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Over capacity forecast to cost hospital $7M in 2016-17

https://www.sudbury.com/local-news/over-capacity-forecast-to-cost-hospital-7m-in-2016-17-562253Health Sciences North continues to battle with capacity issues, as the hospital operated at a critical level for as much as 75 per cent of last year.

Most days, HSN is sitting at 110 per cent occupancy, or in the red level of the hospital’s surge plan that is divided into four categories, with red identified as “Escalation Level 2,” just one level before the fourth and final, black category, “Escalation Level 3 – crisis.”

In the 2015-16 fiscal year, overcapacity cost HSN $3.5 million and that number is projected to double for 2016-17, up to $7 million. A report presented to the HSN board on March 14 by David McNeil, the vice-president of patient services, indicated the hospital is forecasting 5,000 patient days over capacity, with the average cost per patient per day pegged at $1,400.

“We’re in the black (Escalation Level 3) almost 50 per cent of the time,” said David McNeil, vice president of patient services, HSN. “In that instance, we’re shutting down to any patient that is non-life or limb (critical). Obviously, if there’s a life and limb patient we help them.”

“This isn’t a matter of having an inefficient hospital, it’s a matter of being overcapacity,” said McNeil. “We can’t solve this alone and more beds aren’t the solution, it’s a matter of getting patients in the right place at the right time.” See more…

 

Critical Resources for Hospital Surge Capacity: An Expert Consensus Panel

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805833/2013 October 7 [revised 2013 October 7]; 5: ecurrents.dis.67c1afe8d78ac2ab0ea52319eb119688. Abstract Background: Hospital surge capacity (HSC) is dependent on the ability to increase or conserve resources. However, emergency planners need to know which hospital resource are most critical in order to develop a more accurate plan for HSC in the event of a disaster.

In 2009, the Agency for Healthcare Research and Quality (AHRQ) developed a Hospital Surge Model 6 that forecasted the hospital resources required to treat casualties resulting from 13 National Planning Scenarios 7. The AHRQ’s planning tool was discontinued on June 30, 20116. The objective of our study was to identify which of the AHRQ hospital resources were the most critical to care for patients in four of the National Planning Scenarios: pandemic influenza, radiation event, explosion, and nerve gas attack 7. This information is essential for hospital preparedness planners to make supply-chain driven decisions based on the number of patients treated. In addition, we wished to determine which of these critical hospital resources were common across multiple types of events, and distinguish resources that are critical only for specific scenarios.

Of the 132 hospital resources evaluated, 25 were considered critical in all four scenarios by more than 50% of participants (Table 2). There was 90% or more agreement among panelists on 16 of these 25 hospital resources, with agreement ranging from 64.7% to 100%. Crystalloid solution was the only resource that had 100% agreement on being critical, in all four scenarios.

Twenty five hospital resources were found to be critical to maintain continuity medical care in four disaster planning scenarios; namely radiation, pandemic influenza, explosives, and nerve gas scenarios. However, some specific disaster scenarios require additional critical specialized resources necessary for the corresponding type of disaster. Planning for each hospital should be dictated by the hazard vulnerability analysis, gauging their vulnerabilities within the environment, in order to prioritize and maintain adequate supplies of scenario-specific critical hospital resources. Further studies are needed in the field of hospital surge capacity, to validate these findings, determine utilization rates for each of the resources during a surge event, and to identify appropriate alternatives to these critical hospital resources36. Critical Resources for Hospital Surge Capacity: An Expert Consensus Panel

 

Temporary Isolation Rooms and their Application to Hospital Surge Capacity for Infection Control

http://www.microbe.net/2014/10/04/temporary-isolation-rooms-and-their-application-to-hospital-surge-capacity-for-infection-control/Temporary Isolation Rooms and their Application to Hospital Surge Capacity for Infection Control – microBEnet: the microbiology of the Built Environment network Guest Blog Post by Dr. Nick Clements, PhD Post-doctoral Researcher, University of Colorado Boulder, Miller Research Group

In the event of a disaster, hospitals must have plans in place for receiving a surge of patients with a variety of possible infectious diseases or conditions. Pandemic-causing infectious diseases, such as the viruses that caused the SARS (2003), H1N1 (2009), and EBOV (2014) outbreaks, pose a particular public health threat that must be mitigated through careful planning (Lurie et al., 2009; Mead et al., 2012; Frieden et al., 2014). Hospital surge capacity plans commonly include protocols for handling the various stages of crisis. For example, Hick et al. (2009) proposed three categories of hospital operating conditions during a surge: conventional conditions, in which normal operating conditions are maintained but hospital bed capacity and some services are strained; contingency conditions, in which functionally equivalent care is provided to patients even though services are overextended and capacity is overburdened (e.g. operating suites are converted into ICU’s); and crisis conditions, where hospitals must strive to provide only sufficient care considering circumstances where staff may be exhausted, a shortage of supplies could exist, and facility capacity is overwhelmed. Crisis conditions may include adopting triage practices and will require close coordination between many local health organizations for solving logistical issues like transporting patients, maintaining staff, and stocking and distributing supplies (Lurie et al., 2008; Hick et al., 2010).

In the specific case of a large-scale pandemic or bioterrorism attack, hospitals must have the capability to isolate a surge of infectious patients from the public. Hospitals should be prepared for at least a 300-500% increase in ICU and isolation room capacity in the event of a surge (Rubinson et al., 2005). Portable anterooms and negative air machines can be used to construct temporary isolation spaces, and rooms with specialized ventilation conditions, like pre- and post-anesthesia suites and operating rooms, can house infectious patients to increase capacity if needed (Anderson et al., 2007; Hick et al., 2010). Infectious patients require negative pressure in their isolation room relative to the adjacent hallway, so that the direction of airflow is always into the isolation room. This limits the possibility of infectious particles generated by the patient escaping the room. Conversely, positively pressurized protective isolation rooms are needed when patients are immunocompromised, for example if many burn victims are among the patients of a surge or if patients have been exposed to radiation.

When designing negative pressure isolation rooms, the American Institute of Architects (AIA) recommends the room be pressurized to -2.5 Pa relative to the adjacent hallway with 12 air changes per hour (ACH), of which 2 ACH must be outside air (Mead et al., 2012). The AIA also recommends that isolation room exhaust be directed outdoors and HEPA filtered if not released from an on-roof stack (Rosenbaum et al., 2004), though other disposal routes are also possible (e.g. Anderson et al., 2007). For protective positively-pressurized isolation rooms, the Centers for Disease Control and Prevention (CDC) recommends 12 ACH, HEPA filtered supply air, and more than 2.5 Pa of pressure, though 8 Pa is recommended (CDC, 2003). Active monitoring of the pressure differential between an isolation room the adjacent corridor is also recommended. Even though these recommendations are in place, studies of actual isolation room performance show that often these spaces operate with sub-optimal conditions. Saravia et al. (2007) demonstrated that 90% (n=560) of the hospital isolation rooms tested did not have the appropriate ventilation conditions to be used as an infectious isolation room. The long-term assessment of isolation room performance by Rice et al. (2001) demonstrated that isolation room operating conditions may shift away from optimal for a variety of reasons, and operating conditions are somewhat temporally variable. For example, a loose air handling unit fan belt and HVAC personnel accidentally moving a return damper during duct cleaning resulted in sharp changes in isolation room pressure during the Rice et al. assessment.

Use of an anteroom is optional, but highly recommended, as a barrier between the isolation space and the rest of the hospital. The anteroom of a negative-pressure isolation room can be neutrally, positively, or negatively pressurized, depending on how the anteroom will be used and/or how infectious the pathogen being contained happens to be. Positive-pressure protective isolation rooms should always have negatively pressurized anterooms (Anderson et al., 2007). While there is no technical recommendation for anteroom pressures and flow rates, high air exchange rates in anterooms are recommended (ACH>~12), as increasing the rate of dilution will decrease the likelihood of particle escape (Anderson et al., 2007; Wiseman, 2003).

For infectious isolation rooms, a positively pressurized anteroom allows for personal protective equipment (PPE) to be put on in a protective environment prior to entering the isolation room. A drawback of this design is if infectious particles are able to reach the anteroom, from movements of the healthcare personnel for example (Hayden et al., 1998; Adams et al., 2011; Tang et al., 2013), they can be dispersed into the hospital. A negative pressure anteroom should be less pressurized than the isolation room so the flow of infectious particles is from the hallway, to the anteroom, to the isolation room. This arrangement is likely to provide improved physical isolation but may require a larger supply/exhaust flow differential in the isolation room to reach the appropriate pressure differential. Neutrally pressured anterooms only provide a physical barrier and ventilation-based dilution for infection control (Hyttinen et al., 2011). Donning of PPE in a neutral or negatively pressurized anteroom is not recommended.

For infectious isolation rooms, a positively pressurized anteroom allows for personal protective equipment (PPE) to be put on in a protective environment prior to entering the isolation room. A drawback of this design is if infectious particles are able to reach the anteroom, from movements of the healthcare personnel for example (Hayden et al., 1998; Adams et al., 2011; Tang et al., 2013), they can be dispersed into the hospital. A negative pressure anteroom should be less pressurized than the isolation room so the flow of infectious particles is from the hallway, to the anteroom, to the isolation room. This arrangement is likely to provide improved physical isolation but may require a larger supply/exhaust flow differential in the isolation room to reach the appropriate pressure differential. Neutrally pressured anterooms only provide a physical barrier and ventilation-based dilution for infection control (Hyttinen et al., 2011). Donning of PPE in a neutral or negatively pressurized anteroom is not recommended.

Isolation wards were historically used for long-term care of patients with communicable diseases such as tuberculosis. As infection control practices improved, the use of sanatoriums decreased through the middle of the 20th century in favor of treatment at general hospitals and home (Mead et al., 2012). In the event of a patient surge though, establishing a temporary isolation ward, like that shown in Figure 1, can be a solution for increasing isolation room capacity. To date, there are few studies testing the effectiveness of establishing temporary isolation wards during a surge. One published study, by Rosenbaum et al. (2004), demonstrated during a disaster preparedness drill at a hospital that multiple HEPA-filtered negative air machines placed in a physical therapy gymnasium can produce the recommended pressure and ACH for a negative-pressure isolation room. Prior to including the establishment of a temporary isolation ward in a hospital surge capacity plan, a successful full-scale demonstration should be performed to determine logistical and engineering issues that need to be addressed prior to plan adaptation.

 

Hospital Surge, Exercises and Pandemics

http://www.dailykos.com/story/2008/04/13/494601/-Hospital-Surge-Exercises-and-PandemicsA healthcare surge is proclaimed in a local jurisdiction when an authorized local official, such as a local health officer or other appropriate designee,3 using professional judgment determines, subsequent to a significant emergency or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources and/or emergency medical services. The local health official uses the situation assessment information provided from the healthcare delivery system partners to determine overall local jurisdiction/Operational Area medical and health status.

An influenza pandemic is an example of the type of natural disaster that would require health care surge. As an update of where we are at with H5N1 and bird flu, try this piece from the Times (UK):

This triage discussion has already begun. New York State, for example, has developed ventilator triage in the event of a pandemic:

Ventilators may be in short supply in a flu pandemic, so New York state officials have drafted guidelines to determine which patients would get one if there weren’t enough to go around.

Similar suggestions have been made for ICU beds.

Development of a triage protocol for critical care during an influenza pandemic

California takes it one step further:

The new “surge capacity guidelines”  – which authorities hope will serve as guidlines for hospitals nationwide, especially in the event of a pandemic – calls for letting older, sicker patients be allowed to die in order to save the lives of patients more likely to survive a catastrophic public health crisis.

“During a major disaster, the heath care system will look very different from what we are accustomed to,” said Dr. Mark Horton, director of the California Department of Public Health. “These guidelines will help communities as they plan how to sustain a functioning health care system following a catastrophic event such as a severe earthquake, bioterrorism attack or outbreak of pandemic influenza.”

In the event of a pandemic, the hospital would be overflowing with patients. To alleviate some of the bed crunch, the area nursing homes and extended care facilities would pool their available beds, accept transfers from the hospital to free up bed space, and utilize empty beds remaining to act as a 23 hour alternate care facility for flu patients. The Ottilie W. Lundgren Memorial Field Hospital would be set up adjacent to an area nursing home (not the hospital), and the parking garage would be used as a drive-thru (stay in your car) flu clinic…

To minimize is not to eliminate. Tough choices would still be made, and home care in one form or another would still be needed. To that end, personal preparation never stops being needed. More people would need to be cared for at home than in the hospitals, and without decent home care, planned in advance, and including food and water so as to be able to stay at home with ill family members (HHS recommends two weeks of food and water be stockpiled by all Americans), increased surge capacity will not be enough.

Through websites like www.getpandemicready.org and Flu Wiki (both of which I have contributed material to), and though service organizations like American Red Cross and Lions Clubs, and professional organizations like Trust for America’s Health and the American Academy of Pediatrics, serious steps are being taken to prepare. Hospital Surge, Exercises and Pandemics

 

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