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Home My WebLink AboutMINUTES - 12151998 - SD2 FHS#22 TO: BOARD OF SUPERVISORS *:� --''� ° CONTRA COSTAea es r FROM: FAMILY& HUMAN SERVICES COMMITTEE COUNTY DAVE: December 15, 1998 SUBJECT: Flu Season Readiness of Hospital Emergency and Critical Care Services SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION RECOMMENDATIONfS): 1. ACKNOWLEDGE that the winter flu season is imminent and that last year the County declared a state of emergency due to shortages of hospital emergency and critical care services. 2. ACKNOWLEDGE that the Emergency Medical Service Agency and Hospital Council have worked together over the past year to improve the ability of the health care system to handle the winter flu season. 3. EXPRESS concern that there is still not assurance of sufficient capacity within the system. 4. CONSIDER the update from the Family and Human Services Committee's [December 14, 1998 meeting on hospital emergency and critical care service capacity. BACKGROUNDIREASON(S) FOR RECOMMENDATION(SI: On January 27, 1998, the Board declared a local emergency in Contra Costa County pursuant to Government Code Section 85580 in response to shortages of hospital emergency and critical care services available to respond to the medical need's of the flu season. Since that time, the Contra Costa Emergency Medical Services Agency has been working with the Hospital Council and local hospitals to plan for the upcoming winter flu season. CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER Ge onna SI NATUR rbe '' Mark DeSaulnler a D ACTION OF'BOARD ON Decpmhar IS, 1 9 9 A APPROVED AS RECOMMENDED X.X OTHER On this date,the Board of Supervisors heard the presentation by Supervisor Gerber. The public hearing was OPENED,and the following people offered comments: Kay McVay, 3644 Ranchford Court,Concord; Nancy Casazza, California Nurses Assoc.,2690 Sonoma Way,Pinole;Kamal Singh, 136 Peridot Court,Hercules; Jim Ryder, 8393 Capwell Drive, California Nurses Assoc., Oakland;Lynn Baskett,Hospital Council; Susan Bateman Ketcham,R.N., 4875 Thiessen Court,Concord. Those desiring to speak having been heard,the hearing was CLOSED, and the Board APPF07 the'recommendations set forth above. VOTE OF THE SUPERVISORS I HEREBY CERTIFY THAT THIS IS A XX UNANIMOUS(ABSENT_ — 1 TRUE AND CORRECT COPY OF AN AYES: NOES: ACTION TAKEN AND ENTERED ABSENT: ABSTAIN: ON MMES OF THE BOARD OF SUPERVISORS ON THE DATE SHOWN. Contact:Sara Hoffman,335-1090 ATTESTED Decembnr 1 5, 4$ cc: CAO PHIL BATCHELOR,CLERK OF Lynes Baskett,Hospital Council THE WARD OF SUPERVISORS Art Lathrop,EMS AND COUNTY ADMINISTRATOR Bill Welker,Heaps Senor s By DEPUTY ......... ......... ......... ......... _ ..............._... ......... ......... ........ ......... ......... ......... ......... _.._. _....... ......... ......... ......... ......... ......._. ...................................................................................... SUPPLEMENTAL SERVICES Please indicate which of the following Supplemental Services are provided within your facility with current State Department of Health Services approval, meeting ALL provisions of the appropriate section of Title 22 Article 6. SERVICE SECTION(S) Coronary Care Service 70461-69 YES ' NO Dental/Oral Surgery Service 70471-79 YES NO Intensive Care Service 70491-99 YES ' NO Nuclear Medicine Service 70505-13 YES ' NO Occupational Therapy Service 70515-23 Y:=NO Pediatric Service 70535-43 YES ' NO Perinatal Unit 70545-53 YES ' NO Physical Therapy Service 70555-69 YES ' NO Rehabilitation Center 70595-603 YES ' NO Respiratory Care Service 70615-23 YES NO Social Service 70629-37 YES NO Speech Pathology and/or Audiology 70639-47 YES NO If any of these supplemental services are provided in a limited fashion or without current State Department of Health Services approval, please describe here, or on a separate page any discrepancies with these provisions the limitations of the service and the current State approval application status. Contra Costa Health Services ` emergency Medical Servir_es 3 Acute Care Facility Serf-Assessmenr 9198 ......... ......... ......... ._...._.. ........_.......__ ......... ......... ......... ......... ......... ........._..__. _.. ......... ......... ......... ......... ......... ........ ........................................................................................ HC?SPITAL SPECIALTY SERVICES Please indicate if any of the following services are provided (as described) in your facility: SERVICE Inpatient acute hemodialysis services staffed by appropriately trained technicians in-house or on-call 24 hours per day, under the direction of a qualified Nephrologist. YES NO Inpatient acute hemodialysis services provided though not available 24 hours a day, 7 days a week. YES NO Pharmacist in-house 24 hours a day. YES NO Radiation Emergency Medical Team available on 24-hour calls, including radiation medicine physician, health physicist and radiation technician. YES NO Hand surgery service with experienced hand surgeon with experience in macro and micro vascular surgery on- call and promptly available 24 hours a day. YES NO Physical medicine/hand rehabilitation service including psychiatry services on call, occupational therapy services, physical therapy, hydrotherapy, social services, and pain clinic. YES NO Trauma Services (EMS designated Trauma Center). YES NO If designated Trauma Center, special pediatric trauma capabilities? YES NO Trauma rehabilitation services provided by dedicated rehabilitation staff under the direction of physician and supportedby physical therapy, social services, psychologist, and occupational therapy personnel. YES NO Burn Service (organized burn service components including burn service physician director, in-service training for personnel, burn care protocols, and routine evaluation of burn care). YES NO Contra Costa Heaith Services . Emergency Merlical Services 4 Acute Care Facility Se!f-Assessment 9198 PATIENT INTERFAQLIJY TRANSFERS Do you have transfer agreements with other hospitals to facilitate ;the transfer of any of the following types of patients to, or from, your facility? TYPE OF AGREEMENT TO AGREEMENT TO TRANSFER TRANSFER TO (list all): RECEIVE FROM (list all): Traumatic Injuries Spinal Cord Injuries Burn Emergencies Pediatric Emergencies Cardiac Emergencies Other types of transfers (please specify when listing) Contra Costa Health Services ' Emergency Medical Services 5 Acute Care Feci#ry Self-Assessment 9/38 . .......................... ..... _........ . . ..... .......... ......... ........ ......... ......... 111.1.._. ......... ......... ......... ......... ......... ......... ...._.._. . ......................................................................................................... ......................... EMERGENCY SERVICES EMERGENCY DEPARTMENT CAPACITY / RESOURCES 1997 emergency department (ED) patient volume: Novy many total patient treatment spaces (not beds) are available in the ED? Number of Ell resuscitation spaces sufficient to accommodate a portable x-ray machine and 3 staff at the bedside of each patient simultaneously: Other emergency monitored spaces: How many patients can be monitored from the nurses' station simultaneously? Non-critical care treatment spaces: Does your facility have an FAA and CALTRANS approved helipad? YES NO If no approved helipad, does your facility have an identified EMS landing site? YES NO Is your facility an EMS designated base hospital? YES NO Contra Costa Neaith Services ' Emergency Medical Services 6 acute Care Facility Seif-Assessment 9198 RADIATIONMAZARDOUS MATERIAL EXPOSURE PREPARATION RADIATION I HAZMAT CAPABILITIES Does your ED maintain or have reedy access to the following equipment for radiation or hazardous material exposure management: separate decontamination area with buffer zone, control points, shower and sink YES NO area in or near the emergency department designated in advance as a potential decontamination area YES NO radiation detection equipment including portable equipment, survey meter and film badges or dosimeters YES NO decontamination table with drainage system YES NO water resistant floor covering YES NO disposable gowns, masks, gloves YES NO water hose with flexible Shower head YES NO decontamination supplies YES NO Does your ED maintain or have ready access to YES NO written or telephone information for radiation or hazardous material exposure management? Has the federal government designated or YES NO contracted with your facility as a directed support facility for radiationlhazardous material injuries? Corirra Costa Health Services ` 6mryency Medical Serwres 7 Acure Care Fac;f tv Self-Assessmenr 9/98 ......... ......... ......... ............... .. ........ . ......... ......... ......... ......... ......... ......... ......... .._.... ......... ......... ......... ......... ......... ......... ............................................................................................... ............. DISASTER EMERGgNCY PREPAREDNESS DISASTER PREPAREDNESS / CAPACITY Has your facility adapted and integrated the Hospital Emergency Incident Command System YES NO (HEICS)? Does your facility have a written hospital evacuation plan on file with the local EMS YES NO Agency? Do critical resources in your facility meet State mandated 2008 seismic standards: Emergency department NOT YET YES NO DETERMINED Surgical suites NOT YET YES NO DETERMINED number of suites meeting standards NOT YET DETERMINED Laboratory facilities NOT YET YES NO DETERMINED Radiology facilities NOT YET YES NO DETERMINED ' Intensive Care Unit(s) NOT YET YES NO DETERMINED number of beds meeting standard NOT YET DETERMINED General inpatient units NOT YET YES NO DETERMINED number of beds meeting standard NOT YET DETERMINED Does your facility have a National Defense Medical Systems (NDMS) agreement with the Federal Government? YES NO Contra Costa Health ServicesEmrrc�ancy Medical Services 8 -;cute Care Fac,lity self-Assessment 9/98 INTENSIVE CARE UNITS INTENSIVE CARE CAPACITY Number of licensed intensive care beds in your facility: If you have a California Childrens Services (CCS) designated Pediatric Intensive Care Unit, number of beds: Number of intensive care beds with pediatric equipment and nurses trained in pediatric ICU patients: If you have a separate CCU, number of beds: If you have a separate Neurosurgical Intensive Care Unit, number of beds: If other designated intensive care specialty beds, please specify number and type: f OTHER MONITORED INPATIENT BED CAPACITY Number of monitored step-down or telemetry beds: Are these beds in addition to licensed intensive care beds? YES i NO How many patients can be monitored from a central nurses' station simultaneously? If other monitored inpatient beds, please specify number and type: Contra Costa Health Services , Emcryencv^✓Medica!Services 9 Acute C:areFaci)iry&-!F-Assessment 9/98 ......... ......... ......... ......... ....._._. ........_.... .. ......... ......... .......... ....... ......... ......... ......... _. _........ ......... ......... ......... ......... ......... ......... . .................................................................................................... ................... SURGICAL SERVICES SURGICAL SERVICES CAPACITYISTAPPING Number of surgical suites: In-house surgical staffing 24 hours a day: YES NO On-call surgical staffing available 24 hours a day by written policy: YES NO Back-up on-call surgical team available within 1 hour YES NO POST-ANESTHESIA RECOVERY CAPACITY/STAFFING Does your facility have a separate post-anesthesia recovery unit? YES NO Number of dedicated post-anesthesia recovery beds: If no separate post-anesthesia recovery unit, do you use ICU for recovery? YES NO Registered Nurses in hospital 24 hours per day and who are specially trained in post-anesthesia recovery? YES NO RegisteredNurses and other essential personnel available 24 hours per day by written policy? YES NO Contra Costa Heairh Services ' Emerysncv Medical Services 10 Acute Care Facd;ry Self-Assessment 9198 ......... ......... ......... ......... .1.111. _ .. _ ........._.... .......... ......... ......... ......... ._....... ......_.. ........ ......... ......... ......... ......... ......... ................................................................................................ .1.11.1............. CRITICAL ANCILLARY SERVICES LABORATORY SERVICES/STAFFING Does your facility have in-house laboratory staffing 24 hours a day? YES NO On-call or back-up lab staff available 24 hours a day by written policy? YES NO Please indicate which of the following laboratory services are available at your facility 24 hours per day. Chemistry YES NO Hematology YES NO Coagulation YES NO Toxicology YES NO Microchemistry YES NO Blood hank YES NO What is your source of blood products? Contra Costa Health Services " Emargency 'Aettical SdMICe3 l Acute Care Facility Self-A ssessmen r 9198 CRITICAL ANCILLARY SERVICES RADIOLOGY & SPECIAL PROCEDURES 1 STAFFING Does your facility have in-house radiology staffing 24 hours a day? YES NO On-call or back-up radiology staff available 24 hours a day by written policy? Do you have the fallowing special capabilities in-house or available within one hour by written policy: Angiography, coronary artery YESNO Angiography, all other types YES' NO Computer tomography--head YES NO Computer tomography - body YES' NO {Magnetic resonance imaging YES NO Ultra sound (sonography) YES' NO Nuclear scanning YES' NO Echocardiography YES NO Cardiovascular stress testing within 24 hours YES' NO Myelography YES' NO Ventilation perfusion lung scan capabilities YES NO Thallium scanning capabilities within 24 hrs YES NO Contra Cbsta Hnafth Services ' Emergency P4erfrca!Services 12 ,acute Care Facility Seif-Assessmenr 9198 PHYSICIAN SPECIALTY AVAILABILITY Please indicate specialty and sub-specialty practice physician availability in the appropriate category. Refer to the definitions below before checking the appropriate box. IN-HOUSE: In-hospital 24 hours a day, 7 days a week. This requirement may be fulfilled by residents or other in-house (non-emergency department) physicians with special competence in the care of emergencies relevant to that specialty as judged by the chief of the respective service with qualified attending staff specialists on-call and promptly available for consultations and on-site supervision. {Vote: General surgery residents must have completed at least 3rd year of residency to fulfill this requirement. NORMALLY PROMPTLY AVAILABLE: On-call 24 hours a day, 7 days a week and listed on the Emergency Department call list with a minimum of 3 specialists in each category on-staff and routinely participating in the call schedule. OCCASIONALLY AVAILABLE: Staff physicians on-call only intermittently, not always available, available during certain hours only, or fewer than 3 specialists in each category on staff and participating in the call schedule. NOT AVAILABLE: Specialty or sub-specialty practice physician is not available. ' Contra Costa Health Services ' Emergency'Veaical Services 13 Acute Care Facility Seif-Assessment 3188 PHYSICIAN SPECIALTY AVAILABILITY SPECIALIST IN NORM. OCCASION. NOT HOUSE AVAIL. AVAIL. AVAIL. Anesthesiology Cardiac Surgery Cardiology i Dentistry/Oral Medicine Emergency Medicine Family Practice General Surgery Internal Medicine Neurology Neurologic Surgery OB/GYN Surgery Ophthalmic Surgery Orthopedic Surgery Otorhinolaryngologic Surgery Pediatrics Psychiatry Thoracic/Vascular Surgery Radiology Urologic Surgery Contra Costa Health Servjces ' EmGrgency Medical Services 14 Acute Care Factlity Seif-Assessment 3193 ......... ......... ......... ....... .1 .................. ......... ......... ......... ......... ......... _ ................................................................................................................... ................................... PHYSICIAN SPECIALTY AVAILABILITY NOTE: For the following group of specialists, the definition of Normally Promptly Available is revised to "on-call 24 hours a day, 7 days a week with; a minimum of 2 specialists." SPECIALIST IN NORM. OCCASION. NOT HOUSE AVAIL. AVAIL. AVAIL. Allergy Clinical Toxicologist Endocrinology Gastroenterology Gerontology Hand Surgery Hematology Immunology/Rheumatology Infectious Diseases Microsurgery Nephrology Neonatology Neuroradiology Pathology Pediatric Radiology Pediatric Surgery Plastic and Maxillo-facial Surgery Pulmonary Diseases Contra Casra Health Services ' &rergency Medical Services 15 Acute Care Fac;lity Self-Assessment 9198 Hospital Council ATTACHMENT B DATE: December 14, 1998 TO: Supervisor Donna Gerber Supervisor Mark DeSaulnier FROM: Lynn H.Baskett Regional Vice President SUBJECT: Task Force Report--Health Care System: Overview of the Hospital/EMS Crisis— Winter of 1997-98 A multidisciplinary task force that includes the state Emergency Medical Services Authority(SMSA), Department of Health Services Licensing and Certification Division(DHS L&C)and California Healthcare Association(CHA)was formed in January 1998 to review the difficult flu season experienced in California during the Winter of 1997-98.Many factors contributed to this event,which caused a period of high census and stressed California's health care community almost to its limit.For several years prior to the 1997-98 flu season,the state had been fortunate to experience light influenza activity. The task force drafted a report entitled Health Care System: Overview of the HospitallEILIS Crisis— Winter of 1997-98,which has been approved by the governor and will be released publicly before the end of 1998. Introduction i As providers in the health care system,we can all learn from the many factors that affected the situations in our communities during the winter of 1997-98: • lack of accurate predictions about the magnitude of the flu season • ineffective flu vaccine • physician office closures during the holidays • inadequate supply of clinics with extended hours for those whose physician was not available or who did not have an established relationship with a physician • the large number of patients who use the emergency department as their source of primary care due to lack of health insurance, lack of access to other providers or convenience • a growing nursing shortage particularly in the specialty areas Many have attributed problems during high census periods on changes in the model of health care delivery. While the number of acute care hospital beds per 100,000 population has decreased by 16%,it is important to note the occupancy of those beds has declined by 12%. The decline in the number of acute care beds is an appropriate response to the overall decline in the number of patients that effectively utilizes precious health care resources. Given the continued increase in managed care,hospitals have developed strategies to maximize resources and deliver high quality patient care in emergency departments and other areas of the hospital CAWINDOWSWEMMMS rpt SMSA repti.DOC12i11/98 I ospital Council of Northern rind ceniral californin 7901 5toneridgtr Drivr„Sulte 500•Pleasanton,Caliiirrnia 9458X-3600•tax 510-4(A)-5457•Phone 510-460-5444 Task Force Deport December 14, 1918 Page 2 As recommendations for change in the health care delivery system or the monitoring and regulation provisions are developed,the change over time in the model of health care delivery must be acknowledged. As health care providers and policy makers,we have not come to a consensus on how prepared our health care system should be for a disaster. We must ask ourselves-- is the health care system to be prepared for any disaster of any size at any time? If so,there is a cost for that level of preparation'. When there is a consensus on the level of disaster preparation expected and funded,hospitals will do what is needed to meet that consensus expectation. The Report The report is divided into several sections,beginning with an Executive Summary,followed by a Summary of Recommendations,prior to the complete report and numerous addenda. The task force reported in its Executive Summary that"this experience raises questions regarding the ability of the state's health care industry to effectively respond to similar situations and/or a major disaster."This statement causes concern because it does not adequately acknowledge that the 1197-98 flu crisis was a community problem rather than a hospital problem. More effective outpatient and preventative measures,such as flu shots and access to patient-care services,mitigate congestion in hospitals.in fact,SMSA,LHS,the state Health and Welfare Agency, local emergency medical services agencies, local health officers,and all segments of the health care industry are part of California's health care continuum and thus,contribute to patients' health. All these groups, as well as any others necessary to the collaboration,must participate and assist in difficult situations and be involved in solutions to problems.The last sentence of the Executive Summary states,"this can only be accomplished through a partnership of industry,government and the general public."CHA and the Regional iAssociations agree that the only way to continually improve California's health care system and environment is through such a partnership.The task force continues to meet in order to discuss these issues. Community problems require broad-based community participation to find workable solutions.All participants must be at the table in order to develop ongoing monitoring and response mechanisms and policies on such issues as ambulance diversion and computerized,communitywide communications systems. CHA and the Hospital Council have collaborated on the attached responses relative to the task force report,which address each section of the report. Attachment CAWiNDOWMTEMPTHS rpt EMSA reptl.DOC12/11/98 ......... ......... ......... ......... ._...._.. _ ......... ......... ......... ......... ......... ......... ......... ......... ......... . ...................................................................................................................................................._.._........ . . ....... ...................................................................................... Hospital Council Health Care System:Overview of the HospitalJEMS Crisis, Winter of 1997-98 Response to the Task Force Report December 14, 1998 Following are specific which address each area of the task force report. Data Collection • Hospitals support data collection for voluntary,collaborative regional planning which will help providers and local emergency medical services agencies enhance overall the community's EMS systems. Data collection must have a clear value to the health care system. Bad data can result in misunderstandings,misinterpretation,and poor policy formulation. • Hospitals support the implementation of Senate Bill 1973 (Maddy,R-Fresno, Chapter 735)which will assist the health care system in planning by collecting a new data set for hospital emergency services. • Hospitals support clarifying Office of Statewide Health Planning and Development definitions to secure more accurate and useful data. • Many organizations request data from hospitals for numerous valid purposes. While data may be valuable,the process is costly for each hospital. It is therefore imperative that any data collection system be coordinated to minimize duplicate data requests and acknowledge that data collection processes especially those which require manual extraction take staff resources away from patient priorities. • Hospitals must be involved in any data interpretation and analysis, as well as the development of recommendations. • While California's health care providers support the concept of statewide communications systems; these systems are expensive and cannot be required of hospitals without providing a funding source. .Hospitals and EMS Systems-General Authorities • Hospitals are aggressively preparing for the upcoming flu season. We learned from last year's experience and are better prepared. The 1997-98 flu season in California was unexpectedly difficult for California patients and health care providers for a variety of reasons. We are aware of concerns that similar problems may occur this year and are working with state and local agencies, community organizations and the general public to coordinate strategies and plan to avert a repeat of last winter's situation. • Hospitals have developed internal plans to manage periods of high patient volume that include taping steps such as calling in additional staff, stocking supplies and equipment,and expediting admissions,discharges and transfers of patients as appropriate. Hospitals are collaborating and sharing information with each other to facilitate planning efforts. Hospital Council of Northern and Central California f 7401 Stoneridge Drive,Suite 500•Pleasanton,California 44588-3600•Fax 510-460-5457•Phone 510-460-5444 It f December 14, 1398 Page 2 • Collaboration and coordination among local emergency medical services agencies, state and local DHS,public health departments,hospitals,physicians and health plans are essential in planning for periods of high patient volume,as well as for increasing the effectiveness of public education and prevention efforts. • Diversion policies should be decided at the local level. Hospitals are working with their local emergency medical services agencies to develop diversion policies that will allow the overall EMS system to more effectively serve communities and to reduce ambulance diversion during the busy winter season. Hospitals and EMS Systems-Emergency Planning • Hospitals and their clinical staff continuously work to upgrade their crisis readiness. However, successful crisis preparedness and resulting outcomes rely on partnerships. Hospitals participate in proactive coordination with state,regional,local and community agencies and groups, as well as state and regional health care associations, to tackle issues of patient care prior to the winter flu season and pave the way for smoother delivery of emergency services. In addition,hospitals are working with local agencies and other area hospitals to coordinate delivery of care. • Hospitals have disaster plans in place that may be initiated to handle an internal crisis or to respond to a natural disaster. Hospitals are required to prepare and drill for disasters several times each year. • DHS L&C are prepared to expeditiously grant waivers, when appropriate, regarding hospital staffing and bed usage. Responsiveness during pear demand periods is especially critical and should be consistent throughout the state. State and local DHS L&C offices must clearly and quickly communicate with each other and hospitals regarding the waiver process and waiver approval/denial. • Hospitals currently participate in regional disaster planning efforts„ • Hospitals support full implementation of the Hospital Emergency Incident Command System. Disaster,Response and Emergency Proclamations • We must find local solutions for local problems. Many resources and conditions are distinctly different in separate areas of the state. Our health care associations and hospitals are working at the regional and local levels to prepare and coordinate activities with local emergency medical services agencies, local DHS divisions and community organizations. Hospitals are supportive of these efforts. • To effectively handle situations like influenza epidemics,disaster response plans must be developed collaboratively with the participation of hospitals, local emergency medical services agencies, local DHS,physician representatives and other affected parties. • Hospitals should not have to handle situations like influenza epidemics alone. • State agencies,the health care community and the public must work together to educate the public regarding the importance of flu and pneumonia shots, and ensure coordination of patient care information. CABay Area DivisioMEMSA rept tkg pts for PHS-mv.doc December 14, 1998 Page 3 • We must work together to organize communication and appropriate data collection; provide regulatory waivers in times of crisis; and coordinate sharing of resources. All organizations must coordinate to minimize the need for ambulance diversion and,if necessary,make diversion as efficient as possible for all involved. • Without compromising quality,health care providers, state/local agencies, and patients must be flexible during times of crisis or high patient census. This may include utilizing public health.nurses,emergency medical technicians,and/or other appropriate personnel within their scope of practice in hospital settings when necessary,or promptly requesting DHS permission to provide care for critical patients in different hospital areas,such as recovery or special procedure rooms. EMS Community Education • Hospitals are supportive of public education programs related to the appropriate use of the health delivery system in an emergency, such as when to call 911 or when to go to the emergency room. • Community education programs with the full support and participation of county health departments,hospitals, clinics,medical groups and medical societies,health plans, employers,pre-hospital care providers, and schools are critical. One organization should not be expected to carry the message alone. Local emergency medicalservices agencies should provide coordination of information among all health care providers. Public health Prevention of In,fluenza and Influenza-Like Illness • Public health departments on all levels of government must take the lead in coordinating local influenza prevention and public education programs. • Californians must work together to tackle the larger issue of community health. We must assure the outpatient setting is available for patients before they become critical. Hospitals encourage people to take responsibility for their own health by seeking care appropriately. If patients seek care early in an outpatient setting,problems that lead to more severe illnesses and/or hospitalization may often be avoided. Flu and pneumonia vaccinations also are readily available from a variety of state and localhealth care and community organizations. We encourage anyone in a high-risk group to receive a flu vaccination early each year. • High-risk categories including the elderly and those with chronic illness,diabetes or respiratory problems should be the focus of targeted:education campaigns. Children should be included as a targeted population,with schools playing a key role in local public education programs. • Hospitals support increased collaboration with public health departments,community- based organizations and other health care providers to increase preventive efforts for the flu. • As part of their community service commitments,many hospitals take on a public health role in providing flu shots to the community at health fairs,senior centers,and homeless shelters. CABay Area DivisioMEMSA rept tkg pts for FHS-tev.doe December 14, 1998 Page 4 Staffing Shortage • Hospitals are proactively ensuring availability of care during the upcoming flu season. This planning process may include flu shots for employees;rescheduling or limiting vacations as appropriate; stocking additional supplies and equipment; evaluating crisis plan staff assignments; and requesting the postponement of staff jury duty during critical periods. Hospitals also are prepared for potential sharing of resources with other area hospitals. • Nurse registries and physician offices, among others, should also assess their internal processes to assure the necessary staff,resources and facilities are available for patient care. Hospitals also will reschedule non-emergency procedures when and if appropriate during the peak season. • Hospitals support educational programs for nurses at all levels,including internships. • As early as the summer of 1997,hospitals made substantial efforts to enhance the number of available nurses. Educational programs were created and offered(often covering costs, with pay and bonuses for participation). Also, significant recruitment efforts were made by many hospitals regionally,nationally, and internationally. • Hospitals implement staffing options available to them in periods of high demand. • In addition to recruitment and educational efforts, hospitals have responded to the nursing shortage by expanding the levels of nurses used in order to maximize the care to the patient. This is a return to former models of patient care rather than a reflection of less depth of nursing care. • We support linkages between hospital and health system human resources personnel and high schools in order to identify and address new and growing areas of the health care workforce. • Increased efforts are needed to enhance the number of baccalaureate programs by expanding enrollment, as well as the need to continue supporting licensed vocational nurse step-up programs at the community-college level. • Fundamental to the problem of specialty physician shortages,especially for emergency department on-call staffing, is inadequate funding for the health care provided to the poor and the lack of funding for the uninsured. Until this is addressed, adequate physician coverage will not be achieved. • Health plans, medical groups and the government all must play a role in the solution to the specialty physician shortage. Medical Equipment and Supplies Shortages • Hospitals support convening a statewide task force which will: ♦ address the issue of multiple suppliers that all depend on a few manufacturers; ♦ include medical equipment manufacturers in the statewide task force to ensure adequate supplies of equipment, such as ventilators; work with pharmaceutical manufacturers to assure the availability of adequate supplies of flu vaccine and flu-remedy medications;and ♦ better integrate manufacturers of pharmaceuticals,medical equipment and supplies into the regional disaster planning process. CABay Area UivisioMEMSA rept tkg pts for FHS-rev.doc December 14, 1998 Page 5 For questions call: Lynn Basket, Regional Vice President, Bay Area Division,Hospital Council,(510) 705-8990 Dorel Harms, Vice President, Professional Services,CHA, (916) 552-7574 Mary C. Wallace, Manager, Media Relations and Marketing,CHA, (916) 552-7516 C:1Bay Area Division\EMSA rept tkg pts for FHS-rev.doc ......... ......... ......... ......... ............_.__. __....... ......... ......... ......... ......... ......... ......... ......... .... ........................................................................................................................................................ . . . ........................................................................... ATTACHMENT C OF CAUPOWA--iii M AND WWA t +i1GWCY pE�E WlL3{3ri, Cewrner IRGENCY MEDICAL SERVICES AUTHORITY 9M STAW. sm 140 sik4wo.far 15314-ma 341'4..16 W, {914} (24.4173 DATE: October 19, 1998 TO-, Interested Parties pI2OM: Richard A. Watson OS— interim Director SUBJECT: Draft of the California Health Care System: Overview of the Hospital/EMS Crisis Winter of 199''1/98 Task Force Report Attached is a draft of the Calz forma Health Care Systerh. overview of the HospitdllEMS Crisis W-IMter of 1991698 Task Force Repast. The draft report is being distrt'buted at this time in order to solicit review on the preliminary findings and recommendations. The reccmtnendations may be used now as guidance to the health care and governmental communities to help then address the rapidly approaching influcaZa sewOn. If you have comments,please work with your organization's representative on the task force Oisted on the last two pages of the doculn=t), or to any task force member,to provide input If you have any questions regarding the draft report,please contact Jeff Rubin of our staff at 316-322-4336,extension 319. cc: California Health Care System Hospital/EMS Crisis Winter of 1997198 Task Force 1 T n'J / n T t^ 1.J70z17t'Y 1J(>r_,y�y�7 Jrlf rr.r Y OC C T_�fi_'i 7tT CALIFORNIA DEAL,'ITH CARE SYSTEM OVERVIEW OF THE HOSPITAVEMS CRISIS WINTER OF 1997/98 FINDINGS AND RECOMMENDATIONS Task Force Report vim P up_ Pete Wilson , ! , T i 4; d Governor ' w Sandra R. Smoley, RN. Secretary. Health and Weyare Agency DRAFT., October 16, 1998 Released far Comment Purposes Only 7n A 1706 M70 nT!^ 1!'.7Q�l�CY 11i'YC T.n�t�JYtC hrF".CT i.3G�T...�,£•l_"17(i' ......... ......... ......... ....._... ._.......... ......... ......... .......... ........ ......... ......... ......... ......... ......... ......_. ......... ......... ......... ........ . ......................................................................................................... ._........_.................. Elm Ut Aft Executive Summary In December 1997 the state Emergency Medical Services Authority(EMSA)and the Department of Health Services(DHS),Licensing and Certification(L&C)and Emergency Preparedness Programs were alerted to a"hospital overcrowding"problem by the Local Emergency Medical Services Agencies(LEMSAs)in southern California. A targe number of hospital.emergency departments reported overcrowded conditions and requested to go on ambulance diversion. A similar pattettt.'spread throughout the rest of the state in January and February. On January 9, 1998, an initial task farce consisting of representatives from L&C, EMSA and the California Healthcare Association(CHA)began conducting conference calls with LEMSAs, Local Health Officers and others. The purpose of the conference calls was to identify the scope and severity of the overcrowding problem throughout California. The task force developed into a multidisciplinary group that included researchers and representatives of prehospital providers. This group accepted the responsibility of researching,reconunending and reporting solutions to avoid a repetition of the events experienced last winter. This report on the overcrowding of California's health care system includes the following. • A retrospective narrative that addresses the many contributing factors • A review of current data collection • Lists of current standards, authorities and practices • Resources affecting the availability of services • Recommendations to avert a repetition of last winter's situation and assist with future planning related to stress on the health care system. The initial precipitating factor was a sudden increase in the incidence of influenza-like illness (U). This was subsequently determined to be due in large part to an epidemic of influenza type A/Sydney,a swain for which the 1997198 vaccine was not protective.This epidemic fbilowed a number of years of apparently light influenza activity in California, so that hospitals that based their preparations on these preceding years were not prepared for this epidemic. The increase began in southern California during the period between Christmas and the New Year holiday. Compounding the problem was the limited access to physicians' offices that were closed beginning n aid-week, since Christmas and New Year's fall on Thursday. Patients calling their doct+er`s offices frequently received instructions to go to their local emergency department. The increased number of patients treated in emergency departments and admitted to hospitals resulted in a shortage of staffed beds. In some cases hospital beds were physically available but could not be occupied because of unavailability of staff,principally registered nurses and physician;specialists. As hospitals became overcrowded,many requested ambulance diversion$ based on subjective and hospital specific criteria. Hospitals that were geographically distant required ambulance transport over longer distances, further impacting the system. Ambulances were commined for longer periods of time than during non-diversion periods. This reduced the overall availability of ambulances to the system. Oetaber16.1948 Page Z than T OC C T-C n_'\73IT This experience raises questions regarding the ability of the state's health care industry to effectively respond to similar situations and a major medical disaster. As evident from this incident, there exists little residual capacity in the cunt California health care system to respond to and accommodate catastrophic events that involve moderate to large numbers of casualties and displace thousands of residents. The capacity to respond to events of even moderate impact is doubtful. The task force developed several recommendations to better prepare for and manage periods of high service demand coupled with low staffing availability including those caused by ILL The implementation of these recommendations,together with additional research to identify certain aspects of the problem,would improve California's ability to provide necessary health services for its populace in a rapidly changing health care envirownent. This can only be accomplished through a partnership of industry,govermment and the general public. ,n t �1 oaober 1& 1998 3 On* hf�•J i?QO fa�D fh T C 11�01t�K} 1JnC t r1u�Jnr_ �'t^_.C T 04G T...GA-'1�R Summary of Recommendations Hospital Utiftatiun Data • Support implementation of Senate Bill 1973 (Maddy)(Chapter 735 of the Statutes of I998)(Appendix F)that would require the Office of Statewide Health Planning and Development(OSHFD)to: • speed up collection and processing of hospital inpatient discharge data., • begin collection of emergency department encounter data in 2002, and • undertake a study of hospital accounting and utilization data to eliminate redundancies and identify ways to make the data more usefbl (including the support of EMS planning and coordination which could involve more detail,changes in definitions). • Examine possible discrepancies between numbers of staffed beds and their utilization as reported to OSHI?D and as reported to investigators during crisis. • Make data and information available to LEMSAs,county health departments and hospitals for planning and evaluation of local emergency response systems. • Ensure that OSHPD and the EMS Authority work closely in the development of their data systems. 'Wherever possible and practicable, their systems should complement each other and provide the most important data and information while limiting reporting burdens on providers. Emergency Medical Services Data Shorn Term • Implement the provisions of Assembly Bill 2103 (Gallegos) (Chapter 995 of the Statutes of 1998)(Appendix G)under which: • counties or their designated local emergency medical services ag=ies must develop policies on or before June 30, 1999, specifying the criteria they will consider in conducting impact evaluations of proposed downgrades or closures of emergency hospital departffients,acid • the Emergency Medical Services Authority trust develop guidelines for development of local impact evaluation policies. • LEMSAs and their area hospitals collect and obtain the data required to assess and project emergency medical services creeds and resources based upon the policies developed under AB 2103. • LEMSAs work with hospitals to develop an ongoing monitoring system for purposes of . managing peak demand. Long Terre • Support health-planning research to better project and monitor emergency medical service need and utilization_ • Support implementation of Senate Bill 1973 (Maddy) (Chapter 735 of the Statutes of 1998) that would require OSHPD to: • speed up eollection and processing of hospital inpatient discharge data, • begin collection of emergency department encounter data in 2002 and octow 16.199S Paso 4 Draft eta•..t i��+� rano Carr v�aL�c� enc t nv»nr_ rr.rT occ r_err_��rr DRAFT + undittalkc a study of hospital accounting and utilization data to eliminate raduaattdmcies and ids ways to mare the data more useful(including the support of EMS planning and coordination which could involve more detail,changes in definitions).! • Develop recommendations from SMSA to OSPI3D regarding emergency department(ED) data set, collection methods and local interface with LEMSA. • Develop recommendations for monitoring and communicating systems for purposes of managing peak demand in collaboration with CHA and EMSA. • Support the development of a computerized,statewide,inter hospital monitoring system with interactive capabilities. • Communicate and coordinate with public health officials and programs at both the state and local levels. Public Health Data • The Division of Communicable Disease Control of DHS(DCDQ plan and implement as more active,complete,and timely surveillance system for influenza activity in Worraaa. This systema should utilize sentinel indicators that would provide the earliest possible: indications of mcreases in influenza activity, including primary care physicians,who see or receive calls fiom patients with ILI,and prompt and complete reporting of institutional outbreaks of III. • DCDC'will be conducting a pilot program during the. 1998»99 season of such a system. This system will use sentinel physician reporting based in Southern California Kaiser healthcare facilities to monitor the occurrence of ILI. It will attempt to enhance the reporting of institutional outbreaks of ELI through regular reporting by local health depaamtrents of all institutional MI outbreaks. Enhancement of reporting of nursing home ILI outbreaks will be attempted through the annual mailing of set of recommendations to long-germ carne facilities on the reporting and management of influenza outbreaks and a regular survey of nursing homes by the Los Angeles County Department of health. Public health laboratories will be asked to report and forward all influenza isolates to the DCDCviral laboratory for typing. Hospitals and EMS Systems —General Authorities • LEMSAs, as the lead agency,develop in collaboration with ambulance providers, communication centers,hospitals and L&C a comprehensive area-wide diversion program based on the Model Ambulance:Diversion Program standards(Appendix H). • Design ambulance diversion programs to limit request for diversion. • Saturation of an emergency department or other hospital units of the entire hospital may initiate a request for diversion. Internal policies and procedures to avoid or/relieve;sataaration should be in place. (Saturation is when all stations or beds are filled to capacity and/or traditional staffing to patient ratios are at maximum undc:ar the hospitals written staffing plan.) • LEMSAs plana for situations when multiple hospitals experience saturation simultaneously (see next section regarding disaster planning). Hosp>itaals—Emergency Planning +� All hospitals review their emergency response plans and develop procedures relating to high census and low staffing(saturation). These procedures should be part of an aggressive OCUA r aa.a"at Pada S Dmfs t]f'k`.J t-00 n-`O n T t t AU-MA't_^ Oe.t`7 CrCt T_Cf'a_"Y7lY K A3-N u. T coordinated pian for dealing with any type of high periods of hospital utilization(e.g.,flu season). i Hospitals coordinate with LEMSAs,health officers and other local disaster officials in the early partial or complete implementation of emergency preparedness plans necessary to meet community health care needs. • Hospitals review and revise their emergency response plans to follow the Incident Command Systemm as outlined in the Hospital Emergency Incident Command System =ICS). • Hospitals use the Individual Hospital Response Strategies for Saturation(Appendix L) as a model. EMS Systems--Emergency Planning a Hospitals coordinate community disaster planning with their LEMSAs(Ste appendix H). • LEMSAs and hospitals develop Area-Wide Response Strategies for Hospital Saturation that coordinates use of local resources and minimizes requests for ambulance diversion. a LEMSAs develop diversion programs that ensure patients are transported to emergency departments for stabilization and watinuity of care. When saturation is a result of lack of critical care beds,transfer agreements must be in place for secondary transfers. Disaster Response and Emergency Proclamations • Hospitals and health care providem must identify in advance of a disaster their projected resource needs to cope with the event. They roust also identify alternate sources of personnel,supplies and equipment. Requests to government for these resources should only be made when personnel registries and/or suppliers are unable to meet the facility's needs or if a disaster has interrupted normal communications or awisportation systems. • Hospitals and health care providers develop and test emergency preparedness plans in concert with county medical/health officials to develop a coordinated approach to disaster planning and response. EMS Community Education • LEMSAs,hospitals and other EMS system participants along with the healthcare community,join together to more fully understand the needs of the individuals using prehospital and hospital emergency medical services and work together to create effective public education campaigns that help individuals get appropriate services and guide others to use other services. • LEMSAs utilize and implement public education campaigns to promote appropriate use of EMS systems through 9-1-1. Specific campaigns can be targeted for known medical conditions where the value of EMS system utilization is well-established e.g.Heart Attack, Stroke and Trauma. • Local hospital emergency departments coordinate efforts with LEIWAs to create an add-on or complementary public education campaigns to promote appropriate use of Hospital emergency,departments. • LEMSAs, in coordination with flu immunizations programs and public and private health care providers,develop and promote education programs for caring for flu like illness that emphasize when to call their primary care physician,clinic,hospital emergency department and/or 911. The flu immurt 2ation programs traditionally commence in May of each year. ocWhff 16.199S P=se g D mft I n•J t"1fJt.} f91:0 f:iTl 117AL�l� llf'1f"'i h'tl"7 JCV" iF • Assure back-up of synaetic blood products are available and develop criteria for their use during time ofaisis. • Work with local blood donor organizations to plan additional blood drives prior to time of increased need. • Work with local pharmacies to assure the availability of adequate supplies of flu remedy type medications. October 16.194= Past $ Draft ('1f1• •�f"Yr1 PY�e"1 +9Y r \1-1n\l'1Y' �l1P`t n.�i1 PI'S•^ r r 7 n--e-7.Lfa_'17fT Public HealthPrevention of lufluensza and Influenza-Like Mness • D1CCDC seek resources to develop and adult immunization program;influenza immunization would be a major focus of such a program. The Immunization Branch of DCDC has been developing an adult immunization plan,but the resources to implement this are lacking. Components of such a plan would include a yearly assessment of immunization levels in long-tern care facilities,the development and distribution of mate ials to inform and educate the public about methods of protection against influenza, and the training and education of health cart professionals. • ' Until such a program can be developed,advice to comply with the Advisory Committee on Immunization Practices(ACIP)recommendations on prevention and control of influenza (Reference in Appendix A) and other mea=es to reduce the risk of respiratory infection should be distributed as widely as possible, including through public service announcements. Resources--Nursiug Shortage • Support specialty training for nurses in critical care areas. • Prepare and use unlicensed assistive persomncl for tasks not requiring licensed nurses. • Request relaxation of ICU staffing ratios from DHS as appropriate for safe care. • Provide child care(especially during the holiday vacation period). • Contact nurse unions and ask for their cooperation to delay strikes until the crisis is over. • Establish contacts with out of state nurses registries prior to crisis. • Consider and encourage overture. • Support state legislation to fined educational program for nurses at all levels.' • Support the work of the California Strategic Planning Committee for Nursing;(CSPCN) to study the nurse shortage and make recommendations as to the need for nurses especially in critical care areas. • Staff for anticipated fluctuation due to expected influx of patients during"flu"season. • Restrict vacation requests. • Request all critical personnel be excused from jury duty during the crisis. • Implement flexible working hours to increase on-call staffing. Resources—Specialty Pbysiciant Shortage • Explore enhanced Amdiing for specialty physicians taking call. • Partner with medical societies/associations to enforce medical staff by-laws which require specialty physicians to take call. • Support the work of the Hospital Emergency Call task force. • Explore alternatives to physician specialty house staff including use of MD intensivists and advance practice nurses. Resourcts- Medical Equipment and Supplies Shortages • Contact medical equipment companies and make therm part of a plan to access additional equipment if necessary. • Hospitals review their equipment supply inventory procedures to assure adequate supplies are available. • Convent statewide task force to address the issue of multiple suppliers all depending on a few vendors. OeWber 16.19911 gtse 7 tmR gra• 3 7nn r-x-rn nTr �"SrTv-tr"1 \inr 1 n.\I"1 Jnr r.l-r nrr r �n -.-i,� UKAFT MODEL AMBULANCE DIVERSION PROGRAM (Adopted by the Emergency Medical Services Admi:dstrators Association of California, 1998) Purpose: The purpose of an EMS System's ambulance diversion program is to provide a mechanism for hospitals to request a temporary discontinuance of ambulances arriving at their emergency department. Background. Local EMS Agencies develop intricate ambulance destination polices based upon a number of patient care considerations including but not limited to:system response time,continuity of care, appropriate medical responses,and geographic proximity. Almost exclusively,EMS ambulances deliver patients to hospital emergency departments. (This model policy does not include a discussion of non-emergency ambulance transportation nor interfacility ambulance transportation.) Ambulance diversion programs are designed to assist local EMS systems to manage their available hospital resources so that the patients can be received at the hospital best suited to care for them. When hospitals experience brief periods of excess demand upon fixed resources, ambulance diversion may be a reasonable option if neighboring hospitals are adequately prepared and in close geographic proximity. When a local EMS system's network of hospitals is experiencing demand that exceed capacity at multiple hospitals and all hospitals are impacted,ambulance diversion no longer serves the patient. In some regions whore the rerouting of ambulances would greatly prolong transport times, ambulance diversion is not beneficial because it impact the ability of the system j to respond to additional emergencies. Piciples: Ambulance diversion programs must be tailored to meet local needs and other available resources. Ambulance diversion should racist as part of an EMS Systems' day to day management of resources. In situations where extreme demands are placed on the network of resources e.g. flu season or other disaster scenarios,ambulance-diversion from the most appropriate hospital should not be:permitted. ,06t Diversion of ambulance patients from a hospital does-I' the hospital's obligation to continue receiving all walls ins(may be up to 85%of business). Excessive diversion requests from hospital(s)result.from a number of underlying causes; local diversion programs must address these underlying causes. YS'f• �fl.'t t'e-er1 ('tTr ♦1lT\I-1� \1!'1f^T/.\11 )f1(- rtr.rt f'Yf!'T._Cl'X_^L7fT DRAFT EMS Systems managers should work with local public health officials in promoting prevention and interventions to reduce disease and injury,e.g. Au shot campaigns,disaster preparedness. Public information cannpauigns regarding Proper use of ambulance and emergency department services should be on going and reinforced during peak demand periods(e.g. flu season). LEMSA should facilitate the design,development, implementation and evaluation of diversion programs with participation from hospitals,ambulance providers,and the Department of Health Services. Excessive demand on ernergency resources can quickly escalate;emergency preparedness plans should address action to be taken when diversion is no longer an option. Components of a Diversion Program: Representatives from each of the key EMS System components in each local EMS System must collaborate to develop their local diversion program. The roles and responsibilities for each of the participants is listed below: LEMSA • Facilitatemeetings to develop local diversion policy and procedures with representatives from all EMS service providers including but not limited to: first responders,ambulance providers,dispatch centers,receiving hospitals,physicians and urgent care centers. • Facilitate joint meetings of the LEMSA,hospital council and regional DHS office staff to coordinate activities and review action plans and reports for their respective agencies. • Define prehospital clinical triage criteria,transport and response time parameters. • Develop monitoring mechanism,criteria for authorizing and denying diversion requests,data elements reporting requirements and quality improvement plan. • Develop alternative destination criteria and procedures. Hospital(facilitated by California Healthcare Association Area Coordinators) • Define Internal Criteria for Ambulance Diversions: • Emergency department capacity(service demands/resources) • Inpatient bed capacity • Physical Plant • Loss of vital services • Other special circumstances • Develop internal program for avoiding the need to request ambulance diversion,and rapidly coming off diversion as part of their emergency preparedness plana;submit to the LEMSA.for review and approval. • Participate in projects'that develop standardized triage and acuity systems and benchmarks for measuring capacity. Ambulance Providers/Communication Centers • Develop prod and communications plant. • Develop dispatch procedures TT•J l7QQ n70 MTP' 1J7Q1t7ri 11f'iCT/ti1f7Jf'iC n_r.r'T r1C_tT_Gfa_'\']FT ......... ......... ......... ...__._.. ...._.. ......... ......... ......... ......... ......... ..... ... . ._... ....._.. ......... ......... ......... ......... ......._. ... ............................................................................................................... ....._.................................... DRAFT Physicians • Assist in the development of sound clinical parameters for triaging patients in the field, emergencY departments and within critical care units in hospitals. • Collaborate with hospital executives and staff to develop policy and procedures to assist in decompressing units at times of saturation and other disaster scenarios. Urgent Can Centers • Assist in development and dissemination of public education materials for appropriate utilization of emmeargency medical services and prevention campaigns. • Develop action plans to extend hours of operation to assist in offloading non-emergent cases when emergency services are overwhelmed. Department of Health Services and Hospital Council • Review policy and regulatory requirements for hospitals. • Collt ED utilization data and develop capacity benchmarks. • Sup . efforts to resolve the nursing shortage. • Develop public education program about ED utilization,especially during peak periods. ?T J l7dt> M__O rATf' 11�CS]lSCY 11('N=T,1117 Jf1� GC_•C'T GCC T_CfA_'1G(f INDr MUAL HOSPITAL RESPONSE STRATEGIES FDRAFT Hospital saturation* response strategies was created by the]dept of Health Services,Licensing and Certification Program (DHS, L&C)and the Emergency Medical Services Authority(EMSA) to assist both Local Emergency Medical Services Agencies(L.EMSA)and general acute care hospitals develop diversion policies and procedures,This document should be used in conjunction with the EMS Model Ambulance Diversion Program guidelines when developing diversion procedures. It isnot intended to be all inclusive as hospitals or LEMSAs may have developed their own guidelines that are just as effective,however,the concepts or strategies contained in the document should be used as a basis for all hospital saturation plan development. Stage I,Strategies Preevent Plans for ED/Critical Care satttrati ho ital saturation and disaster condition resolution davelo -in coordination with local EMS aggey and other arca bovitals. • Identify available resources,medical material,equipment and staff • Distribute planning information • Conduct hospital wide training • Conduct scenario based practice exercises Stage H**,Strategies Event ED/Critical Care;—saturation/diversion • Increaser staffing,open any unstaffed critical care beds • Eliminate elective surgeries and diagnostic procedures Transfer critical care patients to step-down or other beds as appropriate • Request ambulance diversion from LEMSA • Set tip clinics for non emergency cases + Media release discouraging non-emergency visits • Relaxation of staff:patient ratio(Requires verbal approval by DHS L&C) • Activate emergency preparedness plan using hospital ICS (HEIGS) • Evaluate inventory of equipment and supplies Stage III,Strategies Event Hospital.—saturation/diversion • Increase staffing,open any unstaffed Medical/Surgical beds • Eliminate elective surgeries and diagnostic procedures • Early transfer of patients to Extended Gare Facilities or to home as appropriate f`T 'J 1 7fJC] ("A7f'1 n T/` ll'JfT\t7Yl 1.IC11"''i la\1� 11"1r' T KA I • Temporary increase bed capacity orf Hospital (Requires verbal DHS L&C approval) • Request ambulance diversion from LEMSA • Activate emergency preparedness plan using hospital ICS (HEICS) • Evaluate inventory of equipment and supplies Stage IV,Strategies Event Disaster Condition • Activate emergency preparedness pian • Local proclamation of disaster • State proclamation of disaster • Fede declaration of disaster *Saturation is a collective term meaning when all stations or beds are filled to capacity and/or traditional staffing to patient ratios are at maximum under the hospitals written staffing pian. **Stage II.IIT or rV saturation may occur separately,in any order or combination,or all,at once. 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'µ s «� tt ��jL� � •c�a�"�'tC--;� a 'c'+nj� +r�v�`+c}d�s'f � �•j - xi..�� d�X k+P*�'r�,�.. �,a�.e'"' y,.,,.G4a.>¢4� .j��r �c,�• �h+ts.a, 1-4 R rt ra7ta*k'iMAaicb4 4, . t r `� tt ii-40k; �'` ' �s�•" �•�•'� �"•Gk,':.. _. �' {adz meati.,_^"017:�1_��Ty _ � � � � 'g 1'n�+ �S^D�y."R •�.; M ,s WHY ARE SO :MANY PEOPLE LEAVING THE ED ' The following is a compilation of responses to thrp,Ct - obtained by talking with various staff members . I tr the responses into categories ( though it will become apparent ' that there is much overlapping) and offer some solutions as they were presented to me . The list is not complete bust should serve as a starting point for discussion and problem solving. I am acting as a reporter in this case and even though I agree with most comments-:-please don't shoot the messenger. I would like to propose meetings and work groups to deal with following issues . STAFFING ISSUES -Generally not enough staff, shifts run short routinely, people are leaving in droves . Could use more on-callers . -Need 2 triage nurses at all times especially since the triage nurse makes appts on the computer , orders labwork , runs interference between irrate families and system , igives directions to kR and MIC , gives tylenol and pain meds in some cases , looks for an empty Rx room or geurny, places critical pts ` in rooms , attaches monitor, communicates with the ED physician, reassess pts who wait hrs in the waiting rm, etc . -Not enough regular, experienced staff . Depend too much on travelers . There should be a wap to boost regular staff . May need to have bona fide ED training programs here and offer shift bonuses until working conditions improve. -Experienced RV ' s are being replaced by new grads without adequate monitoring to bring them along safely and to their and our satisfaction . In one case an LVN was responsible for orienting an RN. -;tanagers are doing bargaining unit work on a routine, daily basis and even though it is appreciated we would rather have the managers manage and trouble-shoot and leave the driving to us except in catastrophes . Should have charge nurses or RHC ' s on all shifts. -No back-up staff when transporters/secretaries/phlebotimists on vacation or sick leave. -The weekend ED housekeeper is shared with surgery because of unwillingness of the dent . to pad, overtime. -'The ED transporter leaves at 10pm and it ' s very difficult to get in touch with the house transporter , -The transporter communication boa K seems to ai eviate some problems ; some re;,uest, m pacer for s hp ED runner . t.. ..tin"ity oi' care , . t:o illtinn 1IMN sly..,, . for w t, i y i w Y i"ri-.S 411h nannis 0hanyints assignments c 4 '"'E: q nL ;` c.. i . , t ti - t1 S l hen we A3, t 6n . . "" i rCYuihwi t, _lent. with .3 i,Fi A team approach might hn a havWr m .t.hod cif ass itnn i , n`= slyr`,1F't;;.S , -Conscious sedation/procedural sedation should always have anV RN present. -No clear lines of nursing authority on „off shifts , " i .e. , who to go to with problems . House supervisor? -Spend a lot of time looking for doctors who are out to lunch. Seems there should be an easy solution to this one . Also there should be another contact physician available to relieve for Lunches . -When, if ever, can we go on diversion? What is the process? -The paramedics have told us they were told to take all Kaiser patients here and no longer to Mt. D. --No allowance or support for 1 '. 1 patients due to overload on other staff. -Better communication needed between doctors and TL' s . -B-side float RN has a difficult time covering when there are two LVNs and new RNs who can' t triage ambulance patients . Sometimes it becomes a: necessity to fudge on the standards . MORALE/WORKING CONDITIONS ISSUES -Total sensory overload due to too many patients and not enough space. -No real visitor policy or control . Visitors buzzed in constantly and indiscriminantly. (Also can be a safety problem) Solution : Have a security gaurd posted in the waiting room to monitor the flow of visitors and enforce a policy once in place. Ad hoc task force to work on viable visitor polio- with input from staff . Perhaps restrict visitors when change of shift or when crazy busy as determined by the charge or TL . -No place for nurses to chart . We ' re usually bumping into and tripping over people at least every few minutes . --Can ' t get to phones , reaching over, around and through other staff constantly. -Nursing breakroom "sucks . Refrigerator too small to keep all our Lunches . May be an OSHA violation . Injuries and work restricti,ons not respected or supported by other staff probably due to added workload. -Some staff getpreferential assignmemts . Triage and A-side not equitably assigned. -Responsibility for workload and pt . safety falls on the shoulders of few remaining regular staff. -No help in triage when drowning. tiegative attitudes prevail . -Ulnable to rely can timely authorization for Fd leave , additional vacation days during ;near , and requested days off . No real. policy In efiect that Z,e can reference. Laek of support and courtesy from ether services . - i r i(4, i e-^dowin respons 1 bi tti 't ' ' demoralizing to worli harder and have rno"`o-� piled n its on v r,rif E?fir t}i 3 i -,,;p 1 vr£ heon dinged d on,^e again by Dfis . Solution : DHS---`rake a, like .' Just who ' s resr,onsibf_e lfcr al low;.n.g l�osr i .al.s to close catasirig overl..aad an Uhe r _in n� faci r i ,:,ies? de1r,C7; a I i Z-i i1Set S{ Ttte 1 mprc�vements t.t;efl i back as a i it ani;' main. SYSTEM ISSUES. Patients cared for in hallways . Undertakers often roll dead bodies by the patients ; Less frequently than previously since' reporting to Ann M. -Russian roulette with beds . Don' t open up until Late in the day' due to HBS not discharging until late afternoon., early eves . -No place for families to grieve. Body must go in dirty utility room when busy and. need, room. Tacky': -Meed pager system for bed control . Too many repeat calls must be made. On two occasions that we knew of RN' s had to personally walk down to the admit office to speak to someone. Who to call if they don't return calls? -Better system for contacting and getting responses from XR, RT etc. Ifno answer incumbent upon the SN to repeatedly call or page. Once the techs arrive they must search around for reqs or someone who knows who called. One solution is to have a; communication board. --How many times/hr ( time and money waste ) does the triage nurse give directions to XR, MIC, pharmacy, clinic? Secretaries ' job description unclear. On A-side if the secretary could be closer to the nurses ' station, communication with the team leader would be easier. Also improves ability to assist with paging, trouble-shooting , fielding questions ,- and generally take a more active role in assisting the team leader . -One Dr . states that EKG' s, BHCG' s and other labs are often delayed in being drawn when the tech is very busy. Would make things run more smoothly if during those times the nurses would automatically draw the labs and run EKG' s . -Scattered availability of discharge planner , social workers , psych nurse , re-cuperative skills nurses . Also unclear when and how to get in touch with them and what, hours of availability. -Need to have someone assigned to ED to oversee and organize supplies . C-lockers could be more uniform. Too many different supply drawers and. areas in the code rooms . Need a master list of where supp.1:4es are . To start an IV one must open two or three drawers and more if labs are to be drawn at the same time . EQUIPMENT ISSUES -More phones in easi l.y acc essihl,e l.ar es . -lore stampers . -Updated and easily visible, prone 1- ist in one plac=e', on side . -Mo--(- hlo} iazar£I garbage cans . -More s,3'. r nt i}.r;ti t'£> :y s' C t i1t ;"s , oI �_(a C;E' .i3.t :a (i oLwe guerneys so elderly can easily get on . -More IV poles. -Refrilgerator for patient meals and a ;psi meals, on <a 4 Y`outlnP, bE3Sis to el.i;minais i;lai3} ?r`OS4 { 3a.. 5 tti tioliln F6?rs . Faxing requests, to d i-et,ar e c' ry time !w"^ need e3 tray . -One doctor � for 4�'L � rE�2i i i`F'(�SSe:� �:S �aCJ(>C::,£��; t f}r S i IF? Z t i.1.Y' ones . -D i nemapps and adequate supply of cuffs of all sizes . -Mania l BP for all sizes so we don ' t have to spend valuable time searching . -Few more thermometers and oxymeters . --Few more stele stools . Respectfully submitted on behalf of ED staff, Nancy Casazza. RN October 14 . 1998 cc : ED Staff Trande phiil.iPs RN, PPC Chair FHS#22 BACKGROUND/REASON(S) FOR RECOMMENDATION(S) confd. On October 28, 1998, the Family and Human Services Committee (FHS) met with Dr. William Walker, Health Services Director;Art Lathrop, Director of Emergency Medical Services Agency (EMS); and Lynn Baskett, Regional Vice President, Hospital Council on the status of the planning efforts and the adequacy of the system to handle the upcoming flu season. The Committee also met on this issue at its December 14, 1998 meeting and is reporting to the Board today on the results of that meeting.' Dr. Walker outlined the status of: ongoing monitoring of hospital emergency and critical care; emergency department diversion; emergency department waiting time data; ReddiNet Il; receiving hospital agreements;winter season planning/hospital census alert plan; and hospital facility assessment (See Attachment 1, "Update on Planning for Hospital Emergency and Critical Care Services"). Ongoing monitoring of hospital emergency and critical care status- Since last winter's declaration of the emergency, EMS has continued daily monitoring of hospital emergency and critical care capacity. Hospitals report the noon status of emergency departments (slow, steady, very busy, on diversion) and the number of available ICU, telemetry and medical/surgical beds. As a follow up to the October FHS meeting, EMS reported in a November 20, 1998 memo(See Attachment 2, "Hospital'Status Reporting) that a new hospital status report would be implemented on December 1, 1998 in cooperation with the Alameda EMS. Linder the proposed procedures, hospitals will report, as of midnight each day, the following: >- current status (normal, census alert 1, census alert 2) b number of acute care patients z� number of intensive care patients >_ number of monitored patients outside of intensive care and emergency departments >- beginning and end of a hospital census alert census information as of the change in alert status. Daily patient census data will,also be compared with the number of licensed available beds as definedby OSHP'D to determine the number of empty available beds independent of staff levels. Supervisor Gerber asked the status of the definition of"available beds." Art Lathrop responded that there is a difficulty on this definition: zero available beds does not always mean the same thing every time. For example, are there beds available for what type of patient? When are they available? The hospitals utilize a triage process which can affect bed availability for specific patients. In addition, information on available beds is from the charge nurse and it is not certain that two charge nurses would necessarily come up with the same number of beds. Emergency department diversion and alert plan - Supervisor Gerber asked:the difference between alert one and two and diversion. Lynn Baskett explained that diversion is a measure of a high end emergency whereas alerts are indices of increases in volume. Art Lathrop further explained that the alert system is a set of guidelines for the steps that the hospitals would take. Implementation may not be exactly the same in each hospital, although the guidelines and steps to consider would be the same. He felt the advantage of the alert system is improved communication within hospitals and among hospitals. In response to a question by Supervisor Gerber, Dr. Walker noted that the commitment to the alert system is a voluntary one, but there has been a very impressive level of discussion. (See Attachment 3, "Hospital Census Alert 1/Alert 2 System Plan"). Supervisor Gerber further noted that raiser,under a critical code, would divert not to Mt. Diablo Hospital but to Kaiser Walnut Creek and questioned if this was allowed. Mr. Lathrop responded that the Contra Costa County policy has not changed, that a patient must go to the hospital of the patient's choice; however reimbursement may not be available for the ambulance if the patient doesn't go to Kaiser. Other flu season planning and actions - Dr. Walker further reported that this alert plan is part of a prevention plan that includes encouraging immunization, wise use of health care systems, extra urgent care during the crunch time as well as expanded critical care bed capacity under the alert one and alert two triggers. Lynn Baskett also reported that individual hospitals are gearing up for the flu season by increasing hiring and training as well as adding medical-surgical units. She also thought there was a strong commitment towards readiness for the flu season among the hospitals. 2 FHS#22 Lynn Baskett stated that the hospitals will be better prepared this winter season due to the increased amount of planning, the number of new nurses being hired as well as the implementation of the new alert systems. However, she agreed that much is out of control of the hospital systems. For example, is the vaccine being used for this flu season the right one? Dr. Wafer expressed concern on the continuing nurse shortages and noted that the Contra Costa Regional Medical Center is making extensive use of registry nurses because they cannot fill all authorized RN positions. He reminded the committee that the key to capacity is not only the number of beds, but also the staffing for them. Hospital capacity- Supervisor Gerber referenced EMS data and noted, that outside of the flu season, there have been shortages of beds in Contra Costa County, particularly East and West County. She stated that, in some cases, there are no more than zero to five TCU beds available. Supervisor Gerber further stated that the Kaiser Walnut Creek facility is continually stressed and that there was no relief for Eastand Central County. She felt that the proposed opening of a Kaiser emergency room in Wast County should relieve that facility. She noted that the population is increasing, but hospital beds are not. Dr. Walker agreed that ICU beds are a scarce resource, but that Contra Costa County has limited authority, besides political suasion, to bring people to the table. ReddiNet it - Supervisor Gerber also inquired about the status of the ReddiNet 11 system. She expressed concern that we are not closer to completion prior to the winter season. ReddiNet 11 would be a communication system to enable hospitals and communities to track hospital critical care resource availability on a day-to-day basis as well as during multi-casualty incidents and other major disasters. Cost estimates are currently ander development. Supervisor Gerber stated that she was not confident that, on behalf of the constituents of Contra Costa County, we will do better this winter than last winter in handling flu season. Supervisor DeSaulnier concurred with Supervisor Gerber's frustration, but thought that the County was doing as much as it could within the limitations of its authority. Lynn Baskett agreed to supply the Supervisors with more information to consider prior to their next review. 3 ATTAC,"HMEW 1 Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Jim Rogers,let Dist4ct William 9.Walker,M.D. a"B.lJiikems,2nd District Director&Health Officer Donne Gerber,3rd District Mark Deftuinier,4th District 20 Alien Street Joseph cancismnls,5th District „Lo” Martinez,California 94553-3191 i (510)37Ow5O03 County Administrator :ww FAX(510)370.5099 Phil Batchelor` a ' County Administrator October 21, 1998 TO: Family and Human Services Committee FROM: William B. Walker, M. w �•.� � SUBI: Update on Planning for Hospital Emergency and Critical Care Services This is to update your Committee on the status of planning and monitoring activities following last winter's shortage of hospital emergency and critical care services. (1) On-going monitoring of hospital emer enc and critical care status. The EMS agency has continued daily monitoring of hospital emergency and critical care capacity by requesting that hospitals provide a once daily status report including emergency department status (slow, steady, very busy, on diversion) and number of available ICU, telemetry, and medical/surgical beds. Reports are based upon noon status. Hospitals are asked to fax reports to EMS by l p.m. daily. EMS staff place telephone calls to hospitals which have not responded by fax. During the month of September 1998, out of a possible 240 reports (8 hospitals for each of 30 days) all but 24 reports were obtained. Sixteen of the missing reports were on two weekend days when no follow-up telephone calls were placed to hospitals. There were 19 days during the month for which one or more hospitals reported "very busy" emergency departments, including 7 days for which 3 or more hospitals reported their emergency departments "very busy" at the noon status report. There were 18 days for which one or more hospitals reported having no ICU beds, including 7 days for which one hospital reported having neither TCU or telemetry beds available and five days for which two hospitals reported having neither ICU or telemetry beds available at noon. EMS staff is working with Alameda County EMS and with the .Hospital Council to develop a better mechanism for monitoring hospital status during the coming winter season. Because of the difficulty in defining and measuring "available beds," a more stable measure of hospital status may be the actual midnight hospital census for ICU patients, monitored patients, and medical/surgical patients. These figures can then be compared with the number of licensed and available beds on file with the State Department of Health. Merrnnew Memodal HoW41d a Hoeft Caturs - PcbNc Haaph • ManW►leapt • snbeWw a Abuse • Emkonmarttl"tam Contra CWA HnM Flan • i nr r9wi sy Meftal Somim • Horns MosI h AgvW • Gedshft A-345 (W97) . _........ ......... ......... ......... ......... ... ... ......_..... .__....... _........ ......... ._....... ......._. ......... ......... ......_.. _. . ......._.._._ ......... ......... .......... Family and Human Services Committee October 21, 1998 Page 2 (2) Emergency department diversion. Emergency department diversion is the practice whereby hospital emergency departments, acting in accordance with EMS policy, may temporarily divert ambulance;patients to the next closest hospital. Diversion policies are intended to benefit the patient by avoiding transport to a hospital whose emergency department is already overwhelmed and where care may be delayed. As long as there are other nearby hospitals available, diversion works. A problem arises when multiple hospitals seek to go on diversion at the same time. Also, the availability of the diversion option may deter hospitals from taking other steps to maintain emergency department availability. EMS has modified the emergency department diversion policy to require prior authorization by the on-call health officer. This has effectively eliminated i diversion in all but rare instances and had resulted in hospitals developing better internal strategies for dealing with emergency department overloading. (3) Emergency department waiting time data. EMS staff worked closely with the hospitals and the Hospital Council. to develop a proposal for collection of ernergency department waiting time data. A one-month pilot data collection effort was conducted by the Hospital Council in April 1998. Based on the hospitals' conclusions that variations among hospitals made useful conclusions difficult to draw and that the data would not be useful for regional planning purposes, the hospitals declined to participate in an ongoing data collection and reporting effort on waiting time. (4) ReddiNet 11. Contra Costa EMS assisted the Hospital Council in sponsoring a multi-county presentation of ReddiNet 11 with the goal of identifying a communication; system that would enable hospitals and Counties to track hospital critical care resource availability on a day-to-day basis as well as during multicasualty incidents and major disasters. Cost estimates, which are dependent upon local configuration, are currently being developed. Implementation of a ReddiNet 11 system would require about one year from the decision to implement. (5) Receiving hospital agreements. A draft Receiving Hospital Agreement has been approved by the .Emergency Medical Care Committee and circulated to the hospitals. The agreement provides that hospitals will comply with County Patient Transfer Guidelines, maintain patient transfer agreements in effect with other hospitals to which patients are regularly transferred, include the ambulance prehospital care report as a part of the patient record, include county prehospital identifier as part of patient record to facilitate linkage of prehospital and hospital patient;data, participate in focused studies to improve prehospital patient care, provide County with; specified data for trauma patients, provide County with specified data for interfacility transfers, participate in County's hospital assessment process, and participate in hospital emergency department and critical care resource monitoring as approved jointly by Contra Costa and Alameda Counties and by the Hospital Council. Family and Human Services Committee October 21, 1998 Page 3 A similar receiving hospital agreement is undergoing final review in Alameda County following which hospitals in both counties will be asked to sign agreements. (5) Winter season planning_/ hospital census alert plan. The county health departments in Contra Costa and Alameda have been working with the Hospital Council and hospitals in developing a winter season communication plan which will: - encourage targeted population groups to obtain flu shots; - encourage and educate the general public about how to make the right call (e.g., primary care physician, advise nurse, or 9-1-1) and how to make the right choice about where to seek health care services (e.g., primary care physician, clinic, emergency department); and - establish a framework for monitoring winter volume including criteria to assist the counties in determining the need for proclamationof a local. health emergency. (6) Hospital Facility Assessment. The EMS agency has begun a hospital facility assessment process which will identify hospital resources and capabilities. Information from the assessment instruments, which are currently being completed by the hospitals, will be compiled and shared with all hospitals to facilitate patient transfer decisions. The assessments will be updated annually. To enable hospitals to track and communicate the extent of patient overload, the Hospital Council has developed a set of guidelines defining three phases of operations - normal, census alert I, and census alert Il. These guidelines are being used by the hospitals to establish specific criteria for each hospital for declaring a census alert I or Il. The counties together with the Hospital Council will establish criteria for county action based upon the number of hospitals which may be on alert at a given time or for a given length of time. cc: County Administrator County Counsel Auditor Office of Emergency Services Emergency Medical Services 3 NOV--t ATTACHMENT 'r Nalember 20, 199$ AWWACY me iApacy To William $ F"M An L.atWW �1 � �epazting d a of the Ha diprl deport dw+et ai WPOW with AWneda EM for ase the hcupbds im bath cxmntiest for tt?lt daily census and s alerts. 'ate ace by e g this �13tr�the cut is cal i feWft . Under the propound ptocedtue3, hcxspltals will i►' d critir#1 we daily as of mit. tl� rvnsdyt (normal. COMM SlUt 1, WWA cleat 2); (2) number of acm came padow, (3) number of inkadve arae p rW, and (4) number of ma Awad pada to+ustts&inienive cafe and tmerebwy dtprWmts. Addy, ha 11 wc'11 t Oft on and wming df a HaspiW Comm Alert and the exams Mitten as Of the dw4p in alert sftm Daily patient cents data will be=qWW with the number at licensed beft a$defined Oy USHPD m de mine*e number of empty"labte best h4ppenclw of adLqg lOel. VVfEt Was that these dxbt, kV*w with clue npm%d bospilal CCUM Aleft lapels, will pmm4de,a mane mbable,MeUm of tur*W activity and status. Ow. 5upw4i3w Donna claw 30 U,liraia• r , NOL-M-19 3 lis: 604-179 510 64t5 4''?9 94% P.01 NOV-23-1998 15:43 SUPERV F S©R GERBER 510 820 6627 P.03 Untit i if l tC/9a Iffosp tal Status &RIMport vateirime Reap" t� t ! � teat i pat pe proped" mo eq yrie M rain R*Ort Tdgpbm Tobi nomiber of 6omssd available bWs(t7$HPD definition below) ACtftCwe____ -- haensive CkM Tota number of avad"*Oahseued bobs oe o"4 of flet i damtrt Isere and eaaergeney duets Complete evo oftbe Wkwing bexesr MlditW Comm Rqm trt for W&of dr�afwNk nw e►q yert I. Current Hospital Scotto (ck k on) Normal Como Alert 1 Ctet Apert 2 2. TOW number of paeiteets i» (a)sant cm (b)kftgsi%v cine 3. Ntuabtrofueoui�oead pstets eetteide of"dee ieasive sane trttt#auae rgerecy dtipemorrems h fah t+s H6,pW'Cis Atmt Lttv4 1 ar 2 (gVieaft) 1. DW Md tura*alert iA tit W /,.,,,I M / pen � � roar flour win 2e TOW muyeber of pt leets be (s)teetett:cine_.._r_.___._ (b)ifen:ive care 3. Nwnber of madooeedpotiadbe outade of flet bgaWve care tmd icy deMusM 'I'*rWJas><tt:Bmpftl Conn Alert Lrvtel 1 or 2 (circle one) 1. Dime sed dms bleat initbftd i t am / pm no +lay yar tewr min I rota number0pa in (*) cwt (b)intma"cera 3. Iberaf rtiaoieca+ed pritieerts ua oitfre diva care a�eergisy tpeereneap, ltmrtrartgarerac This fuse sitaiid be taxed ate tine EMS Aeacy(923116-4379)as tt daily b to +eeots asidnigtettus Blood whenever hoq taiabut atop ems. Wbw cm'N RMAL sashes,report nm be faxed by noon the tallowft boines;day. Mum an ALisitr i at 2 or donging a'leart suet m rgeortsborttd be f=W ikntaeditim*. Avail bis Soft 71WAVOW 6*meat of beds isciux&S mmesy bmsitem)phAka ty uhft ted ac elly available At �ase.�i eef spl�b:rtlr. des beds pdcod ba tmepetne ar bt tt tp>Fts ttiottv7ert+txt to�eyt,e arias whkh c--utot bo plmd'bto nrviw with#a 2+4 b mta Atou Carr:i iveww"labia+bob fw floss dim"daly bosplpal sarricaae cm e+aAtes pMvhft 1l .soft"M hwbftsucb cost seaeas ss mgdice6isardlpei acute.vlsitetsia acaer.psir+ebiosiaie . tee='CW depaw aey tervioros no de&idwr obs* --ion taft"t"mere:tWMd tevsiia t bet#t for 60w di craft deity botphtt atrvN0 bast 18110 s pedvidia t 1101010ift cum adudiab wwd1=YswXW hamarm cow.caramwy inumim aso.iesuaaaa inundve *sat,acedoars bCOM R�ted*;Acute cert beds ibr which moaieoeinj euleeipmumt is&vt W610. (Daft not indole intmivt corms or ae0ered tetttaecy dt�ptirttteent besdi NOX19% 16;52 510 646 4 YM 9ta P.ted TOTAL P.03 Hospital Council ATTACHMENT 3 HOSPITAL CENSUS ALERT IIALERT 2 SYSTEM am— For Use Daring Extended High Volume Census Periods Endorsed by Alameda and Contra Costa hospitals,county health departments, EMS Agencies and representatives of key medical groups, clinics, health plans and ambulance providers October 9, f 998. Introduction .As a result of the 1997.98 winter flit season which exceeded all volume projections throughout the state and beyond, the East Bay hospitals,county health departments and EMS Agencies have developed an Alert System for use in future winter flu seasons or any period with sustained,extraordinarily high patient volume. The intent of this Alert System is to articulate what hospitals and other(stakeholders in the health care delivery system do as the patient volume increases and is then 'sustained for extended periods. By having a common terminology, it is our Dope that the various providers will be side to communicate more effectively with each other, as well as with the public, concerning the extraordinary patient volume and the ways in which the public and providers can support an effective EMS and health care delivery system. Alert 11A Cert 2 Triggers Each hospital will have unique indicators which trigger its implementation of Alert 1 and Alert 2 responses. Factors which hospitals consider include the following. • Emergency Department volume • Available staff,e.g.,physician„nurse,technical and support staff • Available beds(e.g.,medicalt'surgical beds,monitored beds,critical care beds, level a neonatal intensive care unit beds) Equipment(ventilators, incubators,telemetry monitors,beds and wheelchairs) • Number of employees who call in sick at the same time in critical patient rare areas • Current and anticipated surgery schedule During the course of the year, hospitals go can Alert i and Alert 2 status for brief periods of time. Itis not unusual for these Alerts to last for a few hours or several shifts. It is when the hospital is at a Alert I or Alert 2 status for a sustained period of time,e.g.,several weeks,that it begins to con4vomise the responsiveness of the entire local health care system. If, as was the case in the 1997-98 winter season,a number of hospitals are at Alert l or Alert 2 status at the same nipple,the ability of neighboring hospitals to hells with overflow is impaired. Say Area VMdon 2450 Teuvao Aveme,G*Pimr.Serko%y.Cali orris 94705*Phare 510.7054990•Fax slo-705.8992*e-man:lbsskett0hcrnccc.com NOV-23-19% 15-10 S JPERV ISOR GERBER 510 820 6627 P.11 Pop 2 Extraordinary Volume Hospital Planning Process The following describes some of the key issues hospitals address in their flu season planning which begins in the summer: • Analyze Emergency Department volume by hour of day and day of the week to plan physiciantrturse,tech,and clerical staffing • Project winter volume based on the increase from summer to winter volume (likely foes on the p.m. shift that sees most of the emergency department volume). • Based on volume: projections,calculate Emergency Department guMeY turnover rate needed and available staff, inpatient beds.monitored beds,critical caw beds • Plan for alternate areas of the hospital to place the patient, e.g., post anesthesia care unit, short stay unit, cath lab, endoscopy unit, observation area, discharge lounge, admissions lounge • Steck up on supplies and equipment for projected volume • Plan staffing for emergency department, inpatient units as well as support departments such as phannacy, cardiopulmonary, respiratory therapy, case management,housekeeping,laboratory,transport,radiologists,medicalrecords,etc. • Notify medical staff, hospital departments, key medical groups,' etc., of the anticipated volume and planned space utilization so that they, in turn, can plan for their speer space,staff and equipment reds • flan for system to expedite the handling of 5150 patients • Plain staffing of hospitalists,if available • Evaluate staffing options to be implemented as needed including RN, physician, and support departments • Consult with unions regarding potential staffing options as appropriate • Evaluate recruitment,retention and incentive plans • ,Hire new graduate nurses • Provide update on plans for individual physicians and their office staff so that the office staff can anticipate the hospital needs and revised policies and practices Alert 1 and Alert 2 Responses The fallowing are examples of the actions that hospitals and other providers take in response to high volume periods. Not all responses listed will be applicable for every hospital. Physical capacity and'layout, as well as types of staff available, influence actual responses. These responses, however, are representative of the concerted effort all hospitals and others make to respond to patient volume increases. Many of the responses cross more than one Alert level. The intensity and sense of urgency for each response increases as the Alert level increases. Normal Alert 1 Alert 2 !Lospiftl Responses Operations Addaddidonurses in aWitiong sUff asst NOV-•23-1998 15:11 SUPERVISOR GERBER 510 820 6627 P.12 Page 3 Normal Alert 1 Alert 2 Hosp fel Res onses Operations Use ta Ists if available Stock UP on su lies and ui Rent 0 er patient or family ride home at discharge by taxi if they are having problems with nation nick obstacles to smooth patient now Expedite admissions/discharge/transfer of patients with the criticalcafe and step down unit medical directors, rase ✓ ✓ mann ws.,and char a nurses Patients are not held in the emergency department for private physicians to see the tient prior to admission Emphasize triage, stabilize and admit with some of the testing ' rd bei g aitn lend for the patient after the have been admitted Share info on hospital volume with neighboring hospitals aler" thein to tcntial requests for transfer or assistance Enforce bed EELOrity policies Conduct meetings with nursing unit,directors and supervisors, discharge planning,and staffing office in the morning and early afternoon tolart for staff,tri e,sine schedules,etc. Initiate STAT team,to pre are and tmnover beds more quickly .�" ✓ .� Implement a notification system for the emergency physicians so that they can be called in early if needed before their regularly scheduled shifts Create or open additional areas for patients suc as observation areas,discharge lounges,admitting lounges and other overflow areas Alert staff'and medical stZ of tightening bed condition through signage,email, broadcast fax fbr physicians who use hospital J J less fmq=n1ly,etc. —gotify hospital departments o Alert status so that emergency department and other patient care and patient support J ✓ departments cern irn lcrncnt their flexible staffing systems Work w medical staff and medical groups to extend office hours and on-call tem. implement available staffing options • Per diem staff` s Enforce weekend availability • 12-hour shifts on weekends • Traveling nurses/guaranteed registry hours 9 Crass train • Mandatory overtime • Cancel vacations • Deny time off requests • Rom staff . ............................................................................................................................................................................................................................._. ......_.. ....._...... ......... ......... ......... ..._......._........_....... ........... ........__. ..._..... ......... ......... ......... NOV-23--1998 15:11 SUPERV T 50R GERBER 510 820 6627 P.13 POt4 , Normal Alert 1 Alert 2 Hosplud Responses Upermtions Nvt`sfy DHS to request program flexibility as needed r/ Expand hours of other departments such as pharmacy,cardio- pulmonary,respiratory therapy,case management,house- 1 J keep' tab,!!arts rtation,radiologists,medical records,etc. Determine,on a case by case basis,whether direct admits will be held in the physician office,the emergency department,or at ✓ „/ home NpO em+erge:ncy departrti+ent and hospitalist physician hours Implement employee incentives for working extra hours,e.g_ food, uccino cart,0 certificates,etc. `r Open closed/suspended licensed beds; use traitor for physician sleeping rooms as needed. Use non-nursing staff'from ether departments to assist in patient care arras with non-nursing tasks. Use tenthrailer for storage to free up patient care areas. Emergency department diversion ✓ Implcment hos ital disaster plan Request medical mutual aid ugh the county f Start admission process in identified holding area to decompress .+r mergemergency De partment Rewhodule procedures-a—nJ surgery,e.g.,hernia repair,hip rep lacem�nt,etc. Cffier Stakeholder Responses Formalp cations Alert I Alert 2 Cour Utilize pullic health nurses for prevention and treatment,e.g., flu shots Rin ention,home visits Develop and distribute consolidated schedule/contact list for u shots{ha 'tats and h sicians to assist in distribution) Increase Co!�n clinic hours Health Plans Corntttceatcatton to members regarding: prevention,how to use advice nurm and available phone numbers,appropriate use of ✓ to use of ambulance. Asst reimburse alterme transportation at discharge to free up �► ✓ bed for tient. NOV-23-1998 15:12 SUPERVISOR GERBER 510 820 6627 P.14 Pfte 5 Other Stakeholder Responses NO al operations Alert X Alert 2 Hesith Phws centiiniied �n urage/meentivize p ysic ans to see patients during off h©urs or expand office hours during extended high volume ✓ ✓ 'ods. Prove 24 hour advice nurse services; evelog the capacity far advice nurses to schedule patients with physicians directly. ''� ✓ ✓ Review advice nurse protocols to add flexibility and more altematves to the emergency#qmwtment ✓ J Ph s ciansftedieal+Grow s/Communi: Clinics Assist h+aspitgls in reviewing patient status for admission/discharge or transfer from critical care and stepdown units F istribute flu season prevention information to patients and affI Expand ,/ ✓ • o Wcall hours to mui m ze referrals o non-urgent tittIts to the enlergvncydepartment ✓ / Ambulance>Prwtders Increase ambulance capacity calls or inter-facility transfers are 11 ✓ k NOV-23-1998 15.12 SUPERVISOR GERBER 510 820 6627 P.15 0 '0 U A FT MWWUAL HOSPITAL RESPONSE STRATEGIES FOR SATURATION Hospital saturation*response strategies was crewed by the Dept of Health Services,Licensing and Certification Program(DHS,L&C)and the Emergency Medical Services Authority(SMSA) to assist both Local Emergency Medical Services Agencies(LEMSA)and general acute care hospitals develop diversion policies and procedures. This document should be used in conjunction with the EMS Model Ambulance Diversion Program guidelines when developing diversion procedures. It is not intended to be all inclusive as hospitals or LEMSAs may have developed their own guidelines that are just as effective,however,the:concepts or strategies contained in the document should be used as a basis for all hospital saturation plan development. Stage i,Strategies Pre-event Pians for ED/Critical Cate saturation,hospital saturation and disaster condition resolution dowel in coordination with local EMS and other area bgs pitals. • Identify available resources; medical material,equipment and staff. • Distribute planning information • Conduct hospital wick training • Conduct scenario based practice exercises Stage II**,Strategies Event nt ED/Critical,Cadre--saturation/diversion • Irease:seen$,open any unstaffed critical care beds • Elimisaate elective surgerics and diagnostic procedures • Transfer critical care patients to step-down or other beds as appropriate • Request ambulance diversion from LEMSA • Set up clinics for non emergency cases • Media release discouraging non-cm envy visits • Relaxation of staff:patient ratio(Requires verbal approval by DHS L&C) • Activate amergency preparedness plan using hospital ICS(HEICS) • Evaluate inventory of equipment and supplies Stage 111,Strategi s ,Event HoVital-saturation/diversion • Increase sWffl g,open any unstaffed Medical/Surgical beds • Eliminate elective surgeries and diagnostic procedures • Early trande r of patients to Extended Gare Facilities or to home as appropriate y NOV-23-1998 15:13 SUPERVISOR GERBER 510 820 6627 P.16 U 1"NA t I * T=por&y increase bed capacity of Hospital(Requires verbal DHS L&Capproval) Request ambulance diversion from LEMISA e Activateemergency preparedness plan using hospital ICS (HEICS) • Evaluate inverttory of equipment and supplies Stage 1Vv Strategies Event D` Condition • Activate emergency preparedness plan • Local proclamation of disaster • State proclamation of disaster • ]Federal declaration of disaster *Sat,tiou is a collective term meaning when all stations or beds arc filled to capacity and/or traditional stn g to patient.cation are at mmumum under the hospitals written staffing plan. "Stage H,III or W saturation may occur separately,in any orders or dation,or all-at once. Strategies should be considered in descending order prior to requesting diversion. I N T E R MEMO 0 F F l C E To: Board of Supervisors From: Supervisor Donna Gerber, Chair Supervisor Mark DeSaulnier, Member Family and Human Services Committee Subject: Update on Agenda Item SD.2 Report from the Family and Human Services Committee on Emergency Hospital Capacity .Date: December 15, 1998 4n Monday, December 14, 1998, the Family and Human Services Committee heard an update on the emergency hospital capacity issue from Art Lathrop, Emergency Services Director and Lynn Baskett, Hospital Council. As a result of that discussion, the committee would also like to recommend that the Board of Supervisors adopt the following: 5. EYPRESS concern that the proposed new Hospital Status Report is based on the lowest census time (midnight) and is not sensitive to staffing availability for beds. b. REQUEST the EMS to continue its daily data collection on Hospital Emergency and Critical Care Status through the winter season to facilitate a valid comparison of capacity to the last winter season. 7. REQUEST the EMS to report to the Family and Human Services Committee in March 1999 to review data from both reporting systems to determine which, if either, methodology of collecting emergency and critical care information best supports the County in its oversight role. Art Lathrop reviewed the proposed new hospital status report with the committee (see Attachment A, Update on Planning for Hospital Emergency and Critical Care Services). The hospital status report provides information on the total number of licensed available beds and available telemetry and/or step-down beds outside of the intensive care and emergency departments. In addition, it provides information on the midnight census Board of Supervisors Page 2 December 15, 1998 under a Normal,Alert 1 or Alert 2 status. The report also provides information on the time and date of initiating and terminating Alert 1 or Alert 2 status. Mr. Lathrop stated that one of the advantages of the new system is that it provides the Health Officer with more information about the overall status of hospitals in the County! Currently, the Health Officer knows which hospitals are or are not on diversion. The Health Officer would know which hospitals are on either Alert 1 or Alert 2 status'; Lynn Baskett explained that it would also help in making decisions as to which hospitals could absorb more patients if diversion was necessary. She also stated that she felt that the new report shows more than just the availability of beds and that it acted as a surrogate for staffing availability. (See Attachment B, Hospital Council memo re Task Force Report) Supervisor Gerber asked if the hospital planning for the flu season and the new alert system was in response to the draft task force report from the State',of California on Overview of the Hospital/EMS Crisis Winter of 1997-98. (See Attachment C) The report includes findings and recommendations, including: ■ An increased number of patients resulted in a shortage of staffed beds and a reduction overall availability of ambulances to the system ■ "'This experience raises questions about the ability of the state's health care industry to effectively respond to similar situations and a major medical disaster." ■ "There exists little residual capacity, and that capacity to respond to events of even moderate impact is doubtful." ■ There is a need to develop emergency room utilization data and capacity benchmarks. ■ Hospitals should implement saturation avoidance actions. Lynn Baskett and Art Lathrop responded that the state actually was following the Contra Costa County model and that their efforts had begun before the state. Art Lathrop said that he had supplied the state with information and data about the efforts of the County EMS and Hospital Council. Supervisor Donna Gerber expressed concern as to what the hospitals are doing differently this winter so that they can be more responsive to the flu season. She also expressed concern that the new system does not tell us how many more patients a certain hospital could handle. She cited the following problems with the new system: ......._. ..._..__. ......... 11..1.1. .. .........._.......__. ..._...... ......... ......... ......... ......... ......... ..........1111.. __ . . _.. .11.11 .. ......... ......... ......... ......... .................... ._.......... _........ Board of Supervisors Page 3 December 15, 1998 ■ Uses midnight census, which is the time of least stress for the hospital system. ■ Counts patients, not available beds. ■ Uses licensed bed counts, which does not reflect staffing ability. ■ Is nothing more than an internal policy to avoid, what the State Department of Health Services calls saturation. ■ Does not trigger disaster proclamations to deal with saturation. Supervisor Gerber further said that anecdotal evidence coming to her indicates that patients are still experiencing long delays in the emergency room. Some of the delays are just inconvenient, but many cause suffering. Patients and families are continuing to file complaints with the Department of Health Services. She also said that investigations by the Department of Health Services show that patients are suffering poor or tragic outcomes due to congested emergency rooms and hospitals. Nancy Casazza, an emergency department staff RN and California Nurses Association member, spoke on her opinions of the new hospital status report. She first said she appreciated the work being done to improve available information and thought that computerizing the hospital status report on the Internet would be a good start. She expressed concern that the report would be as of midnight, since that was the lowest level of activity. She also stated that the number of licensed available beds really means nothing if there is no staff for those beds. The report needs to include information the staff to bed ratio. She also would like to see information on the number of staff and their skill mix, somewhat akin to the "state of medical readiness" used by the military. She also suggested adding the availability of pediatric beds and labor and delivery beds, which could provide emergency room back up. She thought that the Alert I and 2 were good if it was used for a systems approach to providing capacity, but not if it was used to eliminate diversion at all costs. She stated that Kaiser Walnut Creek, where she works, is usually at 96%to 97%capacity. Under normal conditions, there could be more patients than beds, based on the number coming in. She stated that last year Kaiser was not allowed to go on diversion and every effort is made to prevent it, either by forcing the wards to take patients or by other means. With regard to capacity at Kaiser Walnut Creek, she agreed that a new unit will be opening, but her understanding was that a medical/surgical unit will dose at the same time for remodeling. Also, under the increase in Kaiser Walnut Creek beds reported by the EMS, these beds have not yet been staffed. Her understanding was that the beds were created by converting one bed rooms into two bed rooms. She also stated that with regard to the staffing options during flu season that eliminating and canceling vacations and requiring overtime was not a good practice. _. .11 ..... .........__........__.... ......... ......... ......... ...1111_.. ......... ......... ......... .............. _.. _..... ......... ........1 ...... Board of Supervisors Page 4 December 15, 1998 Kaiser Walnut Creek nurses are quitting and going to a per diem status because of these practices. In summary, she said that she felt it was important to maintain a state of readiness in the hospital; for the daily log to report not midnight census, but a more appropriate time; to add data on surgical and emergency department admissions; to take into account projected surgical procedures; to maintain the current daily log; and to continue to ask the charge nurse how busy are they (on a scale of one to five). Art Lathrop explained that the current daily log system requires that one of his staff spend most of the afternoon calling each of the hospitals and that the data is not necessarily consistent, since it is dependent on the interpretation of the reporting person. In addition, the current daftly log cannot distinguish between a report of six beds which are empty (in which case, there would be a report of six empty beds) and whether there was no staff available for six beds (in which case, the report would be no empty beds). Supervisor Donna Gerber reviewed the bed availability charts (See Attachment D) which shows the number of available ICU, telemetry and medical/surgical beds in each of the County's regions between January and August 1998. She noted that in East County, there was an average of no more than 3 to 3'/2 ICU beds available each month and for Central County, it was a maximum of 15, despite their huge patient load. Kaiser Walnut Creek never had more than 4 ICU beds available. West County had a maximum of 10 ICU beds, with 2 months at under 4 beds and 5 months at under 6 beds. Supervisor Gerber did acknowledge that Kaiser has recently agreed to comply with the County Board of Supervisors' request that they reopen Richmond, which could help West County's capacity by the end of 1999, when the emergency room will be open. The addition of ICU and medical beds this winter is also expected addcapacity to that region. She also noted that the press has reported on national data, compiled in Dartmouth,which shows that Contra Costa County is lower than national average on the number of RN's and licensed beds per 1,000 population. She reiterated her concern that the problem with the new status report is it doesn't show how many patients a hospital could take at any given time. Art Lathrop stated that one of the difficulties is the hospitals try to staff to need and it is to their economic advantage not to have more than a few beds available at any time, but to be able to staff for more as the demand increases. He also stated that he was not sure of the hospitals' receptivity of maintaining the current system of reporting and adding a new system, since the new system was promoted as a means of simplifying reporting procedures. _.. . ....................................... ......... ......... ......... ......... ......... ......... ......... ....._... _.. _...... ......... ......... ......... Board of Supervisors Page 5 December 15, 1998 Lynn Baskett said the hospitals would be very concerned if they were required to provide duplicate reporting. The original system was designed for last winter's flu season only and it has continued over the entire year, well beyond the initial time period. Supervisor .Donna Gerber asserted that, if there were no problems in the ability of hospitals to serve patients, then the County wouldn't be involved. She said that the hospitals in Contra Costa have an overall capacity problem. Lynn Baskett stated that last winter the issue of concern was the ability to handle the flu season and she, personally, spent a considerable amount of time focusing on ways to improve the reporting system and to handle the flu season. She stated that the Lowen Group report found that hospitals could have over 40% more capacity quickly in an emergency. She also said that it was not a good idea to spend time on data that is not helpful to the system; however, she would talk to hospitals about providing a dual reporting system in January and February. Art Lathrop suggested that the dual reporting go through the end of March and, at that time, there would be an evaluation of which method to select. Lynn Baskett suggested that, perhaps, there could even be a third system. Supervisor Gerber stated that she could not agree to selecting only one system by the end of March, but agreed that it was a good idea to meet in March to evaluate the data from both of the systems and then determine the best course of action. WILLIAM B. WALKER. M. D. ATTACHMENT A lJOKE OF HED HEALTH SEftvscES DIRECTOR ( 1 RECTO . 220 Alllen Street -f �`" Martinez, California CONTRA COSTA 94553 .3191 Ph (925)--- HEALTH _ HEAL HSERVICES Fax (925) 370-5098 December 14, 1998 TO: Family and Human Services Committee FROM: William B. Walker, M.D. VX-' vi— SUBJ: Update on Planning for Hospital Emergency an Critical Care Services This is to provide additional 'information and update your Committee on the status of planning and monitoring activities following our report of October 21, 1998. (1) Monitoring-of-HospitaleCritical-Care As reported to the Family and Human Services Committee on October 21st, EMS staff have worked with Alameda County EMS and with the Hospital Council to develop a better mechai, >m for monitoring hospital status during the coming winter',flu season. The monitor~ng system that has been developed will include hospital reporting of: (a) Number of licensed available acute care, intensive care, and other telemetry beds. (b) Number of patients in acute care, intensive care, and other telemetry beds. (c) Hospital Census Alert Status - normal, Alert 1, or Alert 2. This information will be reported daily as of the midnight census and at any time a hospital's alert status changed. Alameda County is developing a system for use by both Alameda and Contra Costa hospitals and EMS agencies in reporting and monitoring hospital status via the Internet. Until that system is available, probably in February 1999, information will be provided to EMS via fax using the attached "Hospital Status Report" form. Additionally, Alert 2 status will be reported to Sheriff's dispatch which, in turn will provide notificationto personnel in accordance with Medical Advisory Alert procedures. These procedures provide for notification to key personnel and to all hospitals. Contra Costa Community Substance Abuse Services • Contra Costa Emergency Medical Services + Contra Costa Environmental Health • Contra Costa Health Plan + • Contra Costa Hazardous Materials Programs +Contra Costa Mental Heaith • Camra Costa public Health • Co7tra Costa Regionat Medical Center + Contra Costa Health Centers + _. _. ._..... ......... ......... ......... ......... ........_. ...._.. .. .... ..............._.._.._. ._....... ......... ......... ._....... ......... ......... ......... ......... .............._... _. ... ._._._... .............. ...._...._......_. (2) Kaiser Richmond. Kaiser has announced plans to upgrade its Richmond facility to full Basic Emergency status. The upgrade will be phased in with the opening of an 8-bed ICU scheduled for January/February 1999, the addition of surgical services beginning by September 1999, and full Basic Emergency Services established by the end of 1999. EMS has met with Kaiser officials and will restore ambulance receiving hospital approval to Kaiser Richmond for selected categories of patients upon determination that ICU services are fully available and with Miser's commitment to obtain Basic Emergency designation. Full receiving hospital status will be granted upon State approval of full Basic Emergency designation. (3) Hospital Council Report. A report from the Hospital Council dated November 18, 1998 (attached) has been submitted to the Family and Human Services Committee. That report (1) describes collaborative flu season planning efforts by the Hospital Council, hospitals, and health departments in Alameda and Contra Costa counties, (2) summarizes steps taken by hospitals to prepare for the winter flu season, (3) updates the hospital bed inventory conducted by the Hospital Council in Contra Costa in 1997, and (4) describes a study commissioned by the Hospital Council to be undertaken by The Lewin group to develop hospital'bed projections based upon utilization and population trends in Alameda and Contra Costa'counties. An attachment to the Hospital Council report describes the Hospital Census Alert system which had been placed into effect by hospitals in Alameda and Contra Costa. The number of available ICU beds as reported by the Hospital Council has dropped from 156 in 1997 to 153 in 1998. The number of telemetry beds (outside of ICU's and emergency departments), however, increased from 140 in 1997 to 180 in 1998. There were also small increases in the total number of emergency department beds and the proportion of emergency department beds with monitoring capability. The report also lists several additions to hospital capacity planned from Iate 1998 or 1999. This include 56 additional acute care (medical/surgical) beds, 8 additional ICU beds, and 9 additional',emergency department beds. (4) Hospital Facility Assessment. All hospitals in Contra Costa are participating in the EMS hospital facility assessment process undertaken to identify hospital resources and capabilities. A copy of the assessment instrument is attached. EMS has completed a preliminary compilation of the completed assessment data and has met with the hospitals to review the compiled data. The data is currently undergoing some corrections and revisions and will be completed by January 1999. 2 _... ......... ......... ......... ......... ..__..... ........ ......... ......... ......... ......... ......... ......... ......... ......... ......... _ _........ ......... ......... ......... ........... ................... . ........................................................... (5) Receiving Ho ital Agreements. Draft receiving hospital agreements have been circulated to the hospital for comment and have had a final review by the EMCC Facilities and Critical Care Committee. The contract is currently being by Health Services contract personnel for final approval as to form before being presented to the hospitals for signature. attachments cc: County Administrator County Counsel Auditor Office of Emergency Services Emergency Medical Services 3 ......... ......... ......... ...... ........_._.. ......... ......... ......... ._....... ......... ......... ......... ......... ....... .. __. _._ _...._... .......... ........ ......... 12/8/98 Contra Costa Emergency Medical Services Hospital Status Report Date/Time Hospital Report Prepared I / __ am 1 pin mo day year hr Mm Person Preparing Report _ Telephone Total number of licensed available beds (See definitions below.) Acute Care Intensive Care Number of available telemetry and/or step-down beds outside of the intensive care and emergency departments Complete one of the fallowing boxes: Midnight Census Report for night of day of week mo day year 1. Current Hospital Status (circle one) Normal Census Alert 1 Census Alert 2 2. Total number of patients in (a)acute care (b)intensive care 3. Number of patients in telemetry and/or step-down beds outside of the ICU/CCU or ED Initiate Hospital Census Alert Level 1 or 2 (circle one) 1. Date and time alert initiated / / am / pm mo day year hour min 2. Total number of patients in (a)acute care (b)intensive care 3. Number of patients in telemetry and/or step-down beds outside of the ICU/CCU or ED Terminate Hospital Census Alert Level 1 or 2 (circle one) 1. Date and time alert terminated / I am / pm mo day year hour min 2. Total number of patients in (a)acute care (b)intensive care 3. Number of patients in telemetry and/or step-down beds outside of the ICU/CCU or ED Instructions: This form should be completed and faxed to the EMS Agency(925/646-4379)on a daily basis to report midnight status and whenever hospital alert status changes. When on NORMAL status,report may be faxed by noon the following business day. When on ALERT I or 2 or changing alert status,report should be faxed immediately. Available Beds:The average daily complement of beds(excluding nursery bassinets)physically existing and actually available for overnight use,regardless of staffing levels. Excludes beds placed in suspense or in nursing units converted to non-patient care uses which cannot be placed into service within 24 hours. Acute Care: Licensed available beds for those discrete daily hospital services cost centers providing general,acute care, including such cost centers as medical/surgical acute,obstetrics acute,psychiatric acute, chemical dependency services,and definitive observation. Intensive Care:Licensed available beds for those discrete daily hospital services cost centers providing intensive care,including medical/surgical intensive care,coronary intensive care,and burn care,but excluding neonatal intensive care. (Note that this differs from OSHPD definition which includes neonatal.) Monitored Beds:Acute care beds for which monitoring equipment is available. (Does not include intensive care or monitored emergency department beds. Hospital Council November 18, 1998 Donna Gerber Mark DeSaulinier Contra County Board of Supervisors Contra County Board of Supervisors District 3 District 4 3039 Diablo Road 2425 Bisso Lame, Ste. 110 Danville,CA 94526 Concord, CA 94520 Dear Supervisors Gerber and DeSaulnier- At the October 26, 1998 Family and Human Services Committee meeting you requested more specific information on what.hospitals were doing to prepare for the flu season. We took this opportunity to update our bed inventory last completed in April and July 1997. 1 have also summarized the ether activities undertaken by our members to insure maximum preparation for a busy flu season. Collaborative Flu Season FlanWng The hospitals and County Health Department and EMS Agency have been;active in developing a flu season communication plan to: • encourage targeted papulation,groups to obtain flu shots, Encourage/educate the general public about how to make the right call (e.g.,primary care physician, advise nurse,or 91 I) and how to make the right choice about where to seek healthcare services (e.g.,primary care physician, clinic,emergency department). The County Health Department,E.MS Agency,and hospitals developed a framework for monitoring the winter volume and will develop criteria for determining when it might be appropriate to recommend the declaration of a health emergency. This monitoring framework has been endorsed by the hospitals, health departments, and EMS Agencies in Contra.Costa and Alameda Counties,as well as by representatives from key medical groups,health plans, clinics. AMR, and the California DHS. (A copy is attached.) The FMS agency Directors from Contra Costa and Alameda County have worked with hospital representatives to improve the daily reporting of available beds with the goal of moving toward an electronic system of reporting the information.The information would then be useful to both the E g Agencies and the hospitals who would use a to facilitate transfers when needed. A joint meeting was held with State and Regional Department of Health Services staff as well as HCFA representatives to review procedures for requesting program flexibility and waivers should they be needed.again this winter. The objective was to.make the process as smooth and expeditious as possible should it be necessary to request program flexibility to address patient volumes. say Ares 0MftCNCc%EHI4aIg48LE'-n0M 9RPI.L.AOC,IIIS/98 28S50 Telegraph Avenue.6th Hoar.Berkeley,CaWomta 94705 a Phone 510-705-8990•Fax 310-TOS-S"2+e-mad:lbaskeu0ben e.eon ... L�VJL 1;'SL Flu Season Planning November 18, 1998 Page 2 Hospital Specific Planning?activities Hospitals have taken the following steps to prepare their own operations for the flu season. While some of these actions are limited to individual hospitals, many actions have been taken by most hospitals. These steps are reflective of the hospitals' proactive efforts to prepare for the winter flu season. • Increased core-staffing levels. • Provided training programs for new RIN graduates,critical care,labor,and delivery nursing positions. • Added physician hours in the emergency department to accommodate census increases; two hospitals have also added physician's assistants to assist;in the emergency departments. • Adjusted staff schedules to maximize staff on busiest shifts. • .Increased on call and per diem staff in nursing and other patient care departments. • Enforced weekend availability requirements for staff. • Added urgent care tracks in the emergency department,expanded hours of existing clinics and prepared a plan to f ether increase outpatient clinic hours as patient volume increases. • Increased hours in support departments such as lab, imaging, and cardiopulmonary. • identified areas where critical patients could be cared for beyond licensed bed where program flexibility could be requested from DHS. • Identified overflow and holding areas for emergency department patients waiting for admission. • Opened previously closed nursing units and added staff to cover the re-opened beds. • Opened a 12-bed definitive observation unit(step down from intensive care). }added monitors to medical beds to increase capacity to monitor critical patients. • Encouraged all staff to obtain flu shots. • Made arrangement with traveling nurse registries for staff. • Worked with medical staff to increase communication about flu season plans and daily census. • Discussed mechanism to reschedule non-emergent procedures if needed. .................. Flu Season Planning I,Zovember 18. 1998 Page 3 In addition to the numbers included in the bed inventory below, the following beds will become available in.December, 2998 and early 1999: . 10 rnedicai/surgical beds at Sutter Delta January, 1999 4 additional emergency department beds at Doctors'Medical Center,San Pablo campus December 1999. . 24 medical surgical beds and.5 emergency department beds at Kaiser Walnut Creek April 1999. 8 intensive care beds and 22 medical/surgical beds at Kaiser-Richmond',in January- February, 1399. Bed Inventory 1997 1998 172 161 1 Licensed intensive care , beds 11 153 i R.eadil available beds*' 156 � i 140 180 Teiemet beds � t 79 � Portable monitors `tint curve ed in 199'7 i i i Emergency Department 132 ! 138 y p beds { 59% .Monitored ED beds 63.8% bed include those physically available,not otherwise limited by Readily available hospital policy and available for incoming patients if staff is available. 0,.\Ii''{CC';E39H019961.E'rT1Gmmu.Doci{/t&98 11/18/98 - ; 51 i00S992 IfOSP[rAI Ct3t VCIL s.�'Utl5fU11 Flu Season Planning November 18, 1998 Page 4 Portable monitors were not surveyed in 1997. The number of portable monitors is an indicator of additional capacity for critical patients who may not treed to be admitted to an intensive care unit but who treed monitoring and additional observation. The system can increase its monitoring capacity by 40 per cent. This year we surveyed for intensive care unit emergency response capacity. These beds would be for intensive care patients who could be cared for in areas other than the intensive care unit with appropriate staff and equipment. California DHS program flexibility would be requested each time these alternate care units would be utilized for intensive care patients. These are for short term responses to high patient census. With in the County there are an additional 73 intensive care beds that could be made available, or and increase of 47 percent in the available capacity. It is important to nate that the statewide shortage of registered nurses continues to effect hospitals in Contra Costa to varying degrees. Sufficient critical care nurses will continue to be a concern. The number of hospitals who have provided training for staff in this area underscores both their concerns and their concerted effort to address the staffing challenges. The Hospital Council and the California Healthcare Association are both working to support statewide efforts to address the future needs for registered nurses. Other Collaborative activities to Strengthen the EMS System Completed the review and development of receiving hospital agreements. Agreement is pending County counsel review for standard County contracts provisions: Coordinated a ReddilNet TT presentation for Bay.area counties with the goal of identifying an emergency communication system that would work not only for Contra Costa County but also for other Bay area counties, which would facilitate inter-county disaster communications as well. .A specific proposal is being developed. Completed a pilot study of hospital waiting times. Concluded that variations among hospitals made useful conclusions difficult to draw;the data was not useful for hospital internal performance improvement processes nor would the data be useful for regional planning purposes. 0:mac'4cckaskJc%z LETrncERBRFLUI. CI 111&98 1.:_ .3 _________1jJ E-5i lL3.'3 6&v Z Flu Season Planning November 18, 1998 Page 5 Regional Planning In order to address the questions of long-term adequacy of acute care services, particularly emergency and critical care services,the Hospital Council has engaged The Lewin Group to develop bed projections based on utilization and population trends. Any gaps in services that may be identified in the study will provide the basis for fugue collaborative action and regional planning. Both Alameda and Contra Cosh County health directors will be invited to participate on the study Steering Committee. I would be happy to answer any questions you may have. Sincerely, Lynn H. Baskett Regional Vice President Cc: East Bay Hospital Chief Executive officers William Walker, M.D.,Director, Contra Costa Health Services Art Lathrop,Director,ENIS Agency Supervisors Gayle Uilkema,Jim Rogers,3oe Canciamilla Attachments G:1HC.4CCMIfC,1998L.8'CT1C.MRFLi-DOC1itIV" izratsraa ir:zs C�'�tU�rl�esa�z"" ,: ;;,,; %wr Hospital Council HOSPITAL CENSUS ALERT IIALERT 2 SYSTEM For Use During Extended High Volume Census Periods Endorsed by Alameda.and Contra Costa hospitals, county health departments,EMS Agencies and representatives of key medical groups, clinics, health plans and ambulance providers October 9, 1998. Introduction As a result of the 1997-98 winter flu season which; exceeded all volume projections throughout the state and beyond, the East Bay hospitals, county health departments and EMS Agencies have developed art Alert System for use in future winter flu seasons or any period with sustained,extraordinarily high patient volume, The intent of this Alex* System is to articulate what hospitals and other;stakeholders in the health care delivery system do as the patient volume increases and is then sustained for extended periods. By having a common terminology,it is our hope that the various providers will be able to communicate more effectively with each other, as well as with the public, concerning the extraordinary patient volume and the ways in which the public and providers can support an effective EMS and health care delivery system. Alert VAlert 2 Triggers Each hospital will have unique indicators, which trigger its implementation of Alert 1 and Alert 2 responses. Factors which hospitals consider include the following: • Emergency Department volume • Available staff,e.g., physician,nurse,technical and support staff • Available beds (e.g., medical/surgical beds, monitored beds, critical care beds, level 3 neonatal intensive care unit beds) • Equipment(ventilators, incubators, telemetry monitors,beds and wheelchairs) • Number of employees who call in sick at the salve time in critical patient care areas • Current and anticipated surgery schedule During the course of the year, hospitals go on Alert I and Alert 2 stag for brief periods of time. It is nor unusual for these Alerts to last for a few hours or several.shifts. It is when the hospital is at a Alert I or Alert 2 status for a sustained period of time,e.g.,several weeks, that it begins to compromise the responsiveness of the entire local health care system. If, as was the case in the 1997-98 winter season, a number of hospitals are at Alert I or Alert .2 status at the same time, the ability of neighboring hospitals to help with overflow:is impaired. Bay.Area Dividon 2950 Telegraph Avenue.6th Floor,Berkeley,California 94705+Phone 510-705-8990•Fax 510.705-8992*e-mail:lb"kettohence.cm t�r2aistts ,_ Ii'24 g....li. ii7rtTs£5 :_:.. Hospital Census Alert !/Alert 7 System �f tttittrii�ti Page 2 Extraordinary Volume Hospital Planning Process The following describes some of the key issues hospitals address in their flu season planning which begins in the summer: • Analyze Emergency Department volume by hour of day and day of the week to plan physician/nurse, tech, and clerical staffing • Project winter volume based on the increase from summer to winter volume (likely focus on the p.m. shift that sees most of the emergency department volume) • Based on volume projections, calculate Emergency Department gurney turnover rate needed and available staff,inpatient beds, monitored beds,critical care beds • Plan for alternate areas of the hospital to place the patient, e.g., post anesthesia care unit, short stay unit, cath lab, endoscopy unit, observation area, discharge lounge, admissions lounge • Stock up on supplies and equipment for projected volume • Plan staffing for emergency department, inpatient units as well as support departments such as pharmacy, cardiopulmonary, respiratory therapy, case management, housekeeping, laboratory, transport,radiologists, medical records,etc. • Notify medical staff, hospital departments, key medical groups, etc., of the anticipated volume and planned space utilization so that they, in turn, can plan for their specific space, staff and equipment needs • Plan for systems to expedite the handling of 5150 patients • Plan staffing of hospitalists, if available • Evaluate staffing options to be implemented as needed including RN, physician, and support departments • Consult with unions regarding potential staffing options as appropriate • Evaluate recruitment,retention and incentive plans « Hire new graduate nurses • Provide update on plans for individual physicians and their office staff so that the office staff can anticipate the hospital needs and revised policies and practices Alert 1 and.Alert Z Responses The following are Sx, Ies of the actions that hospitals and rather providers take in response to high volume periods. Not all responses listed will be applicable for every hospital. Physical capacity and layout, as well as types of staff available, influence actual responses. These responses, however, are representative of the concerted effort all hospitals and others make to respond to patient volume increases. Many of the responses cross more than one Alert level. The intensity and sense of urgency for each response increases as the Alert level increases. ormaI Alert 1 Alert Hospital Responses Operations Add a.`ditional triage nurses i �t 311 in atclditiraiial'sta#f of gn stat assignments �✓ �HHLL'.PL.` ei- s.asx �c�z�s C3StJlUSt:JJG... HUJY i I. 'l;i7r(3iVC i�jUTl4llf�.[:t ` Hospital Census Alert llAlat^_System Page 3 North alert 1 Alert 2 � Hospital Responses O '"ati°ns se hospitalises if availalie Stock up on supplies and equipment er patient or tatnily ride home at discharge by taxi if they I ✓ ! 1 are having problems with transportation Track obstacles to smooth patient flow ✓ f pedite Ww—ssionsldischaxgeJttrartster of patients with the critical care and step clown unit medical directors,case � ✓ � ✓ managers, and charge nurses I # a6e-nts are not held in the emergency department for private ✓ ✓ j physicians to see the patient prior to admission Emphasize triage, st ilize an adiiit with same c the testing being completed for the patient after they have been Witted ✓ ✓ I Sham info on hospital volume with neighboring hosFItals ✓ ✓ Ialerting them to potential requests for transfer or assistance Enforce Sed priority policies ✓ ✓ Conduct meetings with nursing unit,directors and supervisors, discharge planning, and staffing office in the morning and ✓ � � ✓ � early afternoon, to pian for staff, triage, surgery schedules,etc. Iniiiii—e" A team to prepare and turnover cis more quickly ✓ ✓ Implement a notification system for e emergency physicians so that they can be called in early if needed before their I +! ✓ ✓ regularly scheduled shifts reale or open ac=tIonal areas for patients such as jobservation areas, discharge lounges, admitting lounges and other overflow areas nd edcastafofigteningbecondition star m I Ithrough signage, entail,broadcast fax for physicians who use ✓ hospital less frequently, etc. ! I ti y hospital departments of Alert status so that emergency department and ether patient care and patient support ✓ �' d epartments can implement their flexible staffing systems rk with medical staff and medical groups to extend Office hours and on-call system p eenr available s fang options • Per diem staff I • Enforce weekend availability I • I2-hour shifts on weekends • Traveling nurses/guaranteed registry hours ✓ �,. Cross train 1 • ?Mandatory overtime #t • Cancel vacations ! Deny time off requests { f + Recall staff t t�HC'�t..l,'P't.:�Si i-Zrsp.das 10/2W98 ISJ12S7a8 Li ::;� _"L��Ill7i13t343yL _ tiC1S!'L13I: GUUiVC1L $UY(ilY71L Hospitai Census Mart I Alert 2 System page 4 ! Norms# Alert 1 Alert 2 � Operations � I f p�fta". ReSp+oltSeS ,, y l7 to request program flexibility as needed nd hours ci other partments such as pharmacy,c I pulmonary, respiratory therapy, case management,house- ( ! I keeping, tab,transportation,radiologists,medical records,etc. ! I Deterine,on a case by case basis, whether t madmits will ✓ be held in the physician Office,the emergency department,or at home ✓ ✓' Expand emergency department and hospitalist physician hours # Implement employee incentives for working extra ours,e.g. � 1 ✓ i food,cappuccino cart, gift certificates,etc. I ! Open c osedlsuspended licensed beds;use trailer for physician � w► sleeping rooms as needed Use non-nursing s from other departments to assist in ! I d patient care areas with non-cursing tasks ' Lrse ten trailer for storage to free up patient care areas I rgency department diversion # ✓ I Implement hospital disaster plan V ! Request medical mutual aid through the county start admission process in menti xed'holding area to # I ✓ I ! decompress Emergency department 1 I I Reschedule procedures and surgeries,e.g.,hernia repair,hip I replacement,etc. I Nornxai alert 1 Alert 2 1 Other Stakeholder ReSpOnses ► €)per dions ! i county 4 Utilize public health nurses for preventaand treatment, flu shots prevention,home visits i i ! ! Develop and distribute consolidated sche ule/contact list for � ✓ I flu Shots(hospitals and physicians to assist in distribution) I ✓ ✓ I ncTease County clinic hours Health Plans ! Corntuunication to-member s regarding: prevention, ow to { I use advice nurse and available phone numbers,appropriate use of 911, appropriate use of ambulance A.ssistlretruburse alternate transportariharge to on at discee iI I up bed for waiting patient Ti/id/UO---- 1t-:-L( `-"i,T7-lcllUiY63l3lG ... _.Q{TJPI1:11.r'�K;ULA\.11;, ;:;;. ....:: .. _. v i'Y i"v'i j..... Hospiw Census alert IlAlert 2 System Page 5 Normal Alert 1 Alert 2 other Stakeholder Respot Operations Health Plans(continued) Encourage/incentivize physiciee parients during of - V, hours or expand office hours dxtended nigh volume 1 Periods. Provide I hour advice nurse services*,deveiop the capacity for advice nurses to schedule patients with physicians directly. Review advice nurse protocols to add flexibility and more ✓ ' { alternatives to the emergency department physiclandMedical,Grou s/C*Mumui Clhtics f assist hospitals in reviewing patient status TOr ✓ ✓ admission/discharge or transfer from critical care and step- down units Distri ute u season prevention i onnatxon to patients and r/ staff panel officeicall hours to minimize referrals of non-urgent ✓ �,/ patients to the emergency department Ambulance Providers ✓ increase arab encs capacity for inter-facility transfers grid ✓ 911 calls \EaiACTLUt'LMt1-2=P doe tOJ2(�98 MEMORANDUM CONTRA COSTA EMERGENCY CONTRA COSTA MEDICAL SERVICES HEALTH SEi't,VICES 50 Glaeier Drive Martinez, California 94553 Ph: 925-646-4690 Pax: 9.25-646-4379 September 10, 1998 To: Hospital Administrators From: Art Lathrop EMS Director sabj: Facility Self-Assessment Tao ;;�:�� Please complete the enclosed EMS hospital and critical care assessment tool and return to the EMS Agency by October 8, 1998. The EMS Facility/Critical Care Committee has developed and endorsed a self-assessment tool for hospitals in Contra Costa County pursuant to Health and Safety Code requirements and the County EMS System Plan priorities. At its September 9, 1998 meeting, the 'full Emergency Medical Care Cbmmittee endorsed this document, and recommended distribution to the hospitals for completion. Our goal is to compile the survey results and distribute it as a resource document for hospital staff, hopefully prior to the height of the "winter flu season". I appreciate your cooperation in completion and return of the survey. If you have any questions, please contact me or Bobbi Bonnet. cc: William B. Walker, MD, Health Services Director Enclosure co=£`tura Subs=.Ahwu Seri+ea C,�nttta l teci Grncreencv t4ediraf Sentices•l;mug C Ku fns frnnmznr�i He s}h+C'<mi:a<'ixb HeIih Piot Contra 1.,+ra t rr&ramn•Comm<_„sW LtemG t Hr�hh+Comm Coa a Cuh4ie Hewth•t.wiira l xta RQnioiwl C,�nter•Contra Heaiih _........ ......... ......... ......... . . . ..... ............... ......... ......... ......... ......... ......... ......... .. ..... ......_.. ......... ......... ......... ......... ................. ................................................................................................ ................ CONTRA COSTA HEALTH SERVICES Emergency Medical Services September 14, 1998 ACUTE CARE HOSPITAL EMERGENCY AMBULANCE RECEIVING FACILITY SELF-ASSESSMENT INSTRUMENT Basis for Conducting Facility Assessments Division 2.5, California Health and Safety Code, Sections 1797.103, 1797.250 and 1798.150, allows the State EMS Authority to estabiish guidelines for the utilization of hospital facilities according to critical care capabilities and requires local EMS agencies to utilize planning and implementation guidelines developed by the State EMS Authority in the assessment of hospitals and critical care centers. 12EMOGRAP'HIC INFORMATION HOSPITAL NAME: MAILING ADDRESS AND PHONE NUMBER: PHYSICAL ADDRESS: cif different) CHIEF EXECUTIVE OFFICER: CHIEF OPERATING OFFICER: CONTACT PERSON for this survey Telephone and FAX Numbers: DATE OF SURVEY: Designation for tax purposes (Public, Private not-for-profit, Private for- profit): Total number of licensed acute care beds, all types: Please attach a copy of your State acute care hospital license. Total number of out-patient treatment areas if integrated or attached out-patient facility: When was your facility last reviewed by the Joint Commission for Accreditation of Health Organizations #JCAHO)? For what period of time was accreditation received? Contra Casts Wealth Services * r'merVency Medical Services l Acute Care Facility Self-Assessment 9198 SPECIAL PERMIT SERVICES Please indicate which of the following Special Permit Services are provided in your facility under a current permit to provide these services from the State Department of Health Services, meeting all provisions of the appropriate section of Title 22 Article 6. SERVICE SECTION{S} Cardiovascular surgery service 70431-39 YES NO Comprehensive emergency medical service 70451-59 YES NO Basic emergency medical service 70411-49 YES NO Standby emergency medical service 70469-57 YES NO Burn Center 70421-29 YES NO Renal transplant center 70605-13 YES NO Chronic dialysis unit 70443-49 YES NO If your facility provides any of these services in a limited fashion with no current permit, please describe here, or on a separate page any discrepancies with the indicated provisions, the limitations of the service, or the current status of permit applications. Contra Costa Health Services ` Emergency Medical Services 2 Acure Care Facifity Self-Assessment 9198