CREATING HOSPITAL SURGE CAPACITY: HOSPITAL

EMERGENCY SUPPORT FUNCTIONS AND REALLOCATION

OF RESOURCES

James L. PaturasYale New Haven Center for Emergency Preparedness

and Disaster Response

PRESENTATION OBJECTIVES

• Identify hospital functions critical to the maintenance and creation of surge capacity.

• Identify a potential method for closing gaps in medical surge demands.

• Identify a scalable method able to meet the demands of different types of incidents, adaptable to a variety of hospital sizes and configurations and consistent with CDC, ASPR, OSHA, CMS and Joint Commission standards and guidelines.

INTRODUCTION• Efforts to contain the economic burden of healthcare in the United

States have resulted in improved efficiency in hospital operations.

• In part, these efficiencies have been obtained by reducing bed capacity, running near maximum hospital capacity and adjusting resources including staffing ratios.

• Healthcare systems are now being charged with the task of increasing surge capacity to accommodate an influx of patients requiring triage and emergent care with little or no advance warning.

• The purpose of the Hospital Emergency Support Functions Projectis to identify staff capabilities and capacity available throughout the hospital that might be reassigned.

MANDATE

Hospitals have been tasked by federal funding mandates and accreditation bodies such as Joint numbers of patients by increasing their in-house bed surge capacity and identifying and establishing plans for additional “alternate care” sites and facilities

Pandemic Update V: A Report from Secretary Michael O. Leavitt,

March 17, 2008

“We don’t know if the H5N1 virus will spark the next pandemic, but we know that it’s just a matter of time before something does. There is simply no reason to believe that this century will be different than any past century. The difference now is that we better understand the threat, so we can increase our preparedness for a pandemic before it comes, in order to diminish its potential impact.”

• Planning for a surge of patients requiring medical care over a significant period of time– Alternate care facilities– Alternate triage sites– Adjusting standards of care– Allocation of medical services (i.e. ventilators,

hospital admissions)

• Planning to adequately staff to care for those patients admitted to our facilities– Alternate staffing hours– Use of volunteers – Reassigning staff within our facilities

Pandemic Preparedness Efforts Must Include…

BACKGROUND• Large scale disasters such as Hurricane Katrina have

drawn attention to the need for medical surge capacity.

• Ironically, it is this surge capacity that was eliminated in order to maximize efficiency.

• Within a hospital environment there are multiple departments with staff that are capable and competent to provide cross coverage to other areas of the hospital where their expertise may be utilized during a large scale surge incident.

CHALLENGES

• Surge needs associated with a pandemic are among the most challenging given that surge capacity would likely be depleted.

• No clear means have been established to determine staff suitably to care for this increased patient load.

• To date, plans nationwide have identified volunteerism and emergency credentialing systems as possible solutions to the staffing issue, however, no evidence has been shown that this approach will appropriately address the staffing needs in a large scale surge incident.

• Commonly, hospital disaster plans rely on external sources to maintain surge capabilities and create additional capacity.

• External mechanisms include alternate care sites, patient transfers, volunteerism and special disaster medical assistance teams.

CHALLENGES

ASSUMPTIONS

• A large scale surge incident including, but not limited to a pandemic event, will likely dramatically decrease the available workers in all departments of the hospital.

• During a large scale surge incident certain hospital services will be cancelled.

• Departments within the hospital may be combined to perform functions required by the particular surge incident that extends over multiple operational periods.

• Staff may be reassigned and function competently within their field of expertise with applicable just-in-time training.

• External assistance is unlikely to be available to hospitals in national catastrophes such as a pandemic.

• Employee illness, care for family members, and fear of contracting serious illness may drive hospital absenteeism rates to 40%¹ while need for services may increase well above the norm.

• Prudent hospital planning must include internal mechanisms for increasing capacity and maintaining capability.

ASSUMPTIONS

SCOPE• The Hospital Emergency Support Functions

Project will identify staff functions within all departments of the hospital and place those “functions” into categories that include clinical and non-clinical services.

• Within each department, staff functions will be identified and categorized in order to create an all-inclusive database.

• This database will be utilized during a large scale surge event to identify staff positions that may be reassigned to support the care of patients and maintain the hospital’s functional capability.

HESF CATEGORIES• The categories of Hospital Emergency Support Functions

will be as follows:– Clinical Services – Clinical Support– Emergency Family and Staff Support– Nutrition Services– Mortuary Services– Maintenance, Engineering and Energy– Resource Support and Materials Management– Communications and Information Technology– Public Information– Transportation– Safety– Security – Information and Planning– Finance– Human Resources

COMPATIBILITY MODELHOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF)

HESF Number

Function Name Description Lead Department(s) Supporting DepartmentsHICS

Section Chief(s)HICS

Branch Director(s)HICS

Unit Leader(s)

HESF #1 Clinical Services

Direct patient care: emergency medicine, critical care, emergency anesthesia/surgery; ambulatory and specialty care as resources allow Patient Care Services

Transportation, Social Services, Pastoral Care, Volunteer Services Operations Section Chief Medical Care Branch Director

Inpatient Unit Leader, Outpatient Unit Leader, Casualty Care Unit Leader

1.1 Ambulatory Services

…

1.25 Trauma/Burn

HESF #2 Clinical Support ServicesLaboratory, Radiology, Pharmacy, Respiratory Care, etc.

Laboratory, Radiology, Pharmacy

Radiation Therapy, Pathology, Medical Education, Anesthesiology, Volunteer Services Operations Section Chief Medical Care Branch Director

Clinical Support Services Unit Leader

2.1 Cath Lab

…

2.19 Wound Center

HESF #3 Emergency Family and Staff Support

Social work; Pastoral care; Critical Incident Stress Management; Interpreter Services; day care, elder care, mental health, temporary sheltering; distribution of essentail supplies

Pastoral Care, Social Services

Volunteer Services, Human Resources Logistics Section Chief Support Branch Director

Familcy Care Unit Leader, Employee Health & WB Unit Leader,

3.1 Care Management

…

3.12 Support Services

HESF #4 Nutrition ServicesCoordinate with materials management to secure bulk food, water and ice; mass feeding Food and Nutrition Services

Environmental Services, Volunteer Services

Logistics Section Chief, Operations Section Chief

Service Branch Director (Logs), Infrastructure Branch Director (Ops)

Staff Food & Water Unit Leader (Logs), Food Services Unit Leader (Ops)

4.1 Cafeteria

…

4.4 Kitchen

COMPATIBILITY MODELHOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF)

HESF Number Function Name Description Lead Department(s) Supporting Departments

HICSSection Chief(s)

HICS Branch Director(s)

HICS Unit Leader(s)

HESF #5 Mortuary Services

Expansion of facilities/capacity; postmortem examination & identification; tracking and liaison to families Pathology

Environmental Services, Hospital volunteer Services, Pastoral Care, Social Services Operations Section Chief Medical Care Branch Director Casualty Care Unit Leader

5.1 Pathology

HESF #6 Maintenance, Engineering & EnergySupport or restore essential plant operations, back-up power and water

Plant Engineering, Hospital Maintenance, Facilities Management, Environmental Services Safety and Security Operations Section Chief Infrastructure Branch Director

Power/Lighting Unit Leader, Water/Sewer Unit Leader, HVAC Unit Leader, Building/Grounds Damage Unit Leader, Medical Gasses Unit Leader, BedicalDevices Unit Leader, Environmental Svs Unit Leader

6.1 Biomedical Engineering

…6.8 Plant Engineering

HESF #7 Resource Support & Materials Management

Expansion of just-in time inventory; purchasing, leasing, management of MOUs/MOAs; Coordination of donations; logistical resource support and liaisons

Materials Management, Purchasing

Development Office, Volunteer Services

Logistics Section Chief, Finance Section Chief Support Branch Director (Logs)

Supply Unit Leader (Logs), Cost Unit Leader (Finance), Procurement Unit Leader (Finance)

7.1 Central Processing

…7.11 Supply Chain Management

HESF #8 Communications & Information Technology

Support or restore information services, telemedicine, telephonics, paging to support internal functions and external connectivity; emergency notification of staff

Information Technology, Telecommunications

Volunteer Services, Public Relations, Safety and Security. Medical Records Logistics Section Chief Support Branch Director IT/IS Unit Leader

8.1 Call Center/Physician Referral Service

…

8.14 Multimedia Services

COMPATIBILITY MODELHOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF)

HESF Number

Function Name Description Lead Department(s) Supporting DepartmentsHICS

Section Chief(s)HICS

Branch Director(s)HICS

Unit Leader(s)

HESF #9 Public Information Risk communications to staff and public; Public Relations

OEP, HR, Information and Planning, Occupational Health, Safety and Security Command Staff Public Information Officer N/A

9.1 Employee Relations Logistics Support Brance Director Employee Health & WB

…

9.8 REACH Program

HESF #10 Transportation

Logistical support for internal and external transport of patients; delivery of energy and supplies; securing of transport routes in conjunction with security; facility evacuation

Transportation Courier, Materials management Safety and Security Logistics Section Chief Support Branch Director Tranportation Unit Leader

10.1 Auxiliary (patient transport)

… Garage

10.5 Patient Escort and Distribution

HESF #11 Safety

Coordinates comprehensive health and safety program to include hazardous material and waster management. Ensure compliance with local, state and federal agencies. Ensures staff safety screening to include PPE, fit testing, etc. Occupational Medicine

Patient Care Services, Pharmacy, Facilities Management Command Staff Safety Officer N/A

11.1 Risk Management

…

11.3 Safety Officer

COMPATIBILITY MODELHOSPITAL EMERGENCY SUPPORT FUNCTIONS (HESF)

HESF Number

Function Name Description Lead Department(s) Supporting DepartmentsHICS

Section Chief(s)HICS

Branch Director(s)HICS

Unit Leader(s)

HESF #12 Security

Provides security resources to support logistical, medical, transportation and security services. Coordinates the mobilization of law enforcement. Security

Plant Engineering, Maintenance, Facilities Management, Volunteer Services Operations Section Chief Security Branch Director

Access Control Unit Leader, Crowd Control Unit Leader, Traffic Control Unit Leader, Search Unit Leader, Law Enforcement Interface Unit Leader

12.1 Protective Services

12.2 Security

HESF #13 Information and Planning

Situational awareness; surge enhancements; mobilization, scaling of response, demobilization; resource capabilities; coordination with state emergency response team

Safety and security, Admitting Office, Incident Command/EM

Manager OEP Planning Section Chief N/A

Resource Unit Leader, Documentation Unit Leader, Situation Unit Leader

13.1 Administration

…

13.13 Strategic Development and Marketing

HESF #14 Finance

Approval and tracking of expenditures; filing of claims (insurers, government disaster reimbursement, etc.); emergency payroll policies Finance

Human Resources, Risk management

Finance/Adminstration Section Chief N/A

Time, Unit Leader, Compensation/Claimes Unit Leader

14.1 Accounting

…

14.13 Worker's Compensation

HESF #15 Human Resources

Coordination of alternate/reassigned staff and volunteers; absentee policies; furloughs; coordination with payroll; coordination of cross-training; credentials verification Human Resources

Finance, Medical Records, Occupational Health, Housing Office, Facilities Management Logistics Section Chief Support Branch Director

Labor Pool & Credentialing Unit Leader

15.1 Float Pool

…

15.8 Volunteers

Hospital Essential Support Functions

Function HESF Number Primary Support

#1Clinical

Services

- Emergency Services- Critical Care- Med/Surg- Labor & Delivery- Maternity- Pediatrics- Psychiatry

- Ambulatory Care- Cardiology- Home Care- Obstetrics & Gynecology- Rehabilitation Services

#2Clinical

Support Services

- Diagnostic Imaging- Epidemiology- Intravenous Therapy- Laboratory- Pharmacy- Respiratory Therapy

- Cath Lab- Echocardiography- EEG- Endoscopy- Interventional Radiology- Perpheral Vascualr Lab- Physcial Medicine- Radiation Therapy- Sleep Lab- Wound Care

#3Emergency Family and Staff Support

- Care Management- Children's Psychiatric Services- Day Care- Pastoral Care- Psychiatry Services- Social Services

- Elder Care Prgram- Employee Wellness- Outreach Program- Support Services- Wellness Program

#4Nutrition

- Cafeteria- Food & Nutrition- Kitchen

- Coffee Shop

PatientCare

#5Mortuary

- Pathology None

HOSPITAL FUNCTIONS

#6Maintenance, Engineering, &

Energy

- Biomedical Engineering- Clinical Engineering- Environmental Services- Laundry/Linen Services- Maintenance- Plant Engineering

None

Facilities

#7Resource Support & Materials

Management

- Central Processing- Finance Department- Human Resources- Material Management- Purchasing- Receiving- Shipping- Stockroom

- Development Office- Foundation- Supply Chain Management

#8Communication & Information

Technology

- Clinical Applications- Help Desk- Information Systems- Interpreter Services- Telecommunications

- Call Center- Compliance Hot Line- Copy Center- Library Services- Marketing and Communication- Marketing and System

Development- Multimedia ServicesCommunications

#9Public Information

- Employee Relations- Mailroom- Patient Relations- Public Relations

- Information Services- Lobby/Main Desk- Physician Relations

HOSPITAL FUNCTIONS

HOSPITAL FUNCTIONS#10

Transportation

- Auxillary- Motor Services- Parking Operations- Patient Escort and Distribution

- Garage

#11Safety

- Risk Management- Occupationsl Medicine- Safety Officer

NoneSafety/Security

#12Security

- Protective Services- Security

None

#13Information & Planning

- Administration- Budget and Planning- Facilities Planning and Management- Legal and Risk Services

- Community & Gov. Relations- Corporate Compliance- Decision Support- Financial Planning- Plan & Business Development- Strategic Develop. & Marketing

Business Continuity

#14Finance

- Accounting- Accounts Payable- Budget and Reimbursement- Credit Union- Finance- Payroll- Worker's Compensation

- Cashiers- Corporate Finance- Fiscal Servives- Grants & Contracts- Patient Financial Services- Reimbursement

#3Emergency Staff & Family

Support

- Employee Assistance Program - Employee Wellness

Staff

#15Human Resources

- Float Pool- Hospitalist Service- House Staff Office- Human Resources- Medical Staff Office- Nursing Office- Volunteers

- Student Services

HOSPITAL FUNCTIONS

SECTIONAL / DEPARTMENTAL RESOURCE TYPING INVENTORY

SECTIONAL / DEPARTMENTAL RESOURCE TYPING INVENTORY

SECTIONAL / DEPARTMENTAL RESOURCE TYPING INVENTORYResource: (Department name)Category: (Function)Minimum Capabilities Normal Operations 25% Loss 50% Loss Crosstraining PossibilitiesComponent MetricPersonnel Training Rqmt.

SpecializationMin. # of staff requiredSustained OperationsOrganizationLogistics

Equipment MedicalTechnicalCommunicationsLogisticsSustained Operations

Alternate Source for Restoring or Maintaining Function

Comments

INVENTORY FOR ALTERNATE ASSIGNMENTS

Personnel Skills and Credentials Inventory for Alternate Assignments

(Construct individual questionnaire to be answered by each employee - assemble aggregate data here)

HESF Number Function Name Skill Alternate personnel name Credential Contact Information

HESF #1 Clinical Services

HESF #2 Clinical Support Services

HESF #3Emergency Family and Staff Support

HESF #4 Nutrition Services

HESF #5 Mortuary Services

HESF #6Maintenance, Engineering & Energy

HESF #7Resource Support & Materials Management

HESF #8Communications & Information Technology

HESF #9 Public Information

HESF #10 Transportation

HESF #11 Safety

HESF #12 Security

HESF #13 Information and Planning

HESF #14 Finance

HESF #15 Human Resources

PLANS

• Within each department, identify staff functions and categorize those functions in order to create an all-inclusive database.

• This database will be utilized during a large scale surge event to identify staff positions that may be reassigned to support the care of patients and maintain the hospital’s functional capability.

POLICIES FOR CONSIDERATION• Who will authorize the implementation of the Hospital

Emergency Support Functions (HESF) in response operations?

• Who coordinates the assessment of staffing needs across all patient care areas?

• In conjunction with ICS/HICS: who authorizes the use of support department’s to augment clinical and non-clinical operations?

NEXT STEPS

• A questionnaire has been developed to ascertain each department’s primary and secondary functions and the staff positions within the department that support those functions.

• The questionnaire will be distributed to clinical and non-clinical department heads that have pre-selected as “pilot” departments for this project.

• The results of the pilot questionnaire will be compiled into a database which will be reviewed by the project team.

• Preliminary results and recommendations for next steps will be provided for review and comment.

“…. The capacity to provide health care represents the most resource-intensive component of the NRF, but the need for resources comes at a time when the economic realities of the health care system in the United States are reflected in the closing of hospitals and the reduction of bed availability….”

SUMMARY

AHRQ Pub. No. 06-0027 January 2006

Contact InformationContact Information

James L. Paturas, CEM, EMTP, CBCP, FACCPDeputy Director

Yale New Haven Center for Emergency Preparedness and Disaster Response(203) 688-3224

James.paturas@ynhh.org

One Church Street, New Haven, CT 06510 One Church Street, New Haven, CT 06510 •• United States of AmericaUnited States of Americacenter@ynhh.orgcenter@ynhh.org •• www.yalenewhavenhealth.orgwww.yalenewhavenhealth.org/emergency /emergency