Public Health Emergency Preparedness

5. Measures of Preparedness

Understanding the degree to which a region is prepared for a bioterrorist event is important to understanding regional surge capacity needs. This chapter defines a specific set of measures for preparedness based on data that is currently collected. As part of the RMBT Working Group collaboration, data collection resources were identified that were available in the six-State region and that provided information about the medical resource capacity of the region. Other measures of preparedness may not only address resource capacity but may also include measures for timeliness of response and effectiveness of the incident command system. As a surge capacity study, the measures of bioterrorism preparedness focus on identifying the gaps between resource capacity and resource needs.

After the RMBT Working Group identified regional medical resource capacity, as outlined in Chapter 3, Profile of Regional Medical Resources, the next step to defining measures of preparedness was to determine medical resource need. Two approaches were used to identify resource need. One was through HRSA surge capacity benchmarks, and the second was to develop a benchmark through the staffing, supply, and equipment templates for a 50-bed unit developed by the Department of Defense⁷ and refined through input from the RMBT Working Group in Table 7.

Based on these benchmarks, four resource areas for bioterrorism preparedness measures have been developed:

• Hospital Beds: Current resources based on NDMS available bed data, need based on HRSA benchmark of 500 beds necessary per 1 million population.
• Medical Staffing: Current resources based on HRSA health workforce profiles, need based on HRSA benchmark of 500 beds necessary per 1 million population combined with the staffing model for a 50 bed alternative care site described in Table 7.
• Equipment: Current resources based on HRSA State hospital preparedness surveys, need based on HRSA benchmarks.
• Infrastructure: Current resources based on HRSA hospital preparedness surveys, need based on HRSA benchmarks.

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^7. 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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Hospital Beds

Current available regional hospital bed capacity was provided by the National Disaster Medical System (NDMS)⁸. NDMS collects bi-weekly hospital bed availability data for hospital members, which is the actual number of beds available on any given day in the region. The NDMS agencies (DoD, VA, FEMA, HHS) have established voluntary partnerships between NDMS and civilian hospitals through a Memorandum of Understanding (MOU). One of the responsibilities of the participating hospitals is to provide bed availability information to the local NDMS Federal Coordinating Center (FCC).

The NDMS has been tracking available hospital beds since January 2003. NDMS partners with approximately 2,000 non-federal hospitals concentrated in major metropolitan areas located in 65 FCCs with 82 reception sites (Appendix C). In Federal Region VIII, NDMS is tracking open beds in the Colorado Front Range (Greeley, Colorado Springs, Pueblo, Fort Collins, Boulder, and Denver) and Utah's Salt Lake City metro area. The FCC calls the hospitals periodically to obtain number of open beds for medical/surgery, critical care, psychiatric, pediatrics, and burns. This data was provided to the RMBT Working Group to determine current available hospital bed resource capacity.

Hospital bed resource need was based on the benchmarks defined by HRSA. In 2003, under the Bioterrorism Hospital Preparedness Program, HRSA provided regional surge capacity standards to guide regional planners. One of the standards or benchmarks was that there should be 500 surge capacity beds per 1 million population for acutely ill patients requiring hospitalization from a bioterrorist event. This 500 beds per million-population HRSA benchmark was used as a basis to define need in this study. In addition, bed need was assessed using a higher benchmark of 750 beds per million based on Working Group member suggestions that HRSA may increase this benchmark in the future.

In Region VIII, both Colorado and Utah have Federal Coordinating Centers for the National Disaster Medical Response System (NDMS). Figure 22 describes available beds over time for a 3-month period for the Colorado Front Range. Figure 23 describes available beds over time for a 6-month period for the Salt Lake City area in Utah. The average number of available beds in Colorado was 663 and in Utah was 406 for the respective time periods.

Figure 24 indicates that the Colorado Front Range region would need to add between 343 and 1,012 beds for the 500 bed benchmark, depending upon how many beds they could vacate for elective conditions or less acute patients over time. For the 750 bed per million population benchmark, the Colorado Front Range region would need to add from 1,181 to 1,850 beds in the event of a bioterrorist attack. This range indicates how sensitive the measure is to the established benchmark.

Figure 25 indicates that the Utah Salt Lake City region would need to add 1, 269 beds based on the HRSA 500 bed per million population benchmark. Utah does not ask hospitals to provide maximum number of beds that can be vacated in 48 hours, and therefore cannot provide a range as reflected in the Colorado Front Range. For the 750 bed per million population benchmark, it is estimated that the Salt Lake City region would need to add 2,107 beds in the event of a bioterrorist attack.

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^8. The NDMS is a cooperative asset-sharing program among Federal government agencies, State, and local governments, and private businesses and civilian volunteers to ensure resources are available to provide medical services following a disaster that overwhelms the local health care resources. The NDMS is a federally coordinated system that augments the Nation's emergency medical response capability. The overall purpose of the NDMS is to establish a single, integrated national medical response capability for assisting state and local authorities in dealing with the medical and health effects of major peacetime disasters and providing support to the military and Veterans Health Administration medical systems in caring for casualties evacuated back to the United States from overseas armed conflicts.

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Medical Staffing

Current regional medical staffing resources were obtained from HRSA State Health Workforce Profiles for each of the six States in Region VIII (see Section 3.2).

Appendix F describes estimated needs for staffing alternative care sites based on the DoD⁹ Concept of Operations for the Acute Care Center staffing requirements for a 50-bed alternative care site (as outlined in Table 7) and the HRSA benchmark of 500 beds per million population. The requirements for a 50-bed unit were multiplied by 10 to obtain an estimate for the staffing necessary for 500 beds. It was assumed that there are 14 12-hour shifts per week and each professional would work 3 shifts per week. The number of shifts in a week (14) was multiplied by the staffing estimate for 500 beds per million population for each profession. It is estimated that it will require 14,777 staff to operate and support the 4,663 alternative care site beds needed in Region VIII based on the HRSA benchmark of 500 beds per million population. Of these 14,777 staff, 464 are physicians, 933 are registered nurses, and 1,865 are LPNs.

The 14,777 number could be less based on the beds available and that are currently staffed as described in the section above. Since available bed capacity is not available for all States and all regions of each State it is currently not possible to know to what extent this bed availability could offset alternative care site need for the six-State region. Consideration was given to whether there is an excess/under supply of medical staff in the region. Some States and regions could have an excess supply of medical staff relative to current demand and other states and regions could have an under supply of personnel. This excess/under supply can also vary by type of personnel. Therefore, the next step was to determine a baseline for whether each state is meeting current demands for medical staffing. The national average of staffing levels per 100,000 population was the best estimate available at this time. This measure has its limitations; because some States may have a healthier population than others, there may be State regulatory requirements that impact State staffing levels, and studies have shown that medical practice behavior can vary by region.

Table 8 contains the expected staffing needs for alternative care sites ("ACS Need" in the table) in Region VIII, based on State population and current medical labor needs/surplus. Since HRSA data was used to determine current capacity, only those professions described in the HRSA Workforce profile are included in this table. For instance, secretaries and housekeeping personnel are not included in Table 8 but are included in Appendix F. Excess capacity was calculated by subtracting the U.S. average per 100,000 population profession estimate from the State per 100,000 population profession estimate (go to the section in Chapter 3 on Medical Staffing Resources). Staff need minus excess capacity results in the net need. On the "Net need/Surplus" line, negative numbers signify a surplus, while positive numbers signify a shortage.

The following nine figures (26-34) depict the net need or surplus for each profession in Region VIII. Based on the HRSA benchmarks, all States in this region may need additional physicians (Figure 26). Region VIII as a whole is estimated to need an additional 1,971 physicians to address a surge based on the HRSA recommendation. The majority of this need is based on this region having an under supply of physicians, particularly in Utah.

Figures 27 and 28 indicate that there is a surplus supply of physician assistants and nurse practitioners in the region, compared to the national average. During a surge event there may be enough people currently in these professions to address surge need. For States such as Utah, North Dakota, and Wyoming, other States in the region could potentially supplement their limited needs.

Figures 29 and 30 indicate that the region as a whole would need 1,240 additional RNs and 6,690 LPNs to address a surge. There is wide variation between the States and their current supply of RNs and LPNs. For instance, Utah has a great need for RNs to address current demands, while North Dakota and South Dakota have a surplus supply of RNs that could help offset this regional need. For LPNs, Colorado and Utah lead all States in need, while North Dakota has a surplus of LPNs when compared to the national average. The majority of the LPN need is based on a current need, where there is a regional excess demand for this profession.

Figures 31-34 depict additional staff shortage or surplus for each of the supplemental health professions: respiratory therapists, social workers, clinical lab staff, and nurse assistants. This region will need an additional 658 respiratory therapists, 923 lab staff, and 6,199 nurse assistants to address a regional surge. For respiratory therapists, only North Dakota has a surplus based on the national average, and South Dakota is expected to be able to meet its surge needs based on the HRSA benchmarks. Utah has a significant need for respiratory therapists because it already has a major shortage based on the national average. Colorado has a substantial need for clinical lab staff, while Utah may have an oversupply. The majority of the need for nurse assistants is based on a current environment of an excess demand to meet current medical needs. For social workers, the region has a large surplus for all States compared to the national average.

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^9. 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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Equipment

Current regional medical equipment resources are difficult to assess, particularly for a multi-state region. It was expected that the HRSA Hospital Preparedness Surveys would provide information describing the number of ventilators, personal protective equipment (PPEs) and other resources. The data from the hospital surveys from the 6 states was evaluated to determine whether these questions were asked and answered by the region's hospitals.

In developing measures of preparedness, equipment need was determined using the HRSA benchmarks. There is no HRSA benchmark for ventilator need. For PPE, the benchmark is 250 per million population in an urban area and 125 PPE per million population in a rural area.

Figure 35 displays the additional PPE figures that would be necessary in our region to meet the HRSA benchmarks. Urban areas would need 1,674 and rural areas would need 329 for a total of 2,003 additional PPE necessary to address the HRSA guidance. The difficulty with this need measure is that it is unclear what types of PPE are necessary in this number. Our region's HRSA Hospital Surveys only assess whether each hospital had PPE; specific counts were not requested by most states and when this information was requested it was not reliable. In order to assess regional preparedness for equipment it is necessary for hospitals to accurately assess their PPE counts and types and for HRSA or other groups to provide benchmarks on ventilator and specific PPE needs.

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Infrastructure

Infrastructure needs related to bioterrorism preparedness could range from basic facility functions, such as heating and ventilation and water supply, to parking capacity. For the purposes of this study we focused on infrastructure needs that are directly related to a bioterrorist event and for which HRSA has developed benchmarks. These include adequate decontamination systems and negative pressure and/or HEPA-filtered isolation facilities. It was hoped that the HRSA Hospital Preparedness Surveys from the six-State region would provide information on the hospital's current infrastructure related to decontamination and negative pressure/isolation capabilities.
The HRSA benchmarks for infrastructure are:

• Adequate portable or fixed decontamination systems for 500 patients per million population.
• At least one negative pressure, HEPA filtered isolation facility per health system able to support 10 patients at a time.

Based on the HRSA benchmark, 4,664 patients would require adequate decontamination for a surge in this region (Figure 36). The HRSA hospital surveys asked if facilities had decontamination capability; they did not address how many patients each hospital with capability could handle. Roughly one third of hospitals in three states that addressed this issue had this capability (Figure 19). Even if we assume that this is representative of the region, it is still unclear exactly how many patients could be handled by these systems. The hospitals may need to be questioned as to the number of patients they are able to decontaminate in a 24-hour period for this measure to be developed further to assess need using the HRSA guidance.

To measure current capacity of isolation beds in our region, we calculated a total of 828 isolation beds for the four states in the region (Figure 21) who asked the question on the HRSA hospital surveys. To begin to address the HRSA benchmark need for at least one negative pressure, HEPA filtered isolation facility per health system able to support 10 patients at a time, we calculated the approximate number of isolation beds per hospital in Table 9. We were not able to access individual level data for each hospital, and therefore made an assumption by dividing total number of isolation beds by total number of hospitals responding to obtain an average number of isolation beds per hospital estimate.

The region as a whole averages 2.7 isolation beds per hospital. It is probable that most of the isolation beds counted in the surveys are in urban facilities and therefore it hard to assume an "average per hospital," especially in our very rural region of the country. In addition, the HRSA benchmark is unclear as to how many isolation beds are needed, the guidance calls for one facility per health system to support 10 patients. Further clarification of a health system is necessary in order to accurately measure our region's need.

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