危机应对医疗方案

DisasterResponseAndRespiratoryCareObjectivesUnderstandtheuniversalcharacteristicsofdisastersandthecomponentsofanallhazardsapproachtodisastermanagementinvolvinghealthcarepractitioners.DemonstrateunderstandingoftheroleofRespiratoryTherapistsindisasterresponseandemergencymanagement;and,describetheroleofRespiratoryTherapistsasvolunteersfordisasterresponse.ObjectivesExplainthevariouslevelsofequipmentandsupportRespiratoryTherapistswillutilizeinrespondingtomasscasualtyincidentsanddisasters.DiscusstheimplicationofPandemicInfluenzaasitrelatestoplanningandresponsecapabilityandcapacity.DescribetheimpactofBioterrorismandman-madedisasterstohealthcaresystems,providers,anddisasterpreparednessplans.What’sTheFuss?HowDoWeRespondToThis…SoWeDon’tFeelLikeThis…DisasterCharacteristicsIncreaseddeath,injury,illnessthatcan’tbemanagedCoordinationpublic,government,andprivateorganizationsEqualtriagedistributionNotificationoffamilyEvacuation/ShelteringofevacueesDisasterCharacteristicsMediaattentionHeightenedsecurity;crimesceneImmediateandlongtermemotionalsupportSignificantpropertydamageImpactofDisastersInthepast20years“Althoughtheyearlydeathtotalsfromdisasterdeclinedbyapproximately30%,thenumberofpeopleaffectedbydisasterincreased59%” (AARCTimes.2006.p.8)ConsequenceManagementTheobjectiveofconsequencemanagementis:ProvidesupportSavelivesRelievesufferingMitigatefurtherharmPreparednessCyclePlanTrainEquipExerciseHealthsystemswillbepreparedthroughacontinuouscycleofplanning,equipping,trainingandexercising.P.E.T.E.PlanPublicHealthPreparednessStrategicPlanEquipVentilators,PPE,Pharmaceuticals,etc…TrainOSHA,DHS,OtherExerciseLocal,Regional,Statewide,Interstate,NationalSurgeCapacityCountyHealthDepartmentsPre-hospitalOutpatientServicesHospitalsPharmaciesLaboratoriesMortuaryServicesPublicHealthResponseHealthCareSystemDomesticSecurityRegionsRegion1Region2Region3Region4Region5Region6Region7IntegratedPlansFederalNationalResponseFramework(NRF)SupportedbyNationalIncidentManagementSystem(NIMS)andtheNationalDisasterMedicalSystem(NDMS)ComprehensiveEmergencyManagementPlan(CEMP)ProvidesguidanceIntegratedandcoordinatedresponseEmergencySupportFunctions(ESF-8)FollowsNRFIntegratedPlansStateFloridaDepartmentofHealthBomb,Blast,Burn(B3)Biological(B4)PandemicInfluenzaPublicHealthandMedicalPreparednessStrategicPlan2007-2010CountyCEMPPlansHospitalCEMPPlansGoalofSurgeThinkingMaximizesurvivalforallplayers!Minimizemorbidity!Maximizeresourceutilization!Willrequirenewthinking!NaturalDisastersNaturalDisastersTornadoesForestFiresFloodsBlizzardsCyclones/TyphoonHurricanesHeatwaveTsunamiVolcanicEruptionEarthquakesMudslidesLimnicEruptionDraught/FamineHailNaturalDisasters-FloridaHurricanesTornadoesForestFiresFloodingFreezingSinkholesDroughtHeatwaveHailNaturalDisasters-Florida2004July31toDecember39Hurricanes;5TropicalStormsCharley,Frances,Jeanne,Ivan2005June8toJanuary615Hurricanes;12TropicalStormsKatrina,RitaCost––2004HurricaneSeasonFlorida’shospitalsincurred$163.2millioninunexpectedcostsExpensesrelatedtofacilitymodificationstoreducedamagefromfuturestormswouldexceed$48millionAveragehospitalimpactofmorethan$1millionTotalimpactonhospitals>$200millionLessonsLearnedPreparationFacilityPlanningPower,MedicalGases,Water,Etc.FloodzoneMaterialResourcesCommunicationRedundancyContingencyplansIncidentCommand!LessonsLearnedWorkforceissuesAdequatestaffHospitalPlanningIncidentCommandEducation/TrainingSpecialNeedsBehaviorHealthPatient&EmployeeLessonsLearnedHospitalSecurityFacilitysupportProtectivemeasuresPatientSafetyMutualAidPublicandprivatepartnersMedivacMan-MadeDisastersUnintentional/AccidentalEngineeringFailuresBridges,Buildings,DamsTransportationPlanes,Trains,Automobiles,ShippingEnvironmentalOilspills,pollution,wasterunoffExplosionsMinedisastersIndustrialaccidentsWarFireTerrorismPokingskunksisdangerous!TerrorismThegoalsofterroristsareto:Createconfusion,fear,chaos,andmistrust.Breakdownthephysicalandpoliticalinfrastructure.Intimidate,subjugate,andweakenauthority.HOWWILLOURENEMIESFIGHTUS?UNCLASSIFIEDChemicalBiologicalRadiologicalNuclearEnergetics/ExplosivesCBRNEAWeaponofMassDestructionisadeviceormaterialspecificallydesignedtoproducecasualtiesorterror.CBRNEincidentsmayresultfromindustrialaccidents,actsofwar,oractsofterrorism.ChemicalAgentsMustardgasSarinPhosgeneCyanideChlorineChemicalAgentsIndustrialChemicalsChokingAgentsBloodAgentsWarfareAgentsBlisterAgentsNerveAgentsRoutesofexposureInhalation,skincontact,ingestion,injectionEffectdependsondoseLargerdose:earlierandmoresevereeffectsEffectsmaybeimmediateordelayedIndividualsusceptibilityvariesAge,chronicillness,medicationsExposureToChemicalsBiologicalAgents:Undetectablebyhumansenses+Prolongedincubationperiod+Limitedsurveillancecapability=UnrecognizedexposureBio-threatsBiologicalagentsmaybe:BacteriaVirusesToxinsTheyarenaturallyoccurringand/orcanbebioengineeredasWeaponsofMassDestruction.RoutesofTransmissionAbsorption:SkinandmucusmembranesInhalationRespiratorythroughairdropletsIngestionGastrointestinalthroughconsumptionoffoodordrinkInjectionFromneedleorotherobjectVectorsLetters/packagesInsects/animalsContaminatedfood/waterContaminatedclothingAirviaaerosoldisseminationdeviceAnthrax(Bacillusanthracis)Botulism(Clostridiumbotulinumtoxin)Plague(Yersiniapestis)Smallpox(Variolamajor)Tularemia(Francisellatularensis)ViralHemorrhagicFevers(Filoviruses[e.g.,Ebola,Marburg]andArenaviruses[e.g.,Lassa,Machupo])CDCCategoryAAgentsNuclear/RadiologicalAgentsAnysourcethatemitsradiationRadiationExposureExternal––depositedonskinInternal––inhaled,swallowed,absorbedthroughskin,orintroducedthroughwoundsIncorporationofradioactivematerials––uptakebybodycells,tissues,ororganssuchaskidney,liver,andboneSymptomsofRadiationExposureNauseaVomitingDiarrheaChangesinmentalstatusEarlyDetectionIsyourkeytolimitingpotentialexposure.Timeisahugefactorinhowmuchexposureonecouldreceive.Beta-bAlpha-aGamma-gNeutron-nRadiationPenetrationDirtyBombvs.AtomicBombTheatomicexplosionsthatoccurredinHiroshimaandNagasakiwereconventionalnuclearweaponsinvolvingafissionreaction.Adirtybombisdesignedtospreadradioactivematerialandcontaminateasmallarea.TerroristAttacksSocalledsuicideattacksUnfortunateexperienceandexpertisefromIsraelUseofexplosivesandshrapnel(bolts,nails,nuts)Predominateinjuryislunginjury(blastinjury)50%ofpatientswhosurvivetohospitalizationdevelopARDSandrequiremechanicalventilationTerroristAttacks20attacks>10woundedTotalof1475wounded,92ICUadmissions,80patientsrequiringMV52%ofpatientshadacutelunginjuryBlastinjuryisthemajormechanismAschkenasy-SteueretalCritCare2005;9:1186TerroristAttacks1983-2004allmultiplecasualtyevents875patientsfrom31eventsinJerusalemAverageof28patientspereventICUadmission5%(n=43)-ofthese70%hadblastlunginjury73%ofpatientsrequiredmechanicalventilationAvidanV,JTrauma.2007May;62(5):1234-9.PlausibleScenariosTrauma–naturalorman-madeNerveagents–sarin,tabun,VX,somanPulmonaryIrritants–phosgene,ammoniaBiologicAgents–plague,tularemia,anthrax,botulismRadiologicEvents–nuclearweapon,dirtybombPlausibleScenariosSCENARIOTIMETOMVDURATIONOFMVVICTIMSNEEDFORMVTraumaImmediateDaystoweeks<100Hemo–pneumothorax,blastinjury,burnssmokeinhalationNerveAgentImmediateHoursUpto1000Paralysis,bronchospasm,bronchorrheaPulmonaryIrritantsHoursDaystoweeksUpto1000ARDS,pulmonaryedema,airwayinjuryBiologicsHourstodaysDaystoweeks1000ARDS,hemorrhagicpulmonaryedemaRadiologicDaystoweeksDaystoweeksHundredsTraumaticlunginjury,sepsis,RubinsonL,BiosecurBioterror.2006;4(2):183-94.VulnerabilitiesHardTargetsMilitaryinstillationsGovernmentbuildingsSecureAreasSoftTargetsHospitalsSchoolsChurchesPreventionEffortsRelyon:Federal,State,&LocalLawEnforcementAgenciesHospitalHazardVulnerabilityAssessmentsAccreditationandRegulatoryAuthoritiesDiligence,Observation,ReportingSafetyCommittees>>>PerformanceImprovementProbabilityvs.ImpactPOTENTIALIMPACTPROBABILITY/LIKELIHOODNUCLEARWEAPONIMPROVISEDNUCLEARDEVICERADIOACTIVEMATERIALCHEMICALAGENTORTOXICINDUSTRIALCHEMICALBIOLOGICALAGENTPandemicInfluenzaIsithereyet?NaturalBiologicThreatWhatisapandemic?ThespreadofdiseaseoverawidegeographicareaaffectingmuchofthepopulationNaturalBiologicThreatPandemicInfluenzaIncreasedmorbidity(sickness)andmortality(death)SocialdisruptionEconomicdisruptionSeasonalvs.PandemicFluSeasonalYearlyFamiliarvirusMild/ModerateSymptomsVeryyoung,veryold;HealthproblemsVaccineavailablePandemicRarelyNewvirusSeveresymptomsHealthypeopleNovaccineInfluenzaDiseaseCharacteristicsInflammationoftherespiratorysystemHeadacheFeverChillsCoughMuscleachesSeveraldayssick,severalweeksrecoveringPanFluStatsPandemicInfluenzaHistory191850––100milliondeaths19572milliondeaths19681milliondeathsFrequency ~every35yearsDuration1––3yearsWorldwide 6––9months,3months?Waves 1––3,4––8weeks/waveNationalStrategy1.Stop,sloworotherwiselimitthespreadofapandemictotheUnitedStates2.Limitthedomesticspreadofapandemic,andmitigatedisease,sufferinganddeath3.SustaininfrastructureandmitigateimpacttotheeconomyandthefunctioningofsocietyU.S.PlanningAssumptionsAttackrate35%ofpopulationTreatmentrate25%ofpopulation~75%ofcasesHospitalizationrate10%ofcasesCasefatalityrate2%(2%-50%)Pre/asymptomatic30%-50%(?)transmissionIncubationperiod 2days(1––8days)FloridaPlanningAssumptions1stWave/2ndWaveTotalCasesHospitalized(10%)320,000 640,000SurgeBeds(130%)65,000ICU48,000ICUVentilator24,000SurgeVentilators5,000Dead(2%)64,000128,000Floridapopulation:18.3millionPlanComponentsRapidResponseIsolation&QuarantineSocialDistancingNon-PharmaceuticalInterventionsPharmaceuticalInterventionsOn-goingPlanningIssuesCommunityInterventionsHospitalPlanningSupportAlternateMedicalTreatmentSitesMasscarewithlimitedsuppliesandresourcesCurrentSituationHumanDeaths*353cases,221deaths(62.2%Mortality)14countriesBirdDeaths150––200millionbirddeaths>50countries(Asia,Europe,Africa)*WHO,24January2008RespiratoryCareYourRoleInADisasterHealthcareConsiderationsAdequatebedspaceICUCapabilityandCapacityWorkforcereductionOptionsPharmaceuticalstockpilesMaterialresourceutilizationContinuityofqualityStandardofCareCommand&Control/SecurityPlanInfectionControlEmployeeandCommunityEducationFinancialChallengeHealthcareConsiderationsExternalInfluencesSocial&EconomicDisruptionMutualaiddifficultiesSchoolandChildWelfareissuesInternalInfluencesEmployeeIssuesSingleparentfamiliesBothparentsworkinhealthcareChildrensick,parent/employee(s)notworkingHospitalIssuesPatientVolumeHigh-volumedemandformedicalattentionCompetitionforscarcemedicalresourcesImpactoncaregiversNeedforpsychologicalsupportNeedforsecurityMaterialResourceManagementIVTubingLabResourcesPharmaceuticalIVFluidsAntibioticsAntiviralVaccineMechanicalVentilatorsMedicalGassupplyFoodServicesEnvironmentalServicesuppliesLinensTheGasSourceIssueTheGasSourceIssueWhatisthebestsourceofoxygen?Whatabouthomehealthagenciesandtheirpatients?Powerisanissue!NecessaryVentilatorFeaturesforEachScenario?Wherewillmechanicalventilationbeperformed?Whowillperformmechanicalventilation?Wherewillthegassupplycomeform?Howlongwillitlast?Doestheventilator’scapabilitiesmatchtheneedsofthepatient,skilloftheoperator?NecessaryVentilatorFeaturesforEachScenario?MostmasscasualtyinjuriesresultinARDSAllscenariosexceptnerveagentexposurerequireconstantvolumedelivery,controlofairwaypressures,monitoring,alarms,andcontrolofPEEPandFIO2Whennerveagentsresultinparalysis––airwaycontrolandshorttermventilation––““goodairin––badairout””maybeallthatisnecessaryVentilatorCharacteristicsFDAapprovedforadults/pedsAbilitytooperatewithoutcompressedgasBatterylife4hrsVolumecontrolCMVandIMVPEEPto20cmH2OUtilizebothhighandlowpressureO2sourcesControlofRR,PEEP,VT,FloworI:EMonitorPawandVTAlarmsDisconnect,apnea,high/lowpressure,highpressuresourcegasdisconnectVentilatorCharacteristicsRuggedLightweight(<10kg)EasytouseGasconsumption-lowBatterylife-longEasytotrigger<$10KVendorsupportandlongevityMaintenanceTrainingCriticalFactorsInaMCI––manypatientswillneedventilationexceedingnotonlyequipmentbutstaffcapabilitiesLikelythatcriticalcareRRTwillsupervisenon-criticalcareRRTandothersincareoftheventilatedpatientsTheventilatormusthaveadequatealarmsandmonitoringTheventilatormusthaveasimpleinterfaceandbeeasytouseSpecificDevicesConcernsEducationandtrainingUniversalresponseDecentralizationofsuppliesandequipmentOperabilityinMCIenvironmentsSafetyAgecapabilityCompensationLegalprotectionCommunicationsVulnerablePopulationsVolunteerismFEHVRMedicalReserveCorpsMission:Toaugmentlocalcommunityhealthandmedicalserviceswithpre-identified,trainedandcredentialedvolunteersduringemergencymedicaloperationsandvitalpublichealthactivities.Purpose:TheFloridaMedicalReserveCorps(MRC)Networkwasestablishedforthepurposeofeffectivelyfacilitatingtheuseofhealthprofessionalvolunteersinlocal,state,andfederalemergencyresponsesineverycountywithinFlorida.LicensureRenewalStatementIfyouarerenewingtoactivestatus,wouldyoubeavailabletoprovidehealthcareservicesinspecialneedssheltersortohelpstaffdisastermedicalassistanceteamsduringtimesofemergencyormajordisaster?□YesOtherIssuesDisasterImplicationsCommunitiesFood,Water,ShelterPowerEconomicandSocialDisruptionChildSafetyDomesticAnimalsPersonalPropertyDamageDisasterImplicationsPatientPopulationsFood,Water,ShelterPowerformedicalequipmentMedicationsRenalDialysisIncreasehospitalsurge!HealthcareImpactsRoadClosuresHospitalClosures/EvacuationWorkforceShortageResourceManagementHVACWater,FoodSanitationSuppliesManagementSurroundingIssuesJust-In-TimeInventoryAccessEquipment&SuppliesVentCircuitsAerosolandHumidityMedicationsOxygenSuppliesOtherMedicalSuppliesInfrastructureSupportMutualAidAgreementsVendorAgreementsHospitalAgreementsGovernmentAgreementsLocal(i.e.––City,Municipality,County)RegionalState/Inter-StateFederalInfrastructureSupportWorkforce&StaffingPersonalPlanPPEPlantFacilitiesSecurityPlansFacilitySafetyCommunicationDevicesPhones:cell,satellite,landbased800mgHz/MEDRadiosPagersOverheadpagingsystemsDispatcherEmailHAMRadioSpecialPopulationsThisisaneverydayissueforhospitalsonasmallscale.Weneedtoplantosupportlargenumbersofpersonswhoarehardtoreachorhavedisabilities.DeadlyMisconceptions“Itwon’’thappenhere””Itwon’’thappentome””“Someoneelsewilltakecareofit””Q&A?ThankYou!AcknowledgementsThe2008-2009FloridaStateWorkingGroupVentilatorCapabilityTeammembersare:JohnWilgis,MBA,RRT-FloridaStateWorkingGroupVentilatorCapabilityTeamChair,Director,EmergencyManagementServices,FloridaHospitalAssociationMelanieMcDonough,MSHS,RRT-FloridaStateWorkingGroupVentilatorCapabilityTeam,EducationSub-GroupChair,DirectorofClinicalEducation,CardiopulmonarySciences,UniversityofCentralFloridaScottKirley,RRT-StateWorkingGroupVentilatorCapabilityTeam,EquipmentSub-GroupChair,WestCentrakFloridaDisasterServices,Inc.MaryMartinasek,MPH,RRT-NPS,RPFT,AE-C-FloridaStateWorkingGroupVentilatorCapabilityTeam,ResponseSub-GroupChair,AmericanPublicHealthStudentAssembly-SecretaryKris-TenaAlbers,ARNP,CNM,MN-FloridaStateWorkingGroupVentilatorCapabilityTeamLiaison,PublicHealthPreparednessHospitalLiaison,FloridaDepartmentofHealthDr.JenniferBencieFairburn,MD,MSA,Director,DivisionofEmergencyMedicalOperations,FloridaDepartmentofHealthDr.DavidV.Shatz,MD,FACS-ProfessorofSurgery,TraumaSurgery/SurgicalCriticalCare,UniversityofMiamiPaulStephan,MPS,RRT-ProgramDirector,RespiratoryCare,SantaFeCommunityCollegeRandyDeKler,MS,RRT-ProgramDirector,RespiratoryCare,MiamiDadeCollegePhilKhan,RRT-FloridaSocietyforRespiratoryCareSandraJ.Barker,MS,RRT-Director,CardiopulmonaryServices,LargoMedicalCenterTimothyJ.Coons-Director,Cardio-PulmonaryServices,ShandsHospitalattheUniversityofFloridaBillCunningham,BS,RRT-AdultCriticalCoordinator,CardiopulmonaryServices,ShandsHospitalattheUniversityofFloridaJosephAlbino,BS,RRT-Manager,RespiratoryCare,MeaseDunedinHospitalKellySebree,RRT,NPS-Director,RespiratoryCare,LawnwoodRegionalMedicalCenterReferences:References:References:9、静静夜夜四四无无邻邻，，荒荒居居旧旧业业贫贫。。。。12月月-2212月月-22Wednesday,December21,202210、雨雨中中黄黄叶叶树树，，灯灯下下白白头头人人。。。。19:37:0619:37:0619:3712/21/20227:37:06PM11、以以我我独独沈沈久久，，愧愧君君相相见见频频。。。。12月月-2219:37:1219:37Dec-2221-Dec-2212、故故人人江江海海别别，，几几度度隔隔山山川川。。。。19:37:1219:37:1219:37Wednesday,December21,202213、乍见见翻疑疑梦，，相悲悲各问问年。。。12月月-2212月月-2219:37:1419:37:14December21,202214、他乡生生白发，，旧国见见青山。。。21十十二月20227:37:15下午午19:37:1512月-2215、比比不不了了得得就就不不比比，，得得不不到到的的就就不不要要。。。。。十二二月月227:37下下午午12月月-2219:37December21,202216、行动出成果果，工作出财财富。。2022/12/2119:37:1919:37:1921December202217、做做前前，，能能够够环环视视四四周周；；做做时时，，你你只只能能或或者者最