Planning for Surge
Capacity in Health Care
Services
Betsey Lyman
Deputy Director, Public Health
Emergency Preparedness
California Department of Public Health
California Faces Disasters on a
Regular Basis
 Examples
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of disasters since 2006:
2006 Extreme Heat
2007 Lake Tahoe Wildfire
2007 Southern California Wildfires
2008 Northern California Wildfires
2008 Chino Hills Earthquake
2008 Los Angeles Metro Link Crash
2008 Southern California Wildfires
2008 Severe Cold
The Challenge
 Meeting
the public health and medical
needs of Californians during and following
disasters
 Addressing
statewide needs during a
catastrophic event when mutual aid is
limited
What is a Healthcare Surge?
……an excess in demand over capacity in
hospitals, long-term care facilities, community
care clinics, public health departments, other
primary and secondary care providers,
resources and/or emergency medical
services
What is NOT a Healthcare
Surge?
 The
frequent emergency department
overcrowding experienced by healthcare
facilities (for example, Friday/Saturday night
emergencies).
A
local casualty emergency that might
overcrowd nearby facilities but have little to
no impact on the overall healthcare delivery
system.
Surge Capacity Basics

Beds: Acute care and critical care beds

Staffing: Licensed healthcare professionals and
support staff

Medical supplies and equipment:
pharmaceuticals, personal protective equipment,
portable and fixed decontamination systems,
isolation beds, ventilators, masks
Measuring the Gap: 2006 California
Healthcare Surge Capacity Survey
Standardized definitions for crisis care:
• Nurse-to-patient staffing ratio of 1:5 for Critical
Care Beds and 1:20 for Other Medical-Surgical
Beds
• Assume self-sustainment within the facility for a
minimum of 72 hours without re-supply of
equipment, supplies or staff
• Assume 30% of staff will not report to work
Measuring the Gap (cont)

Response:
 324 hospital: 80 percent of California’s 73,000
operating licensed acute care hospital beds
 California’s local health departments
 172 community clinics

Identified 19,963 beds California hospitals said
they can surge

Bed shortages:
• Los Angeles area
• Pediatric beds
Greater Gaps in Meeting Needs of
a Catastrophic Event
 Using
CDC’s FluSurge 2.0 computer
modeling program for pandemic influenza:

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California needs 58,723 surge beds for a
moderate pandemic influenza
38,760 beds or 194% above the 19,963 surge
beds California hospitals said they can surge.
Analysis of 2006 Survey Results
 California
has sufficient surge capacity for
a Moderate event: regional earthquake,
fire, flood, or bioterrorist attack.
 California’s
surge capacity is insufficient
for a Catastrophic event: statewide impact,
e.g., Katrina-like event or pandemic
influenza.
2006 Healthcare Surge Initiative
The State of California spent $172 million to
improve its medical surge capacity
Item
Masks (N95 Respirators)
Ventilators
Antiviral medicines -- enough to
treat 25 percent of California's
population
Need
Bought
Cost
100 million
50.9 million
$19.9 million
24,000
2,400
$30.6 million
8 million courses
3.7 million courses
90% Tamiflu,
10% Relenza
$54.6 million
3 - 200 bed
$18.3 million
21,000
$33.4 million
Mobile Field Hospitals
21,000 extra beds with supplies for
alternate care sites
Developing new hospital guidelines
and standards
42,000
$5 million
Alternate Care Site Supplies and
Equipment

State Alternate Care Site Caches contain over
300 items, ranging from patient cots and linens,
routine nursing supplies, suture equipment,
airway breathing supplies, etc.

Supplies and equipment are packed in caches to
support 50 patients
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Each cache is stored on 20 pallets
Standards and
Guidelines for
Healthcare
Surge during
Emergencies
Focus of the Project
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Standards of care for healthcare facilities and
licensed healthcare professionals during an
emergency
Liability of healthcare facilities and licensed
healthcare professionals
Reimbursement of care provided during an
emergency
How to operate Alternate Care Sites
Surge capacity operating plans at individual
hospitals
Project Approach
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Developing and managing a process that
includes government agencies, providers,
stakeholders, and other relevant parties as
participants in this project.
Developing written standards and guidelines
for delivery of medical care services in a
surge environment.
2008 Deliverables
 Foundational
Knowledge document
provides platform for all volumes
 Manuals focused on target audience:
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Hospitals
Alternate care sites
Payers
 Reference
Manual including legal analysis
Volumes under Development
 Licensed
healthcare professionals,
including Crisis Care
 Long
term care facilities
 Clinics
When is a Healthcare Surge Declared?
Surge Monitoring Guidelines Table
Local Surge Emergency
Surge
Level
Enabling
Authorities
Green
Regulatory/
Accrediting
Agency
Waiver
Green:
Yellow:
Orange:
Red:
Black:
Yellow
Orange
Red
Black
Regulatory/
Accrediting
Agency
Waiver
Regulatory/
Accrediting
Agency
Waiver/
Local
Emergency
Declaration
Local
Emergency
Declaration
Local
Emergency
Declaration
Regional
Level
Surge
Statewide
Surge
Level
State of
Federal
Emergency Emergency
Declaration Declaration
Usual day to day status. No assistance required
Surge managed locally. No assistance required
Additional healthcare assets required within jurisdiction
Assistance needed outside local jurisdiction or area.
Significant assistance needed outside local jurisdiction.
HOSPITAL PREPAREDNESS
Hospital Connection to Incident
Command System
 Ensuring
hospitals have internal Incident
Command Systems
 Community
planning: connecting hospitals
to local Emergency Response Structure
 Expanding
needs
hospital capacity to meet surge
Reimbursement
Maintaining existing revenue streams is
critical to hospitals during a healthcare surge.
Key concepts surrounding reimbursement
during surge include:
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Advanced planning and collaboration with
commercial health plan partners
Acquiring detailed knowledge of the resources
available to hospitals during surge conditions
Methods to access additional resources from
federal and State funded programs
Establishment of a
Government-Authorized
Alternate Care Site
What is a Government-Authorized
Alternate Care Site?
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A location that is not currently providing healthcare
services
Will be converted to enable the provision of healthcare
services to support, at a minimum, inpatient and/or
outpatient care required after a declared catastrophic
emergency
Will help absorb the patient load after all other healthcare
resources are exhausted
Types of Government-Authorized Alternate Care Sites

Mobile Field Hospitals

Arenas

Schools

Churches

Shuttered Hospitals

Stadiums
What is NOT a GovernmentAuthorized Alternate Care Site?
A government-authorized Alternate Care Site is NOT
part of the expansion of an existing healthcare facility,
such as
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extensions of general acute care hospitals
clinics, or
long-term care facilities
Government-Authorized Alternate Care Sites DO NOT include:

Tents set up for patient care in the parking lot of a hospital and
under their control

Sites set up for patient triage by Emergency Medical Services

Any temporary space set up for patient care under the authority
of an existing healthcare facility
2009: Current Challenges in Surge
Capacity

Gap in needed surge capacity remains
significant
 2006 Healthcare Surge Initiative
addressed approximately half of the gap
in needed beds
 California
hospitals are struggling for
financial survival. Loss of hospitals would
increase the gap
Current Challenges in Surge
Capacity (cont)
 Unfunded:
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Maintaining surge supplies in operating order
Refreshing expiring supplies (e.g.
pharmaceuticals)
Updating medical equipment
Training staff to manage, deploy and operate
surge beds
Current Challenges in Surge
Capacity (cont)
 California’s
economic situation is resulting
in:

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Decreased expenditures for public health,
with negative impact on the infrastructure to
respond to public health emergencies
Layoffs of trained Local Health Department
staff trained in public health emergency
preparedness
Current Challenges (cont)
 Federal
funds are the financial
support for public health emergency
response capacity
9-11 to current year, California’s
federal grants for public health
emergency preparedness decreased
25 percent.
 From
Accessing the Standards and
Guidelines for Healthcare Surge
During Emergencies:
http://bepreparedcalifornia.ca.gov/EPO/
CDPHPrograms/PublicHealthPrograms/
EmergencyPreparednessOffice/
EPOProgramsServices/Surge/