DRAFT

Pandemic Influenza

Medical Response Model

Includes:

Triage and Treatment Guidelines

Revision 1

DRAFT

May 24, 2007

1

Pandemic Influenza Medical Coordination &Page

Care Delivery Process

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1

Pandemic Influenza Medical Coordination &Page

Care Delivery Process

Table of Contents

Executive Summary

Introduction

Assumptions

Estimates of Impact of Pandemic Influenza

Pandemic Severity Index

WHO Global Pandemic Phases/ Federal Government Stages

Triggers to Activate

Medical Coordination

Triage and Treatment Guidelines

  1. Pre-Tier 1 – EMS Respose and Phone Triage
  1. Tier 1 – Triage and Outpatient Treatment, and Referral (NEHC)
  1. Tier 2 – Alternate Care Facilities (Acute Care Centers)

D. Tier 3 – Hospital Care

Supplement 1:Straw Person

Pre-Tier: Straw Person EMS & Phone Triage

NEHCStraw Person: Tier 1 – Neighborhood Emergency Help Center

ACC Straw Person: Tier 2 – Alternate Acute Care Centers

Supplement 2:Forms

Pandemic Influenza Screening & Triage Form

History and Physical Exam

Table 1: Clinical Criteria Commonly used for Classifying Dehydration Severity

Table 2: Constituten components and Recommendations for Oral Rehydration Therapy (ORT)

Table 3: Age and Weight-based ORT Dosing Guidelines

Admission Orders

Pediatric History and Physical Exam

Table 1: Clinical Criteria Commonly used for Classifying Dehydration Severity

Table 2: Constituent components and Recommendations for Oral Rehydration Therapy (ORT)

Table 3: Age and Weight-based Dosing Guidelines

Pediatric Admission Orders

Central Pierce Fire & Rescue, Release of Responsibility Form

Supplement 2a:Checklists

Supplement 3:Education & Information for Home CareInfection Control Guidelines

Infection Control Practices in the Home

Pandemic Influenza: Tier 1: Infection Prevention Guidelines

Pandemic Influenza: Tier 2: Infection Prevention Guidelines

Pandemic Influenza: Tier 3: Infection Control

Infection Control Guidelines: Residential Group Settings

Executive Summary

A community based group, organized through Tacoma-Pierce County Health Department and Washington State Department of Health, including hospital representatives, doctors, military (Madigan), fire and Emergency Medical Services (EMS), Pierce County Medical Society, Puyallup Tribe, Community Health Clinics, City of Tacoma, and Pierce County Department of Emergency Management (DEM), met to develop a model for medical response in a pandemic influenza scenario. Assumptions include a World Health Organization (WHO) estimated contraction rate of 25%, a very high hospitalization rate, and the local outpatient healthcare systems being overwhelmed.

A four-tiered disaster medical care delivery system is being proposed as follows:

Pre-Tier 1: EMS Response and Health Information Care and Nurse Triage Lines

Tier 1: Neighborhood Emergency Help Centers (NEHC): Triage and Referral function

Tier 2: Alternate Care Facilities (Acute Care Centers)

Tier 3: Hospital care reserved for most critically ill with likely favorable outcomes

Triggers have been defined to activate incremental mobilization, based on need. Specific patient medical symptoms and condition criteria are developed for each evaluative decision resulting in categorization of patients, and referral to appropriate level of care. A Tier 3 (Hospital) Response Matrix has been developed that outlines the Category of the pandemic, the Triggers, the Admission and Triage Guidelines and Actions. The Category and the Triggersrefer to the transition from Normal Standards of Care to Altered Standards of Care as the pandemic moves through the stages of impact and severity and activate certain Admission and Triage Guidelines and Actions.

A Medical Reserve Corps (MRC) is being developed. MRC is a group of community based volunteers called upon during an emergency to supplement existing medical response systems by providing surge capacity and working in alternate triage and treatment facilities. MRC can be practicing or retired doctors, nurses, dentists, EMT, pharmacists, mental health practitioners, medical assistants, and non-medical volunteers to help with management, communication and non-medical clinic roles.

All public health activities and medical response in PierceCounty will be founded on accepted ethical values. Ethicists from the University of Washington have been consulted and reviewed the guidelines for the Alternate Care Facilities and have provided feedback. Legal consultants have also participated at all levels of planning for triage and treatment during a pandemic.

We have built our treatment guidelines primarily on the principal of medical utility, i.e. maximizing the amount of medical benefit we can provide to the most number of people. This includes protecting our medical infrastructure so as to maintain a robust medical capacity, and treating all patients based solely on the amount of benefit they are likely to receive from our treatment of them.

Pre-Tier 1: EMS Response and Health Information Care Lines

To decrease burden on health care facilities and to lessen exposure of the “worried well” to persons with influenza, telephone hotlines will be established to provide advice on whether to stay home, be referred to a triage site, send EMS or a home care or hospice provider. These calls could come directly into 911 and 211 or the nurse advice lines.

Criteria are developed to identify “stable patient” and the “urgent sick” patient. The “stable patient” will be advised to remain at home and will be provided educational materials on home care with access to antibiotics and antiviral medications (AVM), if available.

The “urgent sick patent” will be referred to EMS or the nurse and/or general advice line. The nurse line will evaluate whether patient needs an in-person evaluation. If so, EMS may be sent or the patient will be referred to a Tier 1 NEHC. If EMS is sent, there are different outcomes including “no transport” and “transport” based upon condition criteria. The patient can be transported to Tiers 2 or 3, depending upon condition.

Late phase in the pandemic: when limited EMS available, limited resources, limited or no hospital beds, equipment or supplies available, the criteria for defining “urgent sick” remains the same, however, as resources become scarce, a new category of patient is assigned, the “too sick” patient. Chances of survival are assessed to be minimal, based upon established medical criteria. Morbidity scale to be followed. EMS transport determined by services available. Home health nurse or hospice sent, as appropriate and available. Place on list for follow up when Tier 2 or 3 open up. Provide family with home health care educational materials.

TIER 1: Alternate Care Facilities: Triage and Outpatient Treatment Centers/Neighborhood Emergency Help Centers (NEHC)

Tier 1 sites are located in approximately 36 urgent care and medical clinics located away from, but many in proximity to, hospitals and are geographically distributed throughout the county. Staffing may include MDs, RNs, ARNPs, PAs, LPNs, behavioral health, security staff, health educators, and pharmacy technicians. The Tier 1 sites will provide physical assessments of the patient, treatment per standing protocols for antibioticis and AVM, if eligible and available, and either advise the patient to return home or arrange for transport to Tier 2 (ACC) or to Tier 3 (Hospitals), depending upon patient’s condition. Standard patient screening forms, history and physical exam forms, and admission and treatment orders forms have been developed. A patient tracking system is being developed.

TIER 2: Alternate Care Facilities - Acute Care Centers

Acute Care Centers are 14 proposed locations throughout the county, predominantly high schools, designed to function as alternate inpatient care facilities to augment hospital capacity to admit pandemic influenza patients. Local hospitals may be linked to the alternate triage and treatment centers to coordinate and direct patient care, medical logistics and information flow. Tier 2 facilities are designed to care for patients who are too sick to be cared for at home and might need a few hours to a few days of medical care. Examples of types of services available include supplemental oxygen requirement, oral hydration therapy, IV bolus, O2/NC, as appropriate, antiviral medication, IV antibiotic treatment of pneumonia, vital signs monitoring including pulse oximetry, antipyretics and analgesics, limited airway management (but no ventilators available), lab work, palliative care, and fatality management. No X-ray; no aerosolized procedures. Standard forms will accompany patient from Tier 1.

TIER 3: Hospital Care

A Response matrix has been developed to provide guidelines for hospital personnel in determining admission of patients to critical care units.

Introduction

A major biological incident, such as Pandemic Influenza, has the potential to significantly overwhelm the health and medical capabilities of a region. A major obstacle facing public health and emergency managers is that most communities have limited ability to expand health and medical capacity on a daily basis within existing infrastructure. PierceCounty medical care infrastructure is a patchwork of primarily private and public medical provider offices, hospitals, tribal, military, and mental health practitioners and makes emergency planning for response to medical disasters extremely difficult.

A Pandemic Influenza will most likely present in waves, with the Pandemic lasting as long as 9 months to well over a year. Upwards of one-third of the workforce will be affected with healthcare workers overwhelmingly impacted. Antiviral medications and vaccines may be of limited availability. Hospitalization rates for PierceCounty alone is estimated to be close to 25,000 and over 113,000 outpatient medical care visits. Although social distancing and other methods will be instituted, they will only, at best, mitigate the expected demands on the medical system.

Pandemic Influenza planning assumptions include planning for NO or MINIMAL FEDERAL response capacity. This is very different from other types of emergency response planning, where preparation plans recommend 3 to 7 days of supplies and capabilities to be self-sufficient until help arrives. In the case of a Pandemic Influenza, communities may stand alone throughout the pandemic period.

According to the Pierce County Comprehensive Emergency Management Plan (CEMP) that outlines response authorities, and primary and support agency responsibilities, Tacoma-Pierce County Health Department is the primary agency responsible for health and medical response, coordination and management. For this reason, TPCHD along with many other community partners, has been engaged in a lengthy and challenging process of planning for the county’s medical response to pandemic influenza.

A critical and essential function during a pandemic will be to divert the “worried well,” “stable sick,” and “urgent sick” patients away from the existing hospital medical systems by using alternate care facilities to ensure medical resources are used for maximum benefit. These alternate care facilities will be available for the public to be triaged, receive information, and obtain medical services. A review of existing medical disaster models resulted in the proposal of creating a four-tiered disaster medical care delivery system, using existing infrastructure as much as possible.

Objectives include:

  • Develop processes to recruit, educate, and activate community medical providers and ancillary personnel to deliver medical care during prolonged medical emergencies.
  • Develop standardized triage and treatment protocols for pandemic influenza and clinical standards that include consideration of ethical and legal issues regarding allocation of limited resources.
  • Identify and develop a Concept of Operations document for the PierceCounty integrated medical disaster care delivery system in response to a pandemic influenza.

We understand that difficult decisions may need to be made in implementing a pandemic influenza medical response model, and that regardless of how these decisions are made, some people will be dissatisfied with the outcome. As a community, we must strive to make the best choices possible and remain transparent. To guide our planning, we rely on the following principles:

  1. To the greatest extent possible, everyone in PierceCounty who becomes ill should be given the best care we can provide at that time, regardless of that person’s social worth.
  2. To maximize our ability to implement this model, caregivers who work directly with patients and essential healtcare support workers should be considered a priority group for all preventive healthcare resources that become available (e.g. vaccine, prophylactic antiviral drugs).
  3. If resources become so scarce that we cannot provide all patients with the care they need, care should be given to the patients likely to receive the most benefit from those resources.
  4. If it should become necessary to restrict individual liberties for the sake of the public health, the least restrictive interventions likely to be effective should be employed.

Promoting pre-registration of all healthcare providers in the PierceCounty’s Medical Reserve Corps is essential. Pre-registering provides consistent baseline training on Alternate Care Facilities, Command and Control, and introduction of the medical disaster system. A clinical management group will be established to coordinate evolving standards of care issues consistently across the health care delivery model. Declared emergencieEmergency declarations spermit relaxation of standards of care through waiver of laws and regulations, closure of business, and staff reassignments. PierceCounty medical professionals and their offices will be impacted. In an environment of social distancing, limited resource procurement, equipment and supply shortages, and high absenteeism due to fear and illness, coordination of the medical care delivery system is absolutely necessary.

As stated above, a pandemic influenza will expose healthcare systems to difficult ethical choices that will arise rapidly. All public health activities and medical response in PierceCounty will be founded on accepted ethical values. These include the basic belief that every individual should receive the best care that can be provided as long as this is possible, and that individual liberty should be respected to the greatest extent possible while still protecting the health of the public.

Abiding by these principles can lead to some decisions that are not pleasing. For example, at the height of the pandemic, patients who have little chance of survival may have care denied or be moved to palliative care to free up resources for someone who has a better chance of recovery. Such life and death decisions are not easy to make, so it is crucial that we understand them well and discuss them in detail before such an event occurs. This will help us in making the right decisions when the pressure is on, and it will ease the burden on those who are responsible for making such decisions.

A team of community members has organized to develop a model of medical care delivery during a pandemic influenza. Members include TPCHD personnel, representatives from the hospital systems, Infection Control Practitioners, community medical provider practice representatives, Emergency Response Planners, First Responders such as EMS personnel, PC Department of Emergency Management, Madigan Army Medical Center, Fort Lewis, The Red Cross, and legal and ethics representatives, and the EIS officer from the DOH/CDC.

The medical model formulated is based on a four-tiered response to people who will be seeking medical care during a pandemic influenza.

  • Pre-Tier I – EMS Response and Health Information Care and Nurse Triage Lines
  • Tier 1 – Neighborhood Emergency Help Centers (NEHC): Triage, Outpatient Care, and Referral Function
  • Tier 2 – Alternate Care Facilities (Acute Care Centers)
  • Tier 3 – Hospital care – reserved for most critically ill with favorable outcomes

Assumptions

  • Due to the high degree of infectiousness of pandemic influenza, the number of persons affected will be high. The CDC has estimated a “contraction” rate of 30% of the population for the flu strain that may develop from the current avian flu threat.
  • Due to the severity of the avian flu strain, experts believe that it would result in a very high hospitalization rate. The number of ill people requiring outpatient medical care and hospitalization will overwhelm the local healthcare systems.
  • Health care workers and other first responders will be at higher risk of exposure and illness than the general population, further straining the health care system.
  • Effective therapeutic measures, such as vaccines and antiviral medications will be delayed and in short supply.

Estimates of the Impact of a Pandemic Influenza:

Number of Episodes of Illness, Healthcare Utilization, and Deaths in PierceCounty Associated with Moderate and Severe Pandemic Influenza Scenarios*
Characteristic / Moderate (1958/68-like) / Severe (1918-like)
Illness / 226,500 / 226,500
Outpatient medical care / 113,250 / 113,250
Hospitalization / 2,176 / 24,915
ICU Care / 324 / 3,737
Mechanical ventilation / 163 / 1,876
Deaths / 525 / 4,789
1. Estimates based on extrapolation from past pandemics in the United States. Note that these estimates do not include the potential impact of interventions not available during the 20th century pandemics.
2. Projected impact over 2 waves; majority will occur in one wave; difficult to predict which wave will be worse.
3. The clinical attack rate estimated to be 30% in the overall population. (Ref: CDC, WHO, HHS)

The CDC has recently created a Pandemic Severity Index for categorizing the severity of a pandemic (Feb 2007). The index is designed to enable estimation of the severity of a pandemic on a population to allow better forecasting of the impact and to enable recommendations to be made on the use of mitigation interventions that are matched to the severity.

Pandemic Severity Index Table

Case Fatality Ratio / Pandemic Severity Index / Projected Number of Deaths*U.S. Population, 2006 / Projected Number of Deaths in PierceCounty**
> 2.0% / Category 5 / > 1,800,000 / >4,500
1.0 - < 2.0% / Category 4 / 900,000 - < 1,800,000 / 2,250 - < 4,500
0.5 - < 1% / Category 3 / 450,000 - < 900,000 / 1,125 - < 2,250
0.1 - < 0.5% / Category 2 / 90,000 - < 450,000 / 233 - < 1,125
< 0.1 % / Category 1 / < 90,000 / < 233

*Assumes 30% Illness Rate and Unmitigated Pandemic without Interventions. ** PierceCounty population estimate of 775,000. Ref: Interim Pre-Pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States, February 2007 adapted Figure 4.