopment diseases) – Pregnant women – Indigenous populations – Possible risk groups: Obesity (Body Mass Index ≥ 35), Extreme/Morbid obesity (Body Mass Index ≥ 40)

National Impact Oseltamivir (Tamiflu) and zanamivir are the only FDA-approved antiviral drugs effective against this virus.

Presidential Proclamation President Obama has signed a proclamation declaring this influenza pandemic a National Emergency to facilitate our ability to respond to the pandemic by enabling – if warranted – the waiver of certain statutory Federal requirements for medical treatment facilities.

Presidential Proclamation In particular, this proclamation is aimed at providing HHS the ability to waive legal requirements that could otherwise limit the ability of our nation’s health care system to respond to the surge of patients with the novel influenza virus.

HHS has approved: • Hospitals request to set up an alternative screening location for patients away from the hospital’s main campus (requiring waiver of sanctions for certain directions, relocations or transfers under EMTALA). • Hospitals request to facilitate transfer of patients from ERs and inpatient wards between hospitals (requiring waiver of sanctions under EMTALA regulations).

HHS has approved: • Critical Access Hospitals requesting waiver of 42 CFR 485. 620, which requires a 25 -bed limit and average patient stays less than 96 hours. • Skilled Nursing Facilities requesting a waiver of 42 CFR 483. 5, which requires CMS approval prior to increasing the number of the facility’s certified beds.

State Impact

State Impact Gubernatorial Declaration NOW, THEREFORE, I, EDMUND G. BROWN JR. , Governor of the State of California, in accordance with the authority vested in me by the California Constitution and the California Emergency Services Act, and in particular California Government Code sections 8558(b) and 8625, find that conditions of extreme peril to the safety of person and property exists within the State of California and HEREBY PROCLAIM A STATE OF EMERGENCY in California.

State Impact Gubernatorial Declaration (Cont. ) IT IS HEREBY ORDERED that all agencies and departments of state government utilize and employ state personnel, equipment, and facilities as necessary to assist the State Department of Public Health and the Emergency Medical Services Authority in immediately performing any and all activities designed to prevent or alleviate illness and death due to the emergency, consistent with the State Emergency Plan as coordinated by the California Emergency Management Agency.

LOCAL IMPACT

Local Impact Butte: Both Oroville Hospital and Feather River Hospital reporting >100% capacity. Ambulance turn-around times greatly delayed (60 - 90 minutes).

Local Impact Colusa: Colusa Regional Medical Center has converted the Physical therapy and Outpatient areas into additional inpatient beds, and also reports significant delays in ambulance response.

Local Impact • Nevada: Tahoe Forest and Sierra Nevada Memorial Hospital are both using surge tents and have created surge beds within their facilities. Dispatch is complaining about lack of available ambulances and lack of mutualaid resources.

Local Impact • Placer: All three hospitals have implemented internal surge plans. Kaiser and Sutter Roseville have been in discussions with Public Health to convert a portion of the Maidu Center into an ACS for additional inpatient beds.

Local Impact • Shasta: Fire personnel in Redding reported an incident in which they performed CPR on-scene for 29 minutes before ambulance arrival. 5 ambulances are currently being held at Shasta Regional Medical Center with patients on their gurneys, 2 of these have been waiting more than 90 minutes.

Local Impact • Siskiyou: Mercy Medical Center Mt, Shasta and Fairchild Medical Center are reporting zero inpatient beds, and are holding multiple admissions in the ED. 911 callers are complaining of being put on hold, and ambulances have delayed turnaround times.

Local Impact • Sutter: Fremont Medical Center has a full census, and is reported no available beds. Bi-county ambulance has staffed two additional units, and are complaining about the ED status and turnaround times at Rideout.

Local Impact • Tehama: Due to the recent MCI at the Red Bluff Airport, St Elizabeth Hospital has been dealing with several trauma patients, and has no inpatient beds available. Fire personnel have been unavailable to assist on medical calls due to the MCI and fire.

Local Impact • Yolo: The Yolo Emergency Communications Agency has implemented their Emergency Rule Stage 3 for suspending pre-arrival instructions to attempt to respond to the increased 911 medical-aid requests. Sutter Davis and Woodland Memorial have both activated internal surge plans, and are holding admits in the ED. AMR Yolo is reporting significant delays at the ERs, and are unable to staff additional units due to sick calls.

Local Impact Yuba: Rideout is reporting a significant staffing crisis due to sick call-ins. The HERT team has set up surge tents in the parking lot to receive/triage patients. However, ambulance personnel are reporting that there are no nurses staffing the triage area, and there are three ambulances waiting outside for more than an hour.

S-SV EMS Agency • In response to overwhelming numbers of local requests from MHOACs, Public Health Departments, ambulances, and hospitals; S-SV has been in contact with EMSA and the RDMHSs in Region III and Region IV regarding ambulance mutual-aid, and no additional resources are available at this time.

S-SV EMS Agency • Since outside resources are unavailable, each operational area must determine how to continue to support the 911 system with the current local resources.

“How can the EMS System Continue to sustain this demand? ”

ALTERED STANDARD ORDERS FORM

Altered Standard Order Form

Public Access

Control Facility

EMS Providers

ASO Form Summary • It’s a tool…not a policy • Once reviewed, and signed by the MHOAC or EMS Agency Medical Director it becomes an Emergency Policy and Protocol EMERGENCY Policy and Protocol

System Changes • In response to this Pandemic Outbreak, the EMS Agency staff has met, and would like to present their proposal to the Health Officers to get feedback and consensus.

System Changes • We are going to review those proposals in two segments: – Public Access Changes, and – Field Protocol Changes • Following each segment, there will be a time for open discussion.

Prioritizing the Needs IMMEDIATE DELAYED MINOR DECEASED

Proposed Changes to the Public Access System • Public Access Number/ Website • Scheduled Transport Center • Altered 911/EMD triage

Scheduled Transport Center By establishing a Scheduled Transport Center the stress on the 911 system will be significantly decreased, and will allow dispatchers to manage a higher call volume and improve call turn-around times.

Scheduled Transport Center Activating this separate center will allow the Transport Center staff to explore all the alternatives for the transportation needs of the calling party.

Scheduled Transport Center The Scheduled Transport Center is designed to coordinate all medical transportation requests from all system access points including: • • • hospitals, health facilities, Public Access Number, 911, and the field.

Scheduled Transport Center The Scheduled Transport Center responsibilities include: • Augmenting medical transportation with alternative vehicles: buses, taxis, etc. • Developing and implementing a medical transportation scheduling process • Working with Control Facilities to coordinate the destinations of all transport resources including those to possible Alternate Care Sites, clinics, etc.

Scheduled Transport Center For Ambulatory Patients YES NO Does the patient have their own vehicle? YES Direct the patient to use this transportation resource to seek medical attention NO Does the patient have friends/family that can transport them? YES NO Does the patient have access to public transportation? Schedule transport service (taxi, bus, or BLS transport)

Scheduled Transport Center For Non-Ambulatory Patients NO Is patient able to sit in a wheelchair Schedule BLS transport YES Schedule wheelchair transport

Scheduled Transport Center Two way radio communication between the: • Public Access Number • 911

PUBLIC ACCESS NUMBER

Public Access Number Creating a Public Access Number would greatly relieve the stress on the 911 system by referring the public to the appropriate resources without having to call 911 and utilize emergency responders unnecessarily.

Public Access Number In July 2000, the Federal Communications Commission (FCC) reserved the 211 dialing code for community information and referral services. The FCC intended the 211 code as an easy-toremember and universally recognizable number that would enable a critical connection between individuals and families in need and the appropriate community-based organizations and government agencies.

Public Access Number 211 as an option. The 211 center’s referral specialists: • interview callers, • access databases of resources available from private and public health and human service agencies, • match the callers’ needs to available resources, and • link or refer them directly to an agency or organization that can help.

Public Access Number During a disaster or emergency activation, calltakers for the Public Access Number should be trained to triage calls in a similar fashion as 911 call-takers. Consideration should be given to staffing the call center with Registered Nurses.

Public Access ALGORITHM 211 or Other Public Access Number Call Taker Obtain: • Incident Location • Call back number • Patient age • Level of Consciousness • Status of breathing • Chief Complaint

Public Access Number If a call comes into the Public Access Number that is a medical emergency, the call taker will Instruct the caller to “Hang up and call 911”

Public Access Algorithm YES NO Caller instructed to call 911 Medical Emergency? Provide Paramedic Response At home care Assess the level of medical need Higher level of care No medical need

At Home Care If it is determined that the caller has only minor medical care needs, they may be: • Given self care or family care instructions • Directed to sources of health information on the internet

At Home Care Examples of medical web support include: • • Web. MD. com CDC. Gov (Centers for Disease Control) Bepreparedcalifornia. ca. gov (CDPH), and Local Public Health Department websites

Higher Level of Care If it is determined that the caller needs to be seen by a medical practitioner they should be assessed for their ability to obtain necessary transportation. If the patient is unable to transport themselves or have family transport them to their personal physician, they should be transferred to the Scheduled Call Center.

No Medical Need If it is determined that the caller has no medical need, they may be: • Transferred to other social or public service call center, • Referred to other public information websites, • Referred to appropriate agency or county services.

ALTERED 911 EMD TRIAGE

Altered 911 EMD Triage • Discontinue Use of Emergency Medical Dispatching (EMD) Procedures • Discontinue Use of Pre-Arrival Instructions (PAI) • Implement Altered Triage Algorithm

Altered Triage This triage system will use the following categories to rank patients according to severity of need: Immediate: requires immediate medical intervention Delayed: needs medical attention, however, the response can be somewhat delayed. Minor: May be assisted with self-care or system resources other than 911 medical resources. Deceased: Needs non-medical community services. www. disasterdoug. com

Example of Altered Emergency Medical Dispatch Triage IMMEDIATE DELAYED MINOR DECEASED

Reporting Party Calls 911 Altered 911 EMD Algorithm 911 Call Center Paramedic (QRV) (if any delay in ALS response, a BLS unit is dispatched. ) 1. “Can pt. talk” 2. “Can pt. walk” unassisted NO YES ON SOB Acute ALOC Severe Bleeding Is it a Medical Emergency? YES 211 or (7 digit) Public Access Center Nurse Support Line Transport Center Check availability of: Ø Family/Friend Ø Public Transport Ø Dial-a-Ride Ø Taxi Ø Flu Bus? NO Medical Dispatch YES Schedule BLS Transport (pt call-back-confirm) www. disasterdoug. com

Public Access Summary • The county establishes a Public Access Number / Website. • The EMS Agency to work with providers to establish the Scheduled Transport Centers. • Implement Altered EMD Triage Protocols

ALTERED FIELD RESPONSE

Proposed Altered Field Response • Establishing Quick Response Vehicles (QRVs) • Change in Field Treatment Protocols (e. g. Treat-and. Release, Flu Cache) • Family/Patient Brochure • Just-in-Time Training

Quick Response Vehicles (QRVs)

Altered Field Response One solution may be to convert all ALS ambulances to BLS transport units, allowing us to place paramedics on Quick Response Vehicles (QRVs) This implementation will quickly expand available EMS resources. www. disasterdoug. com

Quick response vehicle (QRV) A Quick Response Vehicle or QRV is a vehicle that is staffed with at least one paramedic, and equipped with Advanced Life Support (ALS) equipment/supplies per local EMS Agency protocol. Such vehicles may include: Ambulance supervisor vehicles, shared resources from other emergency response agencies (fire, law, public works).

Altered Field Response Establishing QRVs will allow the paramedic to: • • Rapidly respond to 911 medical calls Provide ALS intervention as needed Transfer care to a BLS transport unit Clear the scene quickly to be able to respond to the next call www. disasterdoug. com

ALTERED FIELD TRIAGE

This triage system will use the following categories to rank patients based upon the severity of need. Immediate: requires immediate medical intervention Delayed: needs medical attention, however, the response can be somewhat delayed. Minor: May be assisted with self-care or system resources other than 911 medical resources. Deceased: Needs non-medical community services.

Example of Altered 911 Field Triage IMMEDIATE Treat and Transport DELAYED Treat and Release or Refer MINOR DECEASED Refer to Public Access Number Witnessed= Use First Round ACLS protocols Unwitnessed = refer to public access number

IMMEDIATE Patients presenting with life threatening conditions such as Acute MI, uncontrolled hemorrhage, severe shortness of breath, ALOC, etc. , will require treatment and transportation. www. disasterdoug. com

DELAYED Treat & Release or Refer Patients who respond to treatment on scene and afterward present with normal mental status, normal vital signs, and blood sugar will be given a patient brochure then released or referred. Options for referring patients may include: • The Public Access Number • Doctors office • Self-care www. disasterdoug. com

MINOR Upon arrival, if the patient does not present with lifethreatening conditions and does not require any EMS medical intervention, the patient would be given a Patient/Family Brochure and released on scene. www. disasterdoug. com

DECEASED Only if the patient had a witnessed cardiac arrest would the field responders intervene. The patient would be given first round ACLS care and if there is no response the patient would be determined dead in the field. Family would be given a patient brochure with the Public Access Number prior to clearing the scene. www. disasterdoug. com

Disaster Flu Cache The EMS Authority is considering approval of expanding the paramedic scope to include a Disaster Flu Cache. This cache may include flu treatment items such as: powdered Gatorade, Compazine suppositories, ibuprofen, etc. The S-SV Medical Director will continue to work with EMSA to determine if this is viable locally. www. disasterdoug. com

Proposed Altered EMS Response Family/Patient Brochure

Patient Brochure A Family/Patient Brochure should be designed to be distributed by EMS field personnel to patients and family members, including: • Family members of patients transported to the hospital • Patients treated and released on scene • Family of deceased patients • Patients with non-medical emergencies www. disasterdoug. com

Patient Brochure The Patient/ Family Brochure should contain: • information about the current situation, explaining the significant impact of the incident on the population • health threats, including current and projected effects • impact on the hospitals, describing limited resources and alternatives • EMS system changes, including changes in 911 protocols, as well as, what to expect when EMS responders arrive. www. disasterdoug. com

Patient Brochure The Patient/ Family Brochure should contain: • Information regarding the local Public Access Number for individuals with nonmedical emergencies • Information regarding Web-based health information such as the CDC website, local Public Health website, or other private sites such as Web. MD, etc. • Information regarding self-care such as at -home treatment for fever, flu symptoms, minor first-aid, etc. www. disasterdoug. com

JUST IN TIME TRAINING

Just-In-Time (JITT) Training After establishing Altered Standard Orders, responders must be provided with training including: • Rolls and responsibilities of EMS system providers, • Changes made to system protocols, and • Changes made to overall system design www. disasterdoug. com

Just-In-Time (JITT) Training Just-In-Time training would normally be conducted by supervisors or management at each provider agency. www. disasterdoug. com

Just-In-Time (JITT) Training Following any Just-In-Time Training, personnel should be provided an opportunity to: • Practice any new skills • Become familiar with any new equipment or tools • Review new or revised protocols www. disasterdoug. com

Practicing skills Practicing these skills will give the responder confidence when performing the skills. They will also be able to focus clearly on the task at hand.

Altered Field Response Summary • Establish Quick Response Vehicles (QRVs) • Alter Field Treatment Protocols (e. g. Treat-and. Release, Flu Cache) • Develop Patient/Family Brochure • Conduct Just-in-Time Training

Discussion

Wrap-Up • Online training tools: S-SV EMS Agency website at www. ssvems. com (under the HPP Current & Past Projects link) • AAR form / evaluation tool will be emailed to HPP Coordinators and then distributed • After Action Review: April 11 th HPP Project meeting (AAR and CAP)

Thank you for participating in the… Altered Standard of Care Pre-Planning Guide Exercise.