Surge Capacity and Health System Preparedness: Facilities and Equipment: Transcript of Web Conference (continued)

Cindy DiBiasi: So how do you specifically handle the issues that you have just raised about pediatric surge capacity?

Dr. David Markinson: We have to find that same parallel that we just talked about. All surge planning must include children so we must address pediatrics, period. But then, and I think people have done a reasonably good job at starting to look at pediatrics as part of traditional surge or part of the population where we haven't gone and we need to get very quickly is a uniquely pediatric event. This means that the emergency operations plans must include pediatric as part of any event, uniquely pediatric event. Providers must be trained. We must have equipment and pharmaceuticals, drills and exercises and we know if peds are out of proportion to their normal number in the population, it is going to require adult providers, adult units and adult equipment. So we must have the training, the protocol, the procedures and plans to allow that to happen.

Lastly, because of that family unit concept, we also have to think about if there is a charge for pediatric providers. While they said for many years that all of us that take care of adults must think of children, the flip is also true. We are going to keep the family together, children's hospitals, pediatric providers must be prepared to treat adults.

Cindy DiBiasi: So are there Federal and State resources available for use in the event of a public health emergency that is focused on pediatrics?

Dr. David Markinson: In general, almost all surge capacity as well as emergency operations plans take into account Federal and State resources. If I am the hospital director and I am setting out my plans, I would say, "Here is how long I will have to, best case scenario, worst case scenario, handle it on my own." And then I sort of expect certain Federal and State resources.  At the Federal level, this may be the Strategic National Stockpile, the National Disaster Medical Service, DMAT team.  Unfortunately, the assumption that I made for the adult population do not apply to children. For example, the DMATs do not have a requirement for pediatric-trained providers and they do not have a requirement for pediatric equipment.  Some of them may do this on their own, but you cannot assume when you get a DMAT you are going to have pediatric.  You can't build that into your planning. 

The Strategic National Stockpile originally had almost no pediatric considerations. I have to say that they have done an exceptional job of moving forward to get better, but their hands are tied. They are only allowed to stock equipment and pharmaceuticals for its FDA indications.  So if it is not indicated for children, they can't stock it. We know at least half the stuff we use in hospital standard care is not approved for children. We use good medical sense. Unfortunately, the Strategic National Stockpile can't. As a result, when the hospitals or counties or localities make their plans, they cannot assume that for pediatric resources will arrive, even from the State level.

Things like State stockpiles are often based on the list of the National Stockpile, same problems exist. Things like the Medical Reserve Corps, which is the local medical physician volunteers and other health care providers, again, no requirement for pediatric training, no necessity of pediatric providers so you may get lucky and find help, but you may not. So as hospitals plan, they must assume that none of these Federal and State resources have pediatric capability and for their pediatric surge, pediatric planning, they have to survive on their own.

Cindy DiBiasi: David, you have been talking about special considerations when it comes to children.  Does the same hold true for the decontamination of a child?

Dr. David Markinson: Decontamination is a good example of where unique anatomy, physiology, equipment and mental health needs come in. The general premise of decontamination, as I am sure you heard, we heard it a little bit earlier, is for gross removal of clothing and then most commonly water to actually do further decontamination. Taking it just at the simplistic level because of the time allotted, think about it. The first thing we do is we ask people to disrobe and then we, after they are done, get them dressed. How many stockpiles have Pampers or other diapers? How many stockpiled gowns in the size of a child? We may have tons of hospital gowns for adults or other things we can throw over an adult, but what are we going to do for a baby?

In addition, think about the typical decontamination shower or other model.  Building a [unclear] or getting them undressed. That alone can cause hypothermia. We then are spraying them down and how many of our decontaminations are set up to provide hot or warm water as a constant flow for the mass numbers that we have?  So we can be inducing significant hypothermia in the children.

In addition, most of these things run off a fire hose or main line from the hospital. The pressure of the water itself, if not regulated down, may actually knock the child over, cause injury or cause injury to the skin.

Also, what about the child just going through the process? It may be hard enough under times of panic to convince an adult, take off your clothes, walk down this through the shower and do the following things: how are you going to get a toddler to do that, a school-aged child? What if the child doesn't even walk? So we need to account for chaperoning the children through the process and preferentially chaperoning them with people they know and trust and the non-ambulatory. Then the mental health, which comes into that. How do we get children to comply and how to do we not make the process more detrimental than the health?

Cindy DiBiasi: Well, you talked about the problems. Now are there solutions? Are there ongoing efforts to bridge any of these gaps?

Dr. David Markinson: There are some very good efforts. The first step was really identifying where the gaps were and where attention needed to be focused. This was done by the National Advisory Committee on Children and Terrorism. This was a legislated activity of an advisory committee by the Secretary of Health and Human Services that completed about a year ago, a report to the secretary with specific guidelines of what to do for children across the entire agency, the Health and Human Services Agency, as well as some comments from interaction with other agencies such as the Department of Education and Homeland Security.

While some of these have been taken on, again, fulfilling all of these guidelines and recommendations would be helpful, but also for the people at the State, the county, the locality or the local municipality. While these were done from the Secretary of Health and Human Service across all Federal agencies, size may change, the government agency news may change, but these guidelines would easily be applicable to a county government, a State government or a local.

In addition, the specific elements of what you need to do came out of an AHRQ-funded conference that we hosted about a year ago, Pediatric Disaster and Terrorism Preparedness: A National Consensus Guideline. We recognize that the literature, while there, was limited on what kids need so we brought together the best experts from across all the disciplines of the government agencies and looked at the evidence.  Where there was evidence, recommendations were there and in the absence there was consensus. As you look here, you have a list of all the topics.  Unfortunately, time will not allow me to go through each one of these, but you have specific recommendations and they are very specific. They talk about numbers of equipment, numbers of providers, actual dosages, and treatment protocols across all the range of things you see here.

This was one point in time and we knew when we did this that there would be new threats, net technologies out there and new questions that came up. So using this evidence-based consensus model and a wide range of experts in pediatrics, the people have to implement these in terms of emergency preparedness, public health and the government agencies involved, we kept this group together and have actually added to it to create something called the Pediatric Expert Advisory Panel. This is a multi-disciplinary group, both governmental and non-governmental. It is an ongoing program and what it does is give us an ability to rapidly add on as new threats or technology and then disseminate the findings on our Web site through an info brief which summarizes the findings and through conferences and symposiums.

An example of one of the items that came up was earlier this year. The Food and Drug Administration (FDA) approved something called the Pediatric Dosage Atropin. Mark One, many of you may know, is the treatment of choice for adults exposed to chemical nerve agents of a specific type. Unfortunately, while this was touted as a pediatric equivalent, it is not. It is only half of Mark One. It includes atropin and not the paradoxin the patients need.

In addition, the original guidelines for treatment said Mark One is acceptable in appropriate dosages down to any age after bonafide exposure. This data was reviewed. The data about the new device was reviewed and a recommendation came out to continue using the Mark One as a preferred treatment for all children of any age and not to stock and not to use the pediatric atropine. An info brief came out that explained all the key points that went into that decision, what the future recommendations are and why they were made. That was distributed recently by mail and it is now on the Web site.

Cindy DiBiasi: Well, let's talk about where people can get more information because obviously there is some incredibly valuable information in your report.

Dr. David Markinson: The general report, The Pediatric Disaster Conference Consensus Guidelines, are available on our Web site. In addition, on the Web site are these info briefs, the ones we talked about. In addition, this Pediatric Expert Advisory Panel is ongoing. You can send in questions from the Web site and the panel will address them and we release these info briefs. The info briefs are mailed and you can also be asked to be on the mailing list. They are mailed to all government leaders and emergency preparedness at the State and local level, government agencies and all members of the group and professional organizations. So the Web site, I believe the address is being typed up as we speak. This is where you can get all the information about the Pediatric Preparedness Program, all our resources, talks and presentations we have given plus it gives you an avenue to ask us questions about ongoing issues.

Cindy DiBiasi: Great.  Thank you, David. We will be back to ask you some more questions. In a moment, we are going to be opening up the discussion for questions from our listening audience but first I would like to turn to David Gruber from the New Jersey Department of Health and Senior Services.

David, how has New Jersey approached surge capacity within the State?

David Gruber: Good afternoon, Cindy, and I think because I represent New Jersey I feel comfortable in drawing from a Bruce Springsteen line and that is, "One step up and two steps back." I think if you look at how we address surge capacity, we took with our initial funding, one step forward and used a band-aid approach to some of the critical issues that needed to be immediately addressed. However, we realized that we needed an overall strategic plan to make it the most effective program, so we took a few steps back and developed that strategic plan.

When we developed the strategic plan, we decided that we weren't going to go hospital-centric; we were going to go system-centric. We would look at the systems versus the facility. To do that, we had to figure out what the threat was and how we were going to address the issue. So we looked at two separate scenarios. One was an acute event and the other was a chronic event. The classic acute event could be an explosive event or a chemical attack that would really hurt the health system, hurt it bad, hurt it hard and hurt it quick. That we would place that against a chronic event in which would be a slow-moving attack, it would require long-term effects, it would have long-term effects and long-term care requirements.

So to do this and to make this happen and to apply all the assets that the State of New Jersey had, we created what we call the Health Emergency Preparedness and Response Triangle. We recognized that to be most effective, we would have to ensure that public health, health care delivery systems and the emergency management system were all linked together and were all addressing the problem.

Cindy DiBiasi: Now earlier in this broadcast, Sumner spoke about the surge capacity benchmarks that are included in the HRSA program. How does New Jersey address these benchmarks?

David Gruber: Well, we made sure that we didn't look at the benchmarks by themselves but looked at the benchmarks as they applied to our program. So we reviewed our focus and our focus was primarily on situational awareness, knowing what was going on throughout the State at all times with the health system. Also we looked at tempo control; being able to use time to our benefit, not time as an enemy. We looked at passive and active architectures so that we would both push information out to our communities and pull information back. I talked about systems, but we also looked at redundancy knowing that the primary system frequently fails exactly when you need it so we made sure we had backups. Then we had targeted capabilities that we will discuss a little bit later.

So instead of applying the benchmarks, what we did was we applied the benchmarks to our strategy and our programs and used them to evaluate our programs.  Additionally, we created what we call the Health and, excuse me, the Emergency Preparedness and Response Health System Network. The benchmarks were used as measures of this network; they were not drivers of this network.  They were measures of the strategy, not drivers of the strategy.

Finally, what we did was we created a division within the Department of Health that looked at all the issues that the benchmarks would address and that is listed on the next slide you see.

Cindy DiBiasi: How has emergency preparedness funding been used in New Jersey to enhance surge capacity?

David Gruber: What we did was design programs and then figure out how we were going to fund the programs as opposed to seeing a funding source and then seeing how we would spend the money of that funding source. We are very fortunate in New Jersey that the governor and commissioner are exceptionally knowledgeable and dedicated to the program so in addition to large amounts of CDC and HRSA funding and a little bit of ODP funding for health, we have what we call Med Prep funding, which is State bioterrorism funds. That is to the tune of approximately $12 million and has been given to us over the past few years. To put that in perspective, that is about number nine or so, if you look at HRSA grants, as far as amounts of money.

But we took that money, and as I mentioned, we applied it to programs and if we move to the next slide we can see we put a roadmap out there and it was a three-year road map in which we concentrated on developing an infrastructure first, looking at our command and control and communications next and then exercising the system as the final step.

We also tried to focus on the big programs and the big money programs upfront under the assumption that eventually money is going to end and funds will draw down. So if our big investments are paid for upfront, we feel we would have long-term programs.

Cindy DiBiasi: Well, tell us about some of the programs that have been put into place to address surge capacity in New Jersey.

David Gruber: I would like to focus specifically on two programs. The first one is our Medical Coordination Centers. This is in support of our regional concept. In New Jersey, we have five public health regions and we are in the process of standing up a medical coordination center in each of these regions. These medical coordination centers are responsible on a daily basis for the collection of information and giving us the status of the health system as a whole as part of our desire to maintain that situational awareness. During an event, they would be used to guide the resources, personnel and response during a mass-casualty event. What we are looking at is not looking at an individual facility responding, going back to one of our original slides, but looking at the system as a whole responding.

The second thing I would like to talk about is our strategic State stockpile.  About two years back, we recognized that there are some challenges to the Strategic National Stockpile System and its ability to get pharmaceuticals and medical supplies to us in twelve hours.  So we felt that we should create a State stockpile that would bridge the gap between an event and when the national stockpile might arrive. We also recognize that there are some cities in New Jersey that weren't selected as MMRS cities, yet we felt deserved the attention that an MMRS city might have and were susceptible to pharmaceutical shortages during a mass-casualty incident.

The last thing that we recognized, as Dr. Markinson had mentioned, there are parts of the Strategic National Stockpile that don't cover specialized care such as pediatric care. So we have developed our own State stockpile and have applied both HRSA money and also our State money to that.

One other thing I would like to address and that is our information technology initiatives. We have quite a few software packages that will be integrated into our medical coordination centers that provide us both on a daily basis and also during an event, information regarding the health care system. Some of those are listed up on the slide. The first being diversion which tells us the status of emergency rooms and other critical areas of a hospital. Our HRMIS Hospital Capacity System will give us information on bed status but not just generalized bed status but pediatric beds, intensive care unit (ICU) beds, etc.

We are looking at emergency medical services (EMS) and decontamination trailer tracking by using on our vehicles GPS [Global Positioning System].  We are also looking at some project tracking software consistent with the HRSA and CDC grants. Our Strategic State Stockpile will have an inventory system so using GIS mapping and point-and-click we will know, real time, what the inventory is in our State stockpile. A professional health care registry that many of the users are familiar with at the national basis, excuse me, with the national initiative that was just announced and we will have it at our State level. We started that.

And finally credentialing so we know who can do what where, when and how.

Cindy DiBiasi: David, have you run into any challenges with respect to surge capacity?

David Gruber: I think the challenges are more general challenges and obviously every State has things that are particular to them, New Jersey being in that situation. We have some national assets. For example, we are a major rail corridor and road corridor and many of you who have paid tolls on the New Jersey turnpike recognize that. Major ports and airports and also sandwiched between Philadelphia and New York City and I think that it is important to realize that we, we are obviously not just a State, we are treaters of overflow from New York City and Philadelphia should they have major incidents.

We have some national industries that are critical. Agriculture is a major part of New Jersey and we have to protect that. Atlantic City is a target, as mentioned before, and we do have nuclear power plants. Additionally, New Jersey has significant petrochemical industry along with pharmaceuticals; agriculture is a big part as is tourism.

Cindy DiBiasi: And I assume you have a Web site, an E-mail address, that if people want more information to learn about New Jersey's approach, where can they get that?

David Gruber: Should I be, I would be happy to send anybody any information they would like and it would be david.gruber@doh.State.nj.us.

Cindy DiBiasi: David, thank you. In a moment, we will open up the lines for questions from the listening audience, but first let me tell you how to communicate with us. There are two ways you can send in your questions. The first is by telephone and we do encourage that because we would like to hear from you. If you are already listening on the phone, press "*1" to indicate that you have a question. If you are listening through your computer and want to call in with a question, dial 1-888-496-6261 and use the password "surge capacity" and then press "*1".  While asking your question on the air, please do not use a speakerphone or a cell phone to ask your question and please be sure to speak loudly and clearly.

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As you are formulating your questions or queuing up on the phone lines, I would like to say a few words about our sponsor. The mission of AHRQ is to improve the quality, safety, efficiency and effectiveness of health care for all Americans. Two of AHRQ's operating components helped to produce this series of audio conferences. The first is AHRQ's User Liaison Program or ULP. The ULP serves as a bridge between researchers and State and local policymakers.  ULP not only brings research-based information to policymakers so that you are better informed, we also take your questions back to AHRQ researchers so they are aware of priorities at the State and local levels.

The second is AHRQ's Center for Primary Care Prevention and Clinical Partnership expands the knowledge base of clinical providers and patients and assures the translation of new knowledge and systems improvements into primary care practice.  The center supports and conducts research to improve the access, effectiveness and quality of primary and preventive health care services in the United States.  I would like to take a quick moment to thank Dr. Sally Phillips, who is the director of AHRQ's Bioterrorism Preparedness Research Program. She is here in the studio with us today. Sally works in the Center for Primary Care Prevention and Clinical Partnerships and she has been instrumental in helping to produce this series.

It is our hope for today's conference and the remaining events in this series will provide a forum for a productive discussion for our audience of policymakers and researchers. We would appreciate any feedback you have on this Web conference and at the end of today's broadcast, a brief evaluation form will appear on your screen with easy-to-follow instructions on how to fill it out. Please be sure to take the time to complete the form.

For those of you who have been listening by telephone only and not using your computer, we ask that you stay on the line. The operator will ask you to respond to the same evaluation questions using your telephone keypad. Your comments on this Web conference will provide us with a valuable tool in planning future events that better suit your needs.

Alternatively, you could E-mail your comments to the AHRQ User Liaison Program at https://info.ahrq.gov. Well now let's go to questions from the audience and on the phone from New York we have Rick Morrissey. Hello?

Rick Morrissey: How are you? 

Cindy DiBiasi: Fine, Rick, how are you?

Rick Morrissey: Yes, my question deals with the portion of the presentation on national bioterrorism and hospital preparedness program presented by Lt. Commander Sumner Bosler, in his presentation he spoke of critical benchmark number 2.3. That referenced the staff to bed ratios, yet I did not hear anything that indicated what an appropriate staff to bed ratio would be. Can we get that information or an area where we can get information to determine that requirement?

Lt. Commander Sumner Bosler: Well, specifically we actually left the ratios; we put examples into the HRSA continuation application this year just as examples for States or localities to plan out individually on their own. We didn't want to get into, since we are not a regulating agency, into establishing ratios that may not be appropriate for certain localities.

Cindy DiBiasi: Does that answer your question?

Rick Morrissey: Actually it didn't but it does give us an idea of where to go to start looking for something to determine a formulation in determining the needs.

Lt. Commander Sumner Bosler: In the application we reference the old SBC com acute care con ops and that shows ratios or actually does fairly extensive planning for minimal care areas; not really hospital-centric but more off-site care. It depends on the level of planning that you are looking towards whether you are doing inpatient or off-site care and the level of care, minimal versus acute care. So it really depends on what you are looking for and what you are planning for. You can contact me via the phone number that was left on my answer slide and that way we can discuss this at greater length if you are looking for more information.

Rick Morrissey: Well I appreciate the phone number. I will contact you to access and get some more information. Thank you very much.

Cindy DiBiasi: We will be giving the phone number in just a minute. Let me just go back to this next question. This is for David Markinson and the caller wants to know, "How can we determine what items are in the SNS, the Strategic National Stockpile, relating to the care of children?"

David Markinson: Again, the issue of the specific contents of the SNS you can imagine are pretty confidential or somewhat confidential what the specific numbers are. Many of the prophylactic agents have now been included in a formulation that you can get into kits. Probably your best source of information is your local public health department and Office of Emergency Management who has a responsibility for actually distributing and handing out or implementing the SNS should it arrive and when it would arrive.   I would address questions to them about what specific items would not be covered that you would have to provide equipment for locally.

In general, this would be mostly antibiotics that you see commonly published on the CDC Web site or other AHRQ or any other guidelines. If you look at antibiotics and you note that the following wording, "Not indicated for children." I can guarantee you that is not in the SNS because they are bound by FDA rules. So while I will not be able to go into the exact contents, any medication, pharmaceutical or antidote that is not indicated for children by the FDA will not be in the stockpile. Same thing with equipment.

Cindy DiBiasi: David Gruber, "Please describe the type of health system integration software used for credentialing during a mass casualty."

David Gruber: That is a good question. As far as credentialing, right now we are looking at an identification system that the health department will start and then the State as a whole will look at to apply to possibly police, fire, etc. so that the State as a whole has a credentialing system and identification system.

On that identification system, we will have bar coding and the electronic capability to put credentials on the back of the card so that cards can be read at an event or at a facility should someone go to a facility. It is in its early stages so I would love to tell you more, but we haven't moved beyond that part.

Cindy DiBiasi: OK. A couple of follow-ups here. The phone number for Sumner Bosler is (301) 443-1095.  That is (301) 443-1095. While we are giving out contact information, someone has called in and asked for Bettina Stopford's E-mail contact information again so Bettina if you could give us that?

Bettina Stopford: Sure. It is stopfordb@saic.com.

Cindy DiBiasi: OK.  And a question for you Bettina.  How do you feel about portable isolation to support surge capacity needs? Is there any interesting equipment available?

Bettina Stopford: You know there is, and I guess I am lucky in my travels to get to go to some vendor fairs and there is some interesting things out there but it is really important to take a look at it, not just in your facility only but in a community-based effort to see what are some cost effective things that you can do to increase isolation. But there is some vendor-type stuff out there for portable use. There are tents that have filtration in it. There is any number, a plethora of things that you can use.  It is a matter of finding out what exactly is applicable to your area.

Cindy DiBiasi: OK.  David Gruber, "Regarding the State stockpile, did you include psychotropic medication for both adults and children?"

David Gruber: Yes.  The way we determined what was going to be in the stockpile was part of our overall State advisory committee and we got together a group of experts within the State and asked them to identify what was appropriate. We also have a pediatric component of our advisory committee and they are providing the input for children for the State stockpile.

Cindy DiBiasi: I have got a question on a decontamination unit and now that I think maybe Sumner and Bettina might want to talk about it. "Considering a surge using all hospitals, should have a decon unit and a trained decon team?"

Bettina Stopford: I would say yes, absolutely. Now I think that you have to look at it in the regional area too and the only way you are going to be able to determine what your specific needs are for numbers is to make sure that you are embedded in the community base hazard vulnerability assessment. How many people are likely to potentially be exposed? The primary exposure could be from an industrial accident primarily so this is why it is very important for health care facilities and EMS, etc., to be embedded in community planning that would determine your numbers.

This past year, all States have had to participate, if they want, (unclear) funding, in a Homeland Security assessment strategy where they determine some of their top tens or credible threats and that related to the number, the impact number of people that they thought would be potentially contaminated or exposed. That gives you some real, sort of credible threat data if you would work with your State and regional plan people to determine how many people potentially impact our hospital or our community, your EMS, so that is what you build your planning off of. But I think that JCAHO requires a certain amount of decontamination capability although they don't go into numbers; there is sort of an intent there to have some more capacity than most people have now which is usually one or two.

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