Executive Summary. Process Overview: Charlie Cosovich. Shelley Oberlin. Brian Thygesen

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2 Process Overview: Executive Summary Kurt Salmon Associates (KSA) was engaged to assist the California HealthCare Foundation in developing a situation assessment of the acute-care hospital response during the 2007 San Diego Wildfires. The objectives for this project were to identify changes in demand at area hospitals, understand how hospitals responded to the changes in demand and what, if any, lessons could be learned from this disaster. The scope of the engagement included data collection and analysis, as well as conducting interviews with hospitals most impacted by the fires. Interviews were conducted with administrative and physician representatives of affected hospitals along with county emergency services personnel and the San Diego Disaster Planning Council. Combined, the qualitative information captured from the interviews along with background research, formed the foundation for this final report. Charlie Cosovich Kurt Salmon Associates 1250 Bayhill Drive, Suite 201 San Bruno, CA Phone: Fax: [email protected] Shelley Oberlin Kurt Salmon Associates 1250 Bayhill Drive, Suite 201 San Bruno, CA Phone: Fax: [email protected] Brian Thygesen Kurt Salmon Associates 1250 Bayhill Drive, Suite 201 San Bruno, CA Phone: Fax: [email protected]

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4 Process Overview

5 Project Objectives: Process Overview Assess the immediate changes in demand caused by the fire storm (e.g., inpatient transfers, increase in Emergency Department visits, types of patients being seen, etc.) Evaluate how hospitals responded to meet this demand (e.g., operational or facility changes, staffing issues, supply chain disruptions, etc.) Identify issues and events that were not anticipated in the hospitals response plans, and barriers preventing access to care Complete a report outlining findings and implications Caveats and Disclaimers: The focus of this report is on acute care hospitals; however, it should be noted that the fires also had an impact on skilled nursing facilities and outpatient clinics We suggest a practical more than academic approach, aggregating as much information as we can assemble and articulating salient themes that are reflected in the data, rather than developing extensive, statistically valid studies This analysis is NOT An academic, scientific study A statistical analysis A conclusive analysis An analysis of cause and effect

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7 Situation Assessment (Highlights)

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9 Situation Overview Original Hypothesis: While the fires may have caused significant disruption in many aspects of life in the county, local hospitals accommodated the inpatient transfers despite the increased stress on the health care system. There were two significant changes to the acute care hospital system during the 2007 San Diego wildfires: Surge of emergency visits Evacuation of Fallbrook Hospital and Pomerado Hospital The impact of these events was an increase in demand for medical services: Physical capacity Staffing Other resources (e.g., labs, supplies, medications, etc.) Patient transportation vehicles With the assistance of the Medical Operations Center, hospital leadership, coordinated efforts and dedication among the hospital staff and all those involved in the process, the transfer, treatment and safety of patients, family and staff was overall successful despite the many surprises and it is the surprises that lead to lessons learned for the future.

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12 Changes in Demand Immediate changes in demand were for emergency, acute, and post-acute care (long-term care) Emergency Services Most hospitals experienced a surge of patients through the emergency departments ED visits were primarily due to smoke related incidents and minor injuries and burns Tri-City had ~290 ED visits on the first day of the fires (100+ more visits per day than average) Scripps System EDs treated ~ patients due to fire related injuries Fallbrook and Paradise hospitals also experienced an increase in walk-ins Pomerado Hospital which kept its ED open after the mandatory evacuation in Poway treated firemen and other emergency response personnel for minor injuries Acute and Post-Acute Services There was only a minimal influx of acute care inpatients during the fires approximately 77 inpatients were transfer patients due to the evacuation of Fallbrook and Pomerado Hospitals Fallbrook transferred 14 acute care patients (4 Critical Care) to Tri-City Pomerado transferred 64 acute care patients to 13 different hospitals 16 out of 20 hospitals were involved at some level, either transferring or accepting acute patients Multiple SNFs were also required to evacuate patients, as well as one psychiatric hospital 40 SNF patients were evacuated from Fallbrook to Tri-City 120 SNF patients were evacuated from Pomerado to Palomar Medical Center and other longterm care facilities in San Diego County

13 Other Resources Changes in Demand To accommodate the increase in ED visits and ensure the safety of the patients being transferred, the demand for additional resources (e.g., staffing, supplies, support, etc.) also increased Staffing (all levels) Increased need for physicians, nurses and technical staff at receiving hospitals to help treat patients at transferring hospitals to triage, assess and accompany patients as they were transferred Administrative support was also necessary to maintain the lines of communication between the MOC, other hospitals, and their own hospital staff Support services Immediate access to labs, pharmaceuticals and diagnostic equipment Supplies O 2 tanks, IVs and refreshment packs for transfer patients HEPA filters and masks for staff, emergency personnel and patients Food and water for patients, staff and families Transportation vehicles With 78 acute and hundreds of long-term care patients evacuating, substantial numbers of transportation vehicles were needed particularly ambulances (or other large vehicles) to transport gurneys and patients who needed to lie down

14 Hospital Responses to Changes in Demand While the changes in acute demand primarily impacted EDs, the hospital responses to changes in demand were much more significant Responses are categorized into five major areas: Freeing Capacity Communicating Holding Patterns Staffing Supplies Transportation Vehicles

15 Freeing Capacity Hospital Responses to Changes in Demand As part of their disaster response plans, many hospitals have policies in place to increase capacity in anticipation of a surge of patients. Implement Triage Processes Several of the hospitals initiated a triage process to evaluate, treat and direct patients to the appropriate care setting (in some cases, this included being discharged home) Tri-City set up MASH-like tents to accommodate the surge of ED patients Paradise Valley Hospital also implemented a triage process where all patients, including inpatient transfers, were first triaged through the ED On the inpatient side, Tri-City already had available beds (daily census at the time of 220 out of 320 total beds), yet, as part of their disaster response efforts, physicians assessed each patient to identify those that could safely be discharged home Fallbrook Hospital was able to discharge six of its original 20 patients (including ~3-4 on the Mother/Baby Unit) prior to transferring patients Pomerado called in additional physicians to help assess and prepare patients for evacuation Approximately 12 physicians volunteered to assess and determine best placement for patients (e.g., discharge home vs. transfer to other institution)

16 Freeing up Capacity (continued) Hospital Responses to Changes in Demand Initiate strike teams in the community to prevent/reduce surge in hospital volumes Sharp deployed Mobile Intensive Care Nurses to Qualcom with meds and supplies to care for evacuees Scripps Health deployed its Mobile Response Team (SMRT) to Rancho Bernardo Emergency Evacuation Center Cancel elective surgeries and outpatient visits After voluntary and mandatory evacuations were communicated, all hospitals interviewed immediately cancelled elective surgeries, outpatient procedures and visits Cancel meetings Both Paradise and Tri-City canceled meetings to free up conference room space Communicate Holding Patterns Communication was through direct hospital-to-hospital contact, through the MOC, or via the WebEOC Scripps Chula Vista, Scripps Encinitas, and Sharp Chula Vista were in pre-staging phases of evacuation and were not able to accept new or transfer patients After accepting patients from Pomerado Hospital, Scripps Encinitas stopped accepting acute and ED patients Monday afternoon as potential need for evacuation arose

17 Staffing Hospital Responses to Changes in Demand Almost all of the hospitals had additional staff (physicians, nurses, technicians, etc.) in-house or on call during the fires Managers at Fallbrook Hospital contacted their staff daily to check in Tri-City initiated an Incident Command Labor Pool as part of their disaster response efforts, which requires employees at the hospital to check in prior to leaving to see if they are needed elsewhere and offsite employees to call in with their availability Pomerado Hospital had physicians volunteer to come in to help assess patients in preparation for transfer

18 Supplies Hospital Responses to Changes in Demand The availability and distribution of supplies varied by hospital Tri-City assessed and immediately ordered medical and routine supplies (e.g., HEPA filters, medication and ventilators anticipated to be used for a potential smoke inhalation surge, as well as basic items such as bottled water and bread) Emergency planning also included alternative methods for obtaining needed supplies (e.g., airlifting, alternative routes, etc.) Contracted vendors supported Tri City during fires, assisting with real-time information about supply consumption and needs (e.g., albuterols for respiratory illnesses, masks for clinicians/staff) Paradise Valley Hospital distributed masks to the community because the smoke was so bad Through the MOC and WebEOC, hospitals throughout the county identified core supplies necessary and available to be shared among various hospitals during emergency Transportation Vehicles Both Pomerado Hospital and Fallbrook Hospital used ambulances and buses to help transport patients to receiving hospitals

19 Surprises vs. Planning Response planning for San Diego hospitals occurs through two main forums: a centralized Medical Operations Center (MOC) and individual hospital disaster response plans. After the 2003 Cedar Fires, San Diego County developed the MOC, which is now considered a Best Practice among many counties The MOC functions as a communication command center, linking the Emergency Operations Center (EOC) and Sherriff's Department to the hospitals in San Diego County The MOC provides a centralized point of contact for all hospitals through direct communication and the web (WebEOC) This enables hospitals to understand all hospital-related events in the County (e.g., evacuations, diversions, resource availability, etc.) Through collaboration with the EOC, the MOC was actively involved in determining which hospitals needed to evacuate and initiating processes to effectively transfer patients (e.g., receiving hospitals, transportation vehicles, transportation routes, etc.) Given that it is a centralized hub for the county, the MOC is responsible for prioritizing resource availability for those most in need Individual hospitals are still required to have their own disaster response plans Fallbrook, Tri-City, Pomerado and Paradise Hospital each initiated their disaster plans the morning of the fires (in their immediate vicinity), progressing as more information became available through the MOC

20 Surprises vs. Planning Despite any good plan, the following highlights some of the unanticipated events. Category Decision to evacuate and evacuation plan Plan The MOC determines which hospital(s) need to evacuate and initiates processes to provide the necessary resources to assist Given the direction and severity of the fires, Pomerado Hospital was identified as a first priority for evacuation Fallbrook made their own decision to evacuate Both Fallbrook and Pomerado had evacuation plans in place (Fallbrook to Inland Valley and Pomerado to Palomar) Surprise As resources were first deployed to Pomerado, the remaining availability of resources was scarce. Fallbrook staff had to rely on their own personal connections (initially) for transportation vehicles, supplies, and staff (e.g., direct communication with EMS, Tri-City, school bus drivers) The unpredictability and rapid movement of the fires forced both hospitals to adjust evacuation plans, requiring a high level of adaptability on the part of hospital staff and transportation routes Interstate 5 and 15 were closed to traffic at times Communication MOC functions as central communication hub (through WebEOC and direct contact) San Diego residents (including hospital and medical staff) received most of their information through the local news channels (e.g., road barriers, shift in direction of fires) Communication plans during the transferring of patients varied across hospitals There was difficulty getting through to a live person (call volume overwhelmed available staff at MOC); WebEOC was deemed a better form of communication; some hospitals were not trained on WebEOC, leading to difficulty with implementation Both Pomerado and Fallbrook have staff that live in Riverside County and do not receive the same lines of communication many were unaware of the situation until direct observation Many relied on cells phones; however, connections were disrupted; some had no form of communication, resulting in buses getting lost and patients sitting on the side of the road Medical information and phone numbers for staff and patients families are maintained in several locations (e.g., charts or electronically); scale and volume have a direct impact Fallbrook called each patient s family member directly Pomerado posted an 800 number on their website Personal connections and networking with other hospitals still proved invaluable during inter-hospital coordination

21 Surprises vs. Planning Despite any good plan, the following highlights some of the unanticipated events (continued). Category Support Services Plan Tri-City set up MASH-like tents to treat surge of ED patients Surprise ED physicians decided to move tents much closer to hospital, which led to more protection for patients due to hospital overhang, increased efficiencies in triaging and treating patients due to proximity to lab, pharmacy, and other support services Staffing Disaster response planning for most hospitals includes calling in additional staff to ensure resource availability Given the mandatory evacuations and road closures, many staff had to evacuate their homes or were blocked from reaching the hospital Because of the evacuations, many hospitals set up day care and other interim spaces to accommodate staff families Several staff volunteered to come in Fallbrook staff volunteered to help out despite the mandatory evacuation; this proved beneficial during the transportation phase as there were enough nurses to ensure a 1:2 nurse / patient ratio Physicians at Pomerado also volunteered to come in, enabling a prompt triage of inpatients to evaluate those needing to be transferred After the transfer of patients, receiving hospitals had enough staff available to care for the volume of patients. No additional staff was required Supplies Most hospitals have plans in place to access and immediately order medical and routines supplies Tri-City s Food and Nutrition department personally drove to the local store to purchase supplies, due to shipment delays caused by road closures Electronic tracking, JIT inventory management provided information about an greater need for respiratory meds and HEPA filters than anticipated

22 Surprises vs. Planning Despite any good plan, the following highlights some of the unanticipated events (continued). Category Transportation Plan Patients were transported using both ambulances and school buses, attended to by the evacuating hospitals nursing staff Surprise There were not enough ambulances to transfer all patients. School buses were not equipped for transferring medical patients (e.g., patients requiring gurneys, O 2 tanks, etc.) Hospitals identified the need for better transport alternatives and patient refreshment packs to improve the experience for patients Shutting down facilities Fallbrook and Pomerado have policies in place for hospital closures Fallbrook shut down the HVAC system, reversed air flow to help with smoke ventilation Pomerado used air scrubbers to reduce smoke entering facility during closure Evacuation perceived by some as easier than re-opening Exhaustive cleaning to remove smoke from walls, instruments, and reusable supplies All equipment needed recalibration Multiple agencies required inspection/certification prior to hospital being able to re-open (e.g., Joint Commission, OSHPD) Economic Impact No significant planning many anticipate some of the costs will be offset by insurance and government support (e.g., FEMA grants) Significant costs arose that were not anticipated Revenue lost due to closures (inpatient, outpatient reimbursement, elective surgeries, etc.) Fallbrook and Pomerado continued to pay full-time staff while hospitals were closed Clean up costs Pomerado Hospital estimates a $3M loss due to fires

23 Implications and Lessons Learned* 1. Overall, the local hospitals in San Diego County were successful in responding to the 2007 wild fires Within ~4-7 hours all patients were transferred successfully A large part of the success was due to technology (e.g., web, phone, etc.) However, other disasters (such as a major earthquake) may disrupt the lines of communication, requiring different protocols (greater direct communication potential exasperating the problem due to drive times, etc.) 2. Planning is helpful, but having good leadership and staff that are able to think quickly on their feet is critical to successfully respond to a disaster Disaster planning for most hospitals anticipates a surge of patients rather than an evacuation change agents and quick thinking was necessary 3. Scale is important Approximately 80 acute care patients were evacuated during the fires; if Scripps Mercy (470 beds) or UCSD (430 beds) had to be evacuated, the outcome may be substantially different 4. Latency of surge in demand (ED visits, hospitalizations) is also an important consideration As life returns to normal, many seek out care avoided during crisis implications on staffing, supplies, etc. 5. Experience with previous disasters of similar type increases probability of success in the future 2003 Cedar Fires establishment of County MOC, WebEOC, Co. Disaster Planning Council, shared/similar resources CHS (Fallbrook owner) national chain with experience in Hurricane Katrina, other disasters developed extensive protocols utilized by Fallbrook Fallbrook staff involved in 2003 Cedar Fires at another affected hospital; able to anticipate gaps in planning Scripps developed staff of full-time disaster managers after September 11, 2001 * Though the focus of this report is inpatient operations, related findings included: MOC protocols for SNFs and outpatient clinics; importance of access to patient records, staff phone numbers, etc.; need for sufficient emergency transport vehicles capable of accommodating inpatients