Public Health Emergency Preparedness

4. Additional Resources to Meet Surge Needs

Selecting an Alternative Care Site

Through discussions with General Lloyd Dodd, Command Surgeon for U.S. Northern Command² located at Peterson Air Force Base in Colorado Springs, and his staff, the RMBT Working Group found there was a need to develop a tool that assisted planners in identifying potential alternative care sites in the event of a bioterrorist attack (Tool 1). Using existing buildings and infrastructure is the most probable scenario should a surge medical care facility need to be opened. The RMBT Working Group determined that the use of existing buildings and infrastructure is feasible for this region and would meet the needs of frontier, rural, urban and suburban areas. The type of building that will need to be used is dependent upon its infrastructure.

There are many alternatives for equipping an alternative care site once selected. The Department of Defense presented and discussed many equipment concepts with the Working Group. DoD equipment and personnel resources include the Air Force Small Portable Expeditionary Aeromedical Rapid Response (SPEARR), Expeditionary Medical Support (EMEDS), and Army field hospitals. It is important to note that these are Federal resources and may not be available for use during the initial days of response to a bioterrorist attack. In addition, they require training in order for local medical personnel to set-up and use the equipment with design alterations. Another option included an 18-wheeler emergency response vehicle that could be purchased by private carriers and would operate as a high-level mobile medical care facility with an ambulatory surgical unit. This alternative is costly—over $2.4 million—and provides a high level of care that may not be feasible or cost effective for a large-scale medical response effort³.

The RMBT Working Group concluded that an alternative care site would most likely be staffed and supplied by local and regional resources. Three levels of supply caches were developed and are presented in the next section, Supplying and Staffing an Alternative Care Site. In the event of a bioterrorist attack and when a region utilizes an alternative care site, it is probable that one of levels of these caches would be the asset deployed to equip the site to complete its functionality.

The RMBT Working Group agreed with the need to develop a simple tool that could be used by regional planners to predict an appropriate alternative care site from existing structures based on internal requirements. Hospital engineers and facility personnel were presented with the infrastructure requirements for an alternative care site outlined by the DoD⁴ and refined by the RMBT Working Group. This expert team assisted with the development of an alternative care site selection matrix tool. Through discussions with this team, they were able to identify additional factors that should be considered in selecting an alternative care site. When designing the tool, these factors were transformed into a matrix with relative weights. The weights are based on a 5-point scale that compares the alternative care site factor to that of a hospital. For instance, if the potential alternative care site was a local high school, "Is the ventilation system similar to a hospital or less adequate than that of a hospital?"

The RMBT Working Group reviewed and tested the site selection tool matrix during one of the RMBT Working Group meetings. The group was separated into five breakout groups. Each group was provided with pictures and infrastructure descriptions of three potential alternative care sites, an event center, a church and a high school. Each group scored and ranked the three alternative care sites for use in the event that is described in Chapter 8, Example of a Regional Exercise. Table 4 displays the scoring results from these breakout groups (G = Group):

Table 4. Validating the Alternative Care Site Selection Matrix

Potential Site	G1	G2	G3	G4	G5
Event Center	57	65	56	60	52
Church	75	59	56	65	54
High School	84*	68*	61*	67*	61*

The High School obtained the highest score (*) in all five groups and therefore was the best choice for that particular biological event.

Issue areas discussed by the RMBT Working Group while testing the tool included:

• Is each factor of equal weight?
• If a factor is not applicable to the type of event it can be skipped.
• What if another use is already stated for the building in a disaster situation? (i.e. a church may have a valuable community role.)
• This tool may be useful to use in a planning team including: fire, law, Red Cross, security, hospital personnel such as the Local Emergency Planning Commission (LEPC).

The alternative care site selection matrix tool (Table 5) is also available as an Excel file at www.ahrq.gov/research/altsites.htm.

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^2. The Department of Defense established U.S. Northern Command in 2002 to consolidate under a single unified command existing missions that were previously executed by multiple military units. The command's mission is homeland defense and civil support, specifically:

• Conduct operations to deter, prevent, and defeat threats and aggression aimed at the United States, its territories, and interests within the assigned area of responsibility.
• As directed by the President or Secretary of Defense, provide military assistance to civil authorities including consequence management operations.

^3. Medical System Unit for Homeland Defense produced by the Mobile Medical International Corporation, St. Johnsbury, VT.

^4. Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident, May 2003.

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Supplying and Staffing an Alternative Care Site

One of the primary needs identified by the RMBT Working Group was to develop supply and staffing recommendations for the operation of an alternative care site or to augment the capability of a fixed care site, commonly a hospital. It is unlikely that a hospital or alternative care site will have much of the equipment or supplemental staff necessary to provide care or support patient quarantine in the event of surge.

Supply Options

The concept of supplying an alternative care site was, interestingly enough, well developed 5 decades ago with the establishment by the U.S. Federal Civil Defense Agency and the Department of Health, Education, and Welfare of the "Packaged Disaster Hospitals". These units were available in 50 bed, 100 bed, and 200 bed units and contained supplies and pharmaceuticals to provide reasonable medical care at an alternative site. These "PDH"s were also accompanied by "Hospital Reserve Disaster Inventory (HRDI)" for augmentation of hospital capacity. Unfortunately, these units were dismantled and disposed of in the 1980's.

The recognition of ongoing lack of ability for the medical care system to quickly increase the capacity for patients that be cared for led us to investigate a similar approach in terms of having cached material that could be easily activated for increased surge capacity for patient care. Three levels of supply caches were developed based upon available resources and intent. These caches are similar to the old PDH model. Level I cache parallels the HRDI concept of augmenting hospital capacity and the Level II and III caches are a basic and advanced version of the PDH type supplies. The following three example lists of caches are included in Tool 2 and could be used to either augment hospital capacity or supply an alternative care site at varying levels. Costs can vary widely; for example, there is large variation in types of cots that can be purchased.

Level I: Hospital Augmentation Cache—Approximately $20,000 (Tool 2-I)

This list of supplies represents a most basic unit of supply support for increased surge capacity of 50 patients, consisting only of items that have very extended shelf life: cots, linens, masks, gowns, gloves, IV poles, etc. No pharmaceuticals are included. This material is packed in a trailer for mobility. It could be used as additional stocking for an existent hospital (e.g., to set up a medical ward in a cafeteria, utilizing other items as necessary from the hospital) or could offer supplies for limited level care at an alternative care site. This list was created by the RMBT Steering Committee and approved by the RMBT Working Group. In our metropolitan area of 1,000,000 people and 11 hospitals, if each hospital acquired a single cache, we would have a basic supply surge capacity for 550 patients. Estimated cost for this cache (including trailer) is approximately $20,000. One of these units has been purchased and is currently being processed and positioned for potential use in our area.

Level II: Regional Alternative Site Cache—approximately $100,000 (Tool 2-II)

This list represents a more complete list of material to supply a regional alternative care site for 500 patients. This level cache, or medical armory, concept was developed by one of our partners, the Colorado Department of Public Health and Environment, and approved by its Hospital Preparedness Advisory Committee. This cache would be packaged in a modular fashion so material to support multiples of 50 or 100 beds could be easily extracted from the cache (similar in concept to the packaging of the Strategic National Stockpile). Note that the supply list for this cache is more complete, providing more expanded support for an alternative care site compared with the Level I cache. Approximate price for a single cache is less than $100,000. As with the Level I cache, pharmaceuticals are excluded and only items with an extremely long shelf life are included. It is assumed that the Strategic National Stockpile (SNS) would be requested at the recognition of an event and would arrive within 72 hours to augment these simple caches.

The list for the Level II cache is available from Robin Koons, Ph.D., at the Colorado Department of Public Health and Environment. Full contact information is provided in Appendix A.

Level III: Comprehensive Alternative Care Site Cache—No cost estimate currently available (Tool 2-III)

These comprehensive lists of equipment and consumables were adapted by the RMBT Working Group from work done by the U.S. military and published in The Concept of Operations for the Acute Care Center⁵, by the U.S. Army Soldier and Biological Chemical Command (SBCCOM) (available at: www.DenverHealth.org/BioTerror/Document.htm). These represent a specification for a completely supplied 50-bed alternative care site consisting of both long and short shelf life items. This represents a more complete level of cache than the caches above. An attempt has been made to differentiate, when possible, the needs of the unit when caring for infectious patients, non-infectious patients and a situation when the unit would be used as a simple quarantine unit. The initial specification also included pharmaceuticals, but we have elected to not include them here as separate national, regional, and local planning efforts are addressing this issue.

This extensive list has been separated into:

• Equipment Considerations.
• Patient Care Related Consumables.
• Administrative Consumables.
• Oxygen and Respiratory Related Equipment Considerations.

Note that this equipment and the consumables can be pre-acquired and stored in a "medical cache" as well. Consumable items may represent one of the greatest challenges for establishing an alternative care site due to the number and quantity of items. This comprehensive list also includes oxygen and respiratory-related supplies that should be considered to provide limited respiratory support.

Special Consideration: Supplemental Oxygen Supply—approximately $13K-$480K (Tool 3)

The majority of probable bioterrorism agents directly involve the respiratory system, making supplemental oxygen for patients very desirable. This is highly problematic from a logistical point of view, as even the larger oxygen cylinders (H cylinders) have a limited supply when having to service multiple patients. Providing liquid oxygen sources at alternative care sites has been proposed, but presents a significant financial and engineering challenge. Adequate supplemental oxygen supply remains an unresolved issue at this point. One of the problematic concerns in establishing a surge capacity alternative care site is the supply of supplemental oxygen to patients. This need could conceivably be great since a significant number of bio-weapons directly attack the respiratory track, causing hypoxia. Oxygen is not on the supply list for any of the above caches. There are various alternatives to supplying oxygen at an alternative care site. Therefore, a separate description of the oxygen alternatives is presented.

As part of the RMBT Working Group discussions, a group of our Air Force partners developed some potential solutions to addressing oxygen needs. These may be viewed at www.DenverHealth.org/BioTerror/Document.htm under "Deployable Oxygen Solutions" or at Tool 3. Given the variables of cost, general availability, ease of use and sustainability, the most promising option is also the simplest: a rack of interconnected "H" oxygen cylinders, each supplying 7000 liters of oxygen. (A single "H" cylinder could only supply 50 patients at 2 liters of oxygen per minute for 1 hour). Even this most basic of setups would require the rapid installation of a rudimentary gas distribution system. Support for ventilated patients would significantly increase the rate of oxygen consumption, further complicating this issue and may not be possible.

Staffing Considerations

The creation and utilization of any alternative care site will obviously be successful only if a site can be staffed by necessary medical and ancillary personnel. This may be a serious issue for several reasons, two of which include:

1. There is no guarantee that normally available personnel would make themselves available to assist in a bioterrorist event.
2. The simple fact that alternative sites are being implemented implies that the normal health care system is running beyond capacity, stressing routine levels of staffing.

Again, work done by the military and presented in The Concept of Operations for the Acute Care Center lists proposed staffing for a 50-bed unit per 12-hour shift. This proposal was adapted and augmented, including the addition of staffing levels for non-infectious patients and quarantine (only) patients, by the RMBT Working Group. Certainly, it is impossible to forecast absolute requirements without knowing the acuity of patient illness, whether the disease process is communicable or not, or if the unit is being used for quarantine only.

Advance regional planning could include establishment of a registry of backup health care providers, such as those who are licensed but retired, those working in an alternative line of work, or otherwise inactive. An additional degree of preparation, since health care licensing is largely a state issue, involves researching and drafting potential gubernatorial orders to set aside specific aspects of state licensing requirements for physicians, nurses and other health care providers. This would allow easier incorporation of out-of-State professionals into an expanded work core. Even with maximum planning, the establishment and maintenance of a health care workforce for an alternative care site during a bioterrorist event remains a daunting challenge.

A major problem in setting up and running an alternative care site would be the provision of appropriately trained staff to run the site. Staffing alternatives are best dealt with through advance planning. Some of the steps required to enable this advance planning will require specific State legal action, while other responsibilities will fall to local jurisdictions and/or institutions in the area. Table 6 lists several items that will facilitate obtaining and supporting additional staff for area hospitals and alternative care sites. Table 7 lists estimated numbers of staff necessary for an alternative care site 50 bed unit.⁶

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^5. Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident, May 2003.

^6.Adapted from The Concept of Operations for the Acute Care Center, the U.S. Army Soldier and Biological Chemical Command (SBCCOM), 2003, in press. Used by permission.

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