Assignment: Triage from the healthcare facility perspective

Assignment: Triage from the healthcare facility perspective ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Triage from the healthcare facility perspective Define Triage from the healthcare facility perspective. Relate this to the concepts of Surge Capacity and Capability vs. altered standards of care. Assignment: Triage from the healthcare facility perspective The answer should be compatible with the PDF i Uploaded and about 500 words. surge_capacity.pdf CONCEPTS in Disaster Medicine Refining Surge Capacity: Conventional, Contingency, and Crisis Capacity John L. Hick, MD, Joseph A. Barbera, MD, and Gabor D. Kelen, MD ABSTRACT Health care facility surge capacity has received significant planning attention recently, but there is no commonly accepted framework for detailed, phased surge capacity categorization and implementation. This article proposes a taxonomy within surge capacity of conventional capacity (implemented in major mass casualty incidents and representing care as usually provided at the institution), contingency capacity (using adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on delivered medical care), and crisis capacity (implemented in catastrophic situations with a significant impact on standard of care). Suggested measurements used to gauge a quantifiable component of surge capacity and adaptive strategies for staff and supply challenges are proposed. The use of refined definitions of surge capacity as it relates to space, staffing, and supply concerns during a mass casualty incident may aid phased implementation of surge capacity plans at health care facilities and enhance the consistency of terminology and data collection between facilities and regions. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S59–S67) Key Words: surge capacity, disaster, emergency preparedness, hospital preparedness, emergency management H ealth care facility surge capacity has received significant planning attention recently, fueled by events such as the September 11, 2001 terrorist attacks, the spread of severe acute respiratory syndrome, and Hurricane Katrina, and by grants such as the US Department of Health and Human Services Hospital Preparedness Partnership funding to states.1 activated, regardless of how many beds are actually occupied at the time.13,14 As an example, when the Interstate 35 West bridge collapsed in August 2007, Hennepin County (Minnesota) Medical Center had 3 intensive care beds available, but with activation of their disaster plan 25 beds were opened within 30 minutes and an additional 12 to 18 could have been opened.15 Despite multiple articles2– 8 and checklists9 –11 relating to hospital surge capacity, there are few good benchmarks or planning frameworks for health care facilities to use when assessing and reporting resources available to provide care for a specific surge quantity of patients. Too often, this capacity is reported as the number of beds that could be made available, which encompasses too many variables to be useful. This article proposes a taxonomy for surge capacity patient care that may aid hospitals in surge capacity planning and result in more consistent and reliable data for hospital, health care system, and public health planners. It is extremely difficult in the absence of consistent definitions to obtain data from hospitals regarding surge capacity that can be compared. Assignment: Triage from the healthcare facility perspective Some hospitals consider cots placed in ancillary areas to be “surge beds” and others count only actual hospital bed locations. Some hospitals include potential discharges from usual beds; others do not. The lack of consistent definitions has led to variable data collection, making system capacity unclear.12–14 There is a significant difference in a health care facility’s ability to accommodate patients on a daily basis compared with when their disaster plans are SURGE CAPACITY FOUNDATIONS Surge capacity generally refers to the ability to manage a sudden, unexpected increase in patient volume (ie, numbers of patients) that would otherwise severely challenge or exceed the present capacity of the facility. There are many definitions that have been proposed and no commonly accepted definition, meaurement, or trigger distinguishes surge capacity from daily patient care capacity.3– 8,12,14 This article examines surge capacity primarily in the context of responses within the hospital’s physical structure or on its grounds that are managed and staffed by the hospital (ie, do not rely on outside supplies or assistance). However, local and regional hospital partners in aggregate provide much greater Disaster Medicine and Public Health Preparedness S59 Refining Surge Capacity capacity than single facilities; thus, in an area with intact infrastructure it may be appropriate to transfer patients to other facilities/regions rather than continue unconventional patient care surge strategies. Nonhospital alternate care locations are additional important factors in the hospital and community ability to create or maintain surge capacity but are not discussed. There are 4 key interdependent factors that contribute to effective surge response: system, space, staff, and supplies. Work continues to define and refine the subcomponents of these factors and the framework of surge capacity.3,6,8,10 Although each of the 4 factors is important, there is broad expert agreement that without the underlying system components the other variables cannot be appropriately managed. Some of these components include the following: • • • • • • S60 Command—A practiced and robust incident command system16 –18 should provide overall management of the event. The incident command system is part of an overall emergency management plan,19 at the facility and the surge capacity plan is part of the all-hazards response plan. Control—The facility has the ability to control its infrastructure through building access controls, changes in ventilation systems/air intake, and other capabilities that allow incident command personnel to prevent an incident from expanding or at least minimize impact on the facility. Communication—Robust internal and external communications technologies and strategies should be in place. Coordination—The facility should understand its role in the overall community response to a disaster and how it integrates with the response of other health care entities and public safety agencies.20,21 Coordination of hospital response with other hospitals, alternate care sites, outpatient facilities, emergency medical services, home care agencies, long-term care, assisted living, and special needs populations planners is often limited, but such integration is critical to both augment hospital capacity (eg, by supporting early discharges) as well as prevent undue strain on the hospital if one of these partners is unable to cope with incident demands, or has inadequate emergency operations plans in place. Coordination is especially important in larger incidents that affect multiple facilities and agencies. Assignment: Triage from the healthcare facility perspective Continuity of operations—Planning and resources devoted to continuing hospital operations in the face of system or utility failures. Community infrastructure—Functioning prehospital emergency medical services systems, communications infrastructure, government institutions (eg, public health agencies, public safety agencies), and private infrastructure (supply chains, utilities, transportation assets) may have significant impact on the ability of an institution to maximize its surge capacity. Even in the absence of such infrastructure, the hospital must be prepared to continue Disaster Medicine and Public Health Preparedness its services to existing patients, new patients, and staff for a period of several days following an event. The specific timeline may depend on local hazard vulnerability analysis and gap analysis but expert consensus and new Joint Commission guidance recommend plans for not fewer than 96 hours of independent operation.22 The system components outlined above are not generally included in measurements used to gauge a quantifiable component (eg, bed capacity) that are often sought from health care facilities as surrogate markers for preparedness. This article attempts to define parameters for space, staff, and supplies that may result in more consistent use of terminology and more useful data collection and assumes that the facility has the above critical system components in place. CONVENTIONAL, CONTINGENCY, AND CRISIS CAPACITY TAXONOMY We propose that patient care space generation, staffing, and supply discussion and measurements reflect 3 strata that are subsets of overall surge capacity: • • • Conventional capacity—The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan. Contingency capacity—The spaces, staff, and supplies used are not consistent with daily practices but maintain or have minimal impact on usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources). Crisis capacity—Adaptive spaces, staff, and supplies are not consistent with usual standards of care but provide sufficiency of care in the setting of a catastrophic disaster (ie, provide the best possible care to patients given the circumstances and resources available). The same event can result in radically different effects on an institution depending on the size of the institution (an 8-victim motor vehicle crash may be conventional for a level 1 trauma center but a contingency or even crisis for a small rural facility), its role in the community (many pediatric victims arriving at a children’s hospital may be conventional, but could represent a contingency or crisis for a hospital that does not usually provide pediatric services), and the degree to which the infrastructure is functioning (a hospital evacuating in advance of a hurricane may be a conventional event, whereas an evacuation when the power is out may push the institution into crisis mode due to the increase in staff requirements to carry patients down stairwells, among other effects). Finally, an incident does not have to overwhelm assets in all of the categories to result in contingency or crisis care.Assignment: Triage from the healthcare facility perspective For example, a hospital that receives multiple critical burn patients that does not have a burn unit is already by definition VOL. 3/SUPPL. 1 Refining Surge Capacity in a contingency staffing situation and should be planning patient transfer to a higher level of care if possible. The existence (or anticipation) of a contingency or crisis in any of the categories should prompt facility incident management to ensure that appropriate resources are mobilized or patient transfers made to return the facility to conventional mode as soon as possible. SPACE CONSIDERATIONS Physical space creation in many hospitals is difficult and depends on flexibility of space because little reserve space is available. The facility should examine its entire campus to determine the resources and contributions of each area to the surge capacity plan and in what preferred sequence these spaces will be used depending on the ease and rapidity of mobilization. As hospitals remodel or expand, construction of spaces as “dual purpose” is critical; examples include placing couches in hospital rooms that can fold into daybeds for family but also for disaster patients, ensuring adequate suction and oxygen ports in private rooms to accommodate another patient, and ensuring that adequate electrical power, ventilation, and if possible oxygen is supplied to flat space areas (eg, classrooms) that may be used for congregate care. For any area that may be planned as a patient care area many considerations (ground fault interrupter outlets, emergency lighting, evacuation, fire safety planning, ventilation capacity, restroom and shower facilities, and privacy) should be addressed in the planning process to avoid unforeseen compromises when the space becomes functional. Unfortunately, most federal grant (including the Hospital Preparedness Program)1 funding typically restricts funding for new construction, but because these modifications can be relatively low cost, they often can be integrated into new projects, provided that there is early and consistent advocacy for these changes from administration and project planners. Table 1 describes the process of space creation. CONVENTIONAL PATIENT CARE SPACE Conventional patient care spaces are standard inpatient units, and the staffing and resources are generally consistent with daily practices at the facility. Use of these areas requires minimal provider training or adjustments and should not result in a change to the usual standards of patient care. Activation of this level of capacity should not require evacuation of incident patients to other facilities unless the patient requires specialty (eg, burn) care not provided at the present facility. Conventional capacity includes the following: • Using all available staffed beds TABLE 1 Space Creation for a Major Incident Time, Hours 0–2 Traditional care Contingency care Crisis care Evacuation* 2–4 4–12 Fill available staffed beds Provide staff for unstaffed but available beds Cancel elective procedures/surgeries and onsite clinics Use in-place bed additions—day beds in patient rooms converted to patient beds Begin surge discharge Clear patients from preinduction and procedure areas and fill available beds Add in-storage beds to usual patient rooms Place patients in hallways or lobby areas on prestaged cots Evaluate facility impact and options for patient transfer 12–24 Obtain additional beds and add to existing patient rooms Cancellation of elective cases begins to have impact, but does not open new beds Preinduction and procedural areas fully available Assignment: Triage from the healthcare facility perspective Transfer patients from higher acuity care areas to lower acuity care areas according to facility plan (eg, from intensive care to stepdown) Set up preplanned facility areas for austere inpatient care Assessment of situation— consider mechanisms to return to conventional care and request necessary resources Initiate processes (internal or external transfers) to return to conventional care if possible Mobilize resources for alternate care sites Begin patient transfer to alternate care sites Arrange local and interregional patient transfers as possible to return to at least contingency care operations and/or request necessary resources Begin local and regional patient transfers Begin federally facilitated patient transfer Surge discharge opens beds; patients moved to preidentified holding area *If no evacuation of patients is possible, then activate facility crisis standards of care plan. Disaster Medicine and Public Health Preparedness S61 Refining Surge Capacity • • • • • • Mobilizing staff so that any unstaffed inpatient beds can be used Adding beds to usual patient rooms and mobilizing appropriate staff to maintain reasonable staff-to-patient ratios Canceling elective procedures to free up beds in intermediate or long-term timeframe (note that this action, although commonly part of hospital disaster plans, does not generate early-phase surge capacity for inpatient beds although it may create early operating room capacity) Using observation beds for inpatient care Activating surge discharge plans: Health care facilities should have a preplan (and ideally prospective categorization) for patients so that those who can safely be discharged home, to alternate care, or to skilled nursing facilities can be identified and their discharge process expedited. Plans should provide guidance for caregivers and processes for identifying patients, moving these patients to a holding area (or even to designated hall or lobby areas on a unit), and expediting pharmacy, transportation, and social work arrangements as needed to facilitate timely and safe discharge.23,24 Liaison with home health care agencies and long-term care facilities is crucial to success of these early discharges. There is likely substantial variability between institutions in the percentage of patients appropriate for surge discharge, and although 20% is a commonly used figure, it is critical that hospitals evaluate these measurements on the basis of exercises at their institution.5 Canceling onsite clinic appointments to free up clinic space and staff for either overflow outpatient care or augmented inpatient staffing CONTINGENCY PATIENT CARE SPACE Contingency care involves providing inpatient care in areas that have appropriate medical infrastructure but are not typically used for this purpose, or providing a higher level of care than usual on inpatient units—(eg, managing ventilated patients on monitored stepdown units when no intensive care beds are available). Typical contingency care adaptations comprise the following: should then clear available beds and implement any other mobilization measures (eg, obtain select supplies, call back staff) necessary. Contingency care locations are commonly activated during a disaster response, but usually on a temporary basis—in particular the use of pre- and postanesthesia care areas until conventional care locations can be opened via discharges and patient movement. Longer term use of these areas if no alternatives exist (!12 hours may be a reasonable threshold) should prompt consideration for patient transfer to other facilities for ongoing care, if this is an option. Because conventional plus contingency capacity provides an estimate of the number of inpatients that can receive care at the facility while maintaining the usual standards of care, it is the authors’ belief that this combination generally should be the number sought for data comparisons, with crisis space numbers reflected separately. CRISIS PATIENT CARE SPACE Crisis care involves providing inpatient care in areas that are not usually used for patient care.Assignment: Triage from the healthcare facility perspective The institution should identify areas both within the walls of the facility or, in some cases, located on the complex but not in the facility proper (eg, tenting, office space) that could be used for temporary patient care. These locations may include the following: • • • Plans for crisis care must involve the following: • Using postanesthesia and preinduction areas for inpatient care (particularly recovery beds in outpatient surgery and procedure areas) Using procedural suites (eg, endoscopy, cardiac) for inpatient care Using stepdown, observation, or floor beds for higher acuity care (often moving more stable intensive care patients to stepdown or other beds to make room for incident-related patients) • A plan should be in place for activating these areas that involves the incident commander or designee obtaining event information that suggests a need and notifying the units sequentially based on institutional plans. These units • • • • S62 Disaster Medicine and Public Health Preparedness Facility flat space areas— conference rooms, hallways, physical therapy gym area Adjacent flat space areas—areas appropriate for tenting, adjacent physician office space, etc Alternate care site— offsite location for nonambulatory care (These numbers should not be included in measurements of facility surge capacity because they are not actually part of the health care facility [although they may be a component of the facility plan].)25–27 • • Pre-event safety planning to include evacuation, slip/ trip/fall hazards, and so forth A triage plan (similar to early discharge criteria) to select both current inpatients and disaster patients for referral to the crisis care areas (considering for example: requirements for interventions, oxygen, or frequency of intravenous medications) A plan to evacuate critical patients from the facility (especially when the facility infrastructure or utilities are compromised) A transportation plan to crisis care sites (both on campus and in community as applicable) Adequate staff for these areas; staffing req … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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