HomeMy WebLinkAboutalco-pediatric-medical-surge-plan-critical-care-expansion-1
ALAMEDA COUNTY OPERATIONAL AREA
PEDIATRIC MEDICAL SURGE PLAN AND RESOURCES
JULY 6, 2017 – CONDENSED VERSION
PRINCIPLES AND ASSUMPTIONS:
Plan would be activated in response to an event that has a disproportionate number of pediatric patients.
In a medical surge / disaster event, many patients may require a high level of acute care as normally
provided in an ICU. Increased hospital ICU/PICU/NICU capacity will be a priority.
In a “declared disaster” – pandemic or large MCI event, Alameda County EMS may need to expand the
system-wide hospital pediatric staffed bed capability.
GOAL
Increase pediatric medical surge capacity and capability using hospital capability tiered approach and
expansion for critical care during an MCI/disaster event
Expand hospital’s existing capability – each individual hospital will determine what specific strategies to
implement to meet their surge capacity target.
PEDIATRIC MEDICAL SURGE PLAN - CONOPS
This plan is founded on a tiered system based on capacity and capability. Therefore, patient age and acuity
need to be considered when determining the location where children will be treated.
Given the variability in pediatric care on a daily basis, all hospitals are requested to plan for an event
resulting in a surge of pediatric patients. Although hospital capabilities and capacity vary, all hospitals will
need to participate to meet the medical surge needs of children.
This plan is based on caring for more critically ill children in facilities that are accustomed to caring for
children and allowing them to decompress less critically ill children to other facilities.
HOSPITAL CAPABILITY TIERED APPROACH
Patients should be distributed to an appropriate level of care given the specific circumstances of the
situation. The tiered options provide general guidelines that may be used in a surge that disproportionately
affects children as a method for supporting distribution of patients throughout the County.
A pediatric medical subject matter experts should be consulted in the triage and distribution of patients
when operationalizing this plan (including at the OA EOC if activated)
Pediatric acute patients would be cared for at facilities that may or may not typically care for children. The
goal would be to triage older (over age eight), more stable patients to those facilities not accustomed to
caring for children.
The plan includes using existing PICU capacity and expanding that PICU capacity as much as possible
during a surge situation. All facilities with existing PICUs would need to meet the surge for additional PICU
patients. The adult trauma centers and their ICUs would also need to expand capacity and their capability
to meet the PICU need. This plan calls upon hospitals with PICU capability to accommodate the surge of
PICU patients. This may require a shifting of non-critical patients from these facilities so that the most
critically ill children are cared for at hospitals that are accustomed to caring for and treating critically ill
children. The remainder of the hospitals will be called upon to meet the pediatric acute care surge need.
This means that as an event unfolds, there may be a need for secondary transfers of patients to move
more stable patients to alternate locations.
2
HOSPITAL CAPACITY EXPANSION STRATEGIES – FOR CRITICAL CARE ICU/PICU/NICU
HOSPITAL PEDIATRIC TIERED EXPANSION OPTIONS
– FOR CRITICAL CARE ICU/PICU/NICU
The following hospital bed expansion options for critical care will be considered.
UNDECLARED DISASTER
1. OPTION 1A (Table 1):
All hospitals use 5% flex to increase their inpatient PEDIATRIC critical care capacity by 5% in PICU and ICU (not to exceed
total allowed licensed beds).
DECLARED DISASTER
1. OPTION 1B (Table 2):
All hospitals increase their PEDIATRIC beds over their licensed bed capacity by 5% in PICU & ICU
(above total licensed capacity).
2. OPTION 2 (Table 3):
All hospitals in Alameda County with ICU or PICU beds, double their number of staffed ICU and PICU beds.
3. OPTION 3 (Table 4):
All hospitals take 5 additional PEDIATRIC patients in their ICU and PICU.
4. OPTION 4 (Table 5):
All hospitals increase their PEDIATRIC beds over their total licensed bed capacity by 10% in ICU and PICU.
HOSPITAL CAPABILITY (BASED ON LICENSED BEDS) DESCRIPTION
CRITICAL CARE FOR PEDIATRICS
- PICU (UCSF Benioff Children’s Hospital; Kaiser Permanente Oakland) PEDIATRIC PICU
- NICU NICU
- ICU ICU
- TRAUMA CENTERS ADULT & PEDIATRIC TRAUMA CENTERS
GENERAL MEDICAL/SURG CARE FOR PEDIATRICS
- GENERAL PEDIATRIC BEDS PEDIATRIC ACUTE BEDS
- GENERAL MED/SURGE BEDS; NO LICENSED PEDIATIRC BEDS
NO INPATIENT IN-PATIENT PEDIATRIC BEDS
- NO PEDIATRIC CRITICAL CARE; NO PEDIATRIC BEDS - - - -
- EMERGENCY ROOM ONLY
Community Hospitals with
No Pediatric Capacity
Community Hospitals with
Pediatric Capacity
Pediatric
Specialty Centers
Referral Pathway
Referral Pathway
Pediatric Center Bed Decompression
Referral Pathway
PICU/Complex
Pedi Cases Bed
Expansion0-12 yearsPedi General Care
Bed Expansion0-12 years
Pedi General Care
Bed Expansion> 12-14 years
Joint CoCo-ALCO Emergency Medical Services
Recommended Pediatric Surge Bed Preservation Model
3
5 % FLEX OPTION – ALL HOSPITALS
In Alameda County, hospital pediatric expanded bed capacity could increase 100% using the 5% flex
model and critical care expansion options.
Each hospital may identify the 5% flex approach that is within their capabilities. Hospitals would likely be
called on to do more in catastrophic events however building in a 5% flex capacity dramatically increases
the county’s capacity to handle the “in-between” known to be required in disaster response based on the
H1N1 experience.
o Each hospital may consider how far the organization can stretch without disrupting operations is key.
o The Alameda County Medical Surge Model for pediatric and neonatal care allows hospitals to work
toward a minimal level of inpatient pediatric/neonatal capacity that is both sustainable and realistic.
o Fundamental to this approach is the understanding that all health care providers have received training
in pediatric care as part of their path to licensure.
o In addition, it is not unusual to find staff working in non-pediatric settings within the hospital who have
significant experience in pediatrics.
What follows is a description of the different pathways hospitals can use to expand neonatal or pediatric
medical surge capacity. It utilizes a cafeteria plan approach for hospitals to respond.
o Determine with appropriate hospital leadership how your facility may be using 5% flex to accommodate
the influx of neonatal/pediatric patients during a medical surge.
o Hospitals are allowed by CDPH to use 5% of their total licensed beds (known as Flex Beds) to
accommodate patients of all types without special permissions, provided Title 22 standards of care are
met for competency, equipment and staffing for the patients involved is met.
If the number of patients cannot be managed using 5% flex, altered standards of care may be required,
generating the need for additional permissions, interruptions in normal hospital operations (e.g. elective
surgeries cancelled) and approval from CDPH Licensing and Accreditation prior to implementation.
Hospitals who do not adhere to these strict requirements may be subject to fines and penalties.
HOSPITALS WITH EMERGENCY DEPARTMENTS
All hospitals in Alameda County have 9-1-1-approved emergency departments, and emergency department
boarding is the most common approach used in normal and surge conditions.
Pediatric patients have been reported to require boarding for up to 3-5 days in emergency departments
under surge conditions.
All emergency department personnel are competent in the care of pediatric patients and emergency
departments are equipped with appropriate equipment to care for children.
However, emergency department providers may lack confidence or experience in the care of the critically ill
child who comes to the ED much less often.
In any pediatric event of scale, equipment, personnel and ED pediatric boarding capacity could be
overwhelmed.
Therefore, alternatives may be considered and planned to supplement this strategy.
4
HOSPITALS WITH PEDIATRIC INPATIENT CARE UNITS AND PICU
Hospitals with inpatient pediatric units during surge are best able to manage more complex pediatric
patients that may not be suitable for settings that are less familiar with this population.
Equipment, staff and competency are part of the normal workflow.
However, in surge it may be necessary to utilize these staff to train and supervise the care of nursing staff
not experienced in pediatrics in order to accommodate numbers of children for extended periods of time.
This allows hospitals to expand bed capacity in ways not previously anticipated yet continue to give
reliable, safe patient care.
Hospitals with these resources may be able to expand well beyond the 5% flex bed goal in these
conditions.
HOSPITALS WITH WELL BABY, SPECIAL CARE NURSERY OR NICU
For hospitals with these resources, inpatient neonatal or pediatric capacity may include a plan to use a
hospital’s licensed 5% flex bed capacity to care for children up to 1-3 years of age.
Equipment issues, including appropriate cribs would need to be addressed, however, all hospitals have
vendors and supplies for appropriate pediatric equipment for their emergency departments.
Additional just-in-time training to support staff competency could be rapidly achieved in this workforce and
supplemented with pediatricians, mid-level pediatric practitioners or nurses with strong pediatric experience
from the emergency department or pediatric unit or ambulatory care clinics as needed.
The ESCAPE (Enhanced Surge Capacity and Partnership Effort) Project, using pediatric/neonatal ICU
consultation via telehealth, has demonstrated in Critical Access Hospitals, that neonatalogists, pediatricians
and nursing staff are effective in managing acutely ill and selected critically ill pediatric and neonates.
HOSPITALS WITHOUT NICU, OB OR INPATIENT PEDIATRICS
In these facilities, it is recommended that pediatric medical surge plans utilize their 5% flex capacity to take
adult-size children from age 12 to 18.
In this scenario, equipment needs are minimized due to the patients adult size and adolescent-patient care
competency is not that different from the young adults staff already interact with.
Competency requirements and specialized staffing needs would be reduced while still accommodating
pediatric patients.
RESOURCES:
National EMSC Pediatric Disaster Preparedness Toolbox
https://emscimprovement.center/resources/toolboxes/pediatric-disaster-preparedness-toolbox/
EMSC National Pediatric Readiness Project
http://www.pediatricreadiness.org/
California Hospital Association – Pediatric Disaster Planning
http://www.calhospitalprepare.org/pediatrics-nicu
National Pediatric Disaster Coalition
https://sites.google.com/site/pedineonetwork/
National Advisory Committee on Children and Disasters – Pediatric Surge Capacity Report
https://www.phe.gov/Preparedness/legal/boards/naccd/meetings/Documents/naccd-surge-capacity-rpt042815.pdf