危机应对医疗方案

DisasterResponseAndRespiratoryCare第一页，共一百零三页。ObjectivesUnderstandtheuniversalcharacteristicsofdisastersandthecomponentsofanallhazardsapproachtodisastermanagementinvolvinghealthcarepractitioners.DemonstrateunderstandingoftheroleofRespiratoryTherapistsindisasterresponseandemergencymanagement;and,describetheroleofRespiratoryTherapistsasvolunteersfordisasterresponse.第二页，共一百零三页。ObjectivesExplainthevariouslevelsofequipmentandsupportRespiratoryTherapistswillutilizeinrespondingtomasscasualtyincidentsanddisasters.DiscusstheimplicationofPandemicInfluenzaasitrelatestoplanningandresponsecapabilityandcapacity.DescribetheimpactofBioterrorismandman-madedisasterstohealthcaresystems,providers,anddisasterpreparednessplans.第三页，共一百零三页。第四页，共一百零三页。What’sTheFuss?第五页，共一百零三页。HowDoWeRespondToThis…第六页，共一百零三页。SoWeDon’tFeelLikeThis…第七页，共一百零三页。DisasterCharacteristicsIncreaseddeath,injury,illnessthatcan’tbemanagedCoordinationpublic,government,andprivateorganizationsEqualtriagedistributionNotificationoffamilyEvacuation/Shelteringofevacuees第八页，共一百零三页。DisasterCharacteristicsMediaattentionHeightenedsecurity;crimesceneImmediateandlongtermemotionalsupportSignificantpropertydamage第九页，共一百零三页。ImpactofDisastersInthepast20years“Althoughtheyearlydeathtotalsfromdisasterdeclinedbyapproximately30%,thenumberofpeopleaffectedbydisasterincreased59%” (AARCTimes.2006.p.8)第十页，共一百零三页。ConsequenceManagementTheobjectiveofconsequencemanagementis:ProvidesupportSavelivesRelievesufferingMitigatefurtherharm第十一页，共一百零三页。PreparednessCyclePlanTrainEquipExerciseHealthsystemswillbepreparedthroughacontinuouscycleofplanning,equipping,trainingandexercising.

第十二页，共一百零三页。P.E.T.E.PlanPublicHealthPreparednessStrategicPlanEquipVentilators,PPE,Pharmaceuticals,etc…TrainOSHA,DHS,OtherExerciseLocal,Regional,Statewide,Interstate,National第十三页，共一百零三页。SurgeCapacity

CountyHealthDepartmentsPre-hospitalOutpatientServicesHospitalsPharmaciesLaboratoriesMortuaryServicesPublicHealthResponseHealthCareSystem第十四页，共一百零三页。DomesticSecurityRegionsRegion1

Region2

Region3

Region4

Region5Region6

Region7第十五页，共一百零三页。IntegratedPlansFederalNationalResponseFramework(NRF)SupportedbyNationalIncidentManagementSystem(NIMS)andtheNationalDisasterMedicalSystem(NDMS)ComprehensiveEmergencyManagementPlan(CEMP)ProvidesguidanceIntegratedandcoordinatedresponseEmergencySupportFunctions(ESF-8)FollowsNRF第十六页，共一百零三页。IntegratedPlansStateFloridaDepartmentofHealthBomb,Blast,Burn(B3)Biological(B4)PandemicInfluenzaPublicHealthandMedicalPreparednessStrategicPlan2007-2010CountyCEMPPlansHospitalCEMPPlans第十七页，共一百零三页。GoalofSurgeThinkingMaximizesurvivalforallplayers!Minimizemorbidity!Maximizeresourceutilization!Willrequirenewthinking!第十八页，共一百零三页。NaturalDisasters第十九页，共一百零三页。NaturalDisastersTornadoesForestFiresFloodsBlizzardsCyclones/TyphoonHurricanesHeatwaveTsunamiVolcanicEruptionEarthquakesMudslidesLimnicEruptionDraught/FamineHail第二十页，共一百零三页。NaturalDisasters-FloridaHurricanesTornadoesForestFiresFloodingFreezingSinkholesDroughtHeatwaveHail第二十一页，共一百零三页。NaturalDisasters-Florida2004July31toDecember39Hurricanes;5TropicalStormsCharley,Frances,Jeanne,Ivan2005June8toJanuary615Hurricanes;12TropicalStormsKatrina,Rita第二十二页，共一百零三页。Cost–2004HurricaneSeasonFlorida’shospitalsincurred$163.2millioninunexpectedcostsExpensesrelatedtofacilitymodificationstoreducedamagefromfuturestormswouldexceed$48millionAveragehospitalimpactofmorethan$1millionTotalimpactonhospitals>$200million第二十三页，共一百零三页。LessonsLearnedPreparationFacilityPlanningPower,MedicalGases,Water,Etc.FloodzoneMaterialResourcesCommunicationRedundancyContingencyplansIncidentCommand!第二十四页，共一百零三页。LessonsLearnedWorkforceissuesAdequatestaffHospitalPlanningIncidentCommandEducation/TrainingSpecialNeedsBehaviorHealthPatient&Employee第二十五页，共一百零三页。LessonsLearnedHospitalSecurityFacilitysupportProtectivemeasuresPatientSafetyMutualAidPublicandprivatepartnersMedivac第二十六页，共一百零三页。Man-MadeDisasters第二十七页，共一百零三页。Unintentional/AccidentalEngineeringFailuresBridges,Buildings,DamsTransportationPlanes,Trains,Automobiles,ShippingEnvironmentalOilspills,pollution,wasterunoffExplosionsMinedisastersIndustrialaccidentsWarFire第二十八页，共一百零三页。Terrorism第二十九页，共一百零三页。Pokingskunksisdangerous!第三十页，共一百零三页。TerrorismThegoalsofterroristsareto:Createconfusion,fear,chaos,andmistrust.Breakdownthephysicalandpoliticalinfrastructure.Intimidate,subjugate,andweakenauthority.第三十一页，共一百零三页。HOWWILLOURENEMIESFIGHTUS?UNCLASSIFIED第三十二页，共一百零三页。ChemicalBiologicalRadiologicalNuclearEnergetics/ExplosivesCBRNEAWeaponofMassDestructionisadeviceormaterialspecificallydesignedtoproducecasualtiesorterror.CBRNEincidentsmayresultfromindustrialaccidents,actsofwar,oractsofterrorism.第三十三页，共一百零三页。ChemicalAgentsMustardgasSarinPhosgeneCyanideChlorine第三十四页，共一百零三页。ChemicalAgentsIndustrialChemicalsChokingAgentsBloodAgentsWarfareAgentsBlisterAgentsNerveAgents第三十五页，共一百零三页。RoutesofexposureInhalation,skincontact,ingestion,injectionEffectdependsondoseLargerdose:earlierandmoresevereeffectsEffectsmaybeimmediateordelayedIndividualsusceptibilityvariesAge,chronicillness,medicationsExposureToChemicals第三十六页，共一百零三页。BiologicalAgents:

Undetectablebyhumansenses+Prolongedincubationperiod+Limitedsurveillancecapability=

Unrecognizedexposure

第三十七页，共一百零三页。Bio-threatsBiologicalagentsmaybe:BacteriaVirusesToxinsTheyarenaturallyoccurringand/orcanbebioengineeredasWeaponsofMassDestruction.第三十八页，共一百零三页。RoutesofTransmissionAbsorption:SkinandmucusmembranesInhalationRespiratorythroughairdropletsIngestionGastrointestinalthroughconsumptionoffoodordrinkInjectionFromneedleorotherobject第三十九页，共一百零三页。VectorsLetters/packagesInsects/animalsContaminatedfood/waterContaminatedclothingAirviaaerosoldisseminationdevice第四十页，共一百零三页。Anthrax(Bacillusanthracis)Botulism

(Clostridiumbotulinumtoxin)Plague(Yersiniapestis)Smallpox(Variolamajor)Tularemia(Francisellatularensis)ViralHemorrhagicFevers

(Filoviruses[e.g.,Ebola,Marburg]andArenaviruses[e.g.,Lassa,Machupo])CDCCategoryAAgents第四十一页，共一百零三页。Nuclear/RadiologicalAgentsAnysourcethatemitsradiation第四十二页，共一百零三页。RadiationExposureExternal–depositedonskinInternal–inhaled,swallowed,absorbedthroughskin,orintroducedthroughwoundsIncorporationofradioactivematerials–uptakebybodycells,tissues,ororganssuchaskidney,liver,andbone第四十三页，共一百零三页。SymptomsofRadiationExposureNauseaVomitingDiarrheaChangesinmentalstatus第四十四页，共一百零三页。EarlyDetectionIsyourkeytolimitingpotentialexposure.Timeisahugefactorinhowmuchexposureonecouldreceive.第四十五页，共一百零三页。Beta-bAlpha-aGamma-

gNeutron-nRadiationPenetration第四十六页，共一百零三页。DirtyBombvs.AtomicBombTheatomicexplosionsthatoccurredinHiroshimaandNagasakiwereconventionalnuclearweaponsinvolvingafissionreaction.Adirtybombisdesignedtospreadradioactivematerialandcontaminateasmallarea.第四十七页，共一百零三页。TerroristAttacksSocalledsuicideattacksUnfortunateexperienceandexpertisefromIsraelUseofexplosivesandshrapnel(bolts,nails,nuts)Predominateinjuryislunginjury(blastinjury)50%ofpatientswhosurvivetohospitalizationdevelopARDSandrequiremechanicalventilation第四十八页，共一百零三页。TerroristAttacks20attacks>10woundedTotalof1475wounded,92ICUadmissions,80patientsrequiringMV52%ofpatientshadacutelunginjuryBlastinjuryisthemajormechanismAschkenasy-SteueretalCritCare2005;9:1186第四十九页，共一百零三页。TerroristAttacks1983-2004allmultiplecasualtyevents875patientsfrom31eventsinJerusalemAverageof28patientspereventICUadmission5%(n=43)-ofthese70%hadblastlunginjury73%ofpatientsrequiredmechanicalventilationAvidanV,JTrauma.2007May;62(5):1234-9.第五十页，共一百零三页。PlausibleScenariosTrauma–naturalorman-madeNerveagents–sarin,tabun,VX,somanPulmonaryIrritants–phosgene,ammoniaBiologicAgents–plague,tularemia,anthrax,botulismRadiologicEvents–nuclearweapon,dirtybomb第五十一页，共一百零三页。PlausibleScenariosSCENARIOTIMETOMVDURATIONOFMVVICTIMSNEEDFORMVTraumaImmediateDaystoweeks<100Hemo–pneumothorax,blastinjury,burnssmokeinhalationNerveAgentImmediateHoursUpto1000Paralysis,bronchospasm,bronchorrheaPulmonaryIrritantsHoursDaystoweeksUpto1000ARDS,pulmonaryedema,airwayinjuryBiologicsHourstodaysDaystoweeks1000ARDS,hemorrhagicpulmonaryedemaRadiologicDaystoweeksDaystoweeksHundredsTraumaticlunginjury,sepsis,RubinsonL,BiosecurBioterror.2006;4(2):183-94.

第五十二页，共一百零三页。VulnerabilitiesHardTargetsMilitaryinstillationsGovernmentbuildingsSecureAreasSoftTargetsHospitalsSchoolsChurches第五十三页，共一百零三页。PreventionEffortsRelyon:Federal,State,&LocalLawEnforcementAgenciesHospitalHazardVulnerabilityAssessmentsAccreditationandRegulatoryAuthoritiesDiligence,Observation,ReportingSafetyCommittees>>>PerformanceImprovement第五十四页，共一百零三页。Probabilityvs.ImpactPOTENTIALIMPACTPROBABILITY/LIKELIHOODNUCLEARWEAPONIMPROVISEDNUCLEARDEVICERADIOACTIVEMATERIALCHEMICALAGENTORTOXICINDUSTRIALCHEMICALBIOLOGICALAGENT第五十五页，共一百零三页。PandemicInfluenza第五十六页，共一百零三页。Isithereyet?第五十七页，共一百零三页。NaturalBiologicThreatWhatisapandemic?Thespreadofdiseaseoverawidegeographicareaaffectingmuchofthepopulation第五十八页，共一百零三页。NaturalBiologicThreatPandemicInfluenzaIncreasedmorbidity(sickness)andmortality(death)SocialdisruptionEconomicdisruption第五十九页，共一百零三页。Seasonalvs.PandemicFluSeasonalYearlyFamiliarvirusMild/ModerateSymptomsVeryyoung,veryold;HealthproblemsVaccineavailablePandemicRarelyNewvirusSeveresymptomsHealthypeopleNovaccine第六十页，共一百零三页。InfluenzaDiseaseCharacteristicsInflammationoftherespiratorysystemHeadacheFeverChillsCoughMuscleachesSeveraldayssick,severalweeksrecovering第六十一页，共一百零三页。PanFluStatsPandemicInfluenzaHistory 1918 50–100milliondeaths1957 2milliondeaths1968 1milliondeathsFrequency ~every35yearsDuration 1–3yearsWorldwide 6–9months,3months?Waves 1–3,4–8weeks/wave第六十二页，共一百零三页。NationalStrategy 1.Stop,sloworotherwiselimitthespreadofapandemictotheUnitedStates 2.Limitthedomesticspreadofapandemic,andmitigatedisease,sufferinganddeath 3.Sustaininfrastructureandmitigateimpacttotheeconomyandthefunctioningofsociety第六十三页，共一百零三页。U.S.PlanningAssumptionsAttackrate 35%ofpopulationTreatmentrate 25%ofpopulation ~75%ofcasesHospitalizationrate 10%ofcasesCasefatalityrate 2%(2%-50%)Pre/asymptomatic 30%-50%(?) transmissionIncubationperiod 2days(1–8days)第六十四页，共一百零三页。FloridaPlanningAssumptions

1stWave/2ndWave

TotalCases 3.2million 6.4millionHospitalized(10%) 320,000 640,000 SurgeBeds(130%) 65,000 ICU 48,000 ICUVentilator 24,000 SurgeVentilators 5,000Dead(2%) 64,000 128,000Floridapopulation:18.3million

第六十五页，共一百零三页。PlanComponentsRapidResponseIsolation&QuarantineSocialDistancingNon-PharmaceuticalInterventionsPharmaceuticalInterventions第六十六页，共一百零三页。On-goingPlanningIssuesCommunityInterventionsHospitalPlanningSupportAlternateMedicalTreatmentSitesMasscarewithlimitedsuppliesandresources第六十七页，共一百零三页。CurrentSituationHumanDeaths*353cases,221deaths(62.2%Mortality)14countriesBirdDeaths150–200millionbirddeaths>50countries(Asia,Europe,Africa)*WHO,24January2008第六十八页，共一百零三页。第六十九页，共一百零三页。RespiratoryCareYourRoleInADisaster第七十页，共一百零三页。HealthcareConsiderationsAdequatebedspaceICUCapabilityandCapacityWorkforcereductionOptionsPharmaceuticalstockpilesMaterialresourceutilizationContinuityofqualityStandardofCareCommand&Control/SecurityPlanInfectionControlEmployeeandCommunityEducationFinancialChallenge第七十一页，共一百零三页。HealthcareConsiderationsExternalInfluencesSocial&EconomicDisruptionMutualaiddifficultiesSchoolandChildWelfareissuesInternalInfluencesEmployeeIssuesSingleparentfamiliesBothparentsworkinhealthcareChildrensick,parent/employee(s)notworking第七十二页，共一百零三页。HospitalIssuesPatientVolumeHigh-volumedemandformedicalattentionCompetitionforscarcemedicalresourcesImpactoncaregiversNeedforpsychologicalsupportNeedforsecurity第七十三页，共一百零三页。MaterialResourceManagementIVTubingLabResourcesPharmaceuticalIVFluidsAntibioticsAntiviralVaccineMechanicalVentilatorsMedicalGassupplyFoodServicesEnvironmentalServicesuppliesLinens第七十四页，共一百零三页。TheGasSourceIssue第七十五页，共一百零三页。TheGasSourceIssue

Whatisthebestsourceofoxygen?Whatabouthomehealthagenciesandtheirpatients?Powerisanissue!第七十六页，共一百零三页。NecessaryVentilatorFeaturesforEachScenario?Wherewillmechanicalventilationbeperformed?Whowillperformmechanicalventilation?Wherewillthegassupplycomeform?Howlongwillitlast?Doestheventilator’scapabilitiesmatchtheneedsofthepatient,skilloftheoperator?第七十七页，共一百零三页。NecessaryVentilatorFeaturesforEachScenario?MostmasscasualtyinjuriesresultinARDSAllscenariosexceptnerveagentexposurerequireconstantvolumedelivery,controlofairwaypressures,monitoring,alarms,andcontrolofPEEPandFIO2Whennerveagentsresultinparalysis–airwaycontrolandshorttermventilation–“goodairin–badairout”maybeallthatisnecessary第七十八页，共一百零三页。VentilatorCharacteristicsFDAapprovedforadults/pedsAbilitytooperatewithoutcompressedgasBatterylife4hrsVolumecontrolCMVandIMVPEEPto20cmH2OUtilizebothhighandlowpressureO2sourcesControlofRR,PEEP,VT,FloworI:EMonitorPawandVTAlarmsDisconnect,apnea,high/lowpressure,highpressuresourcegasdisconnect第七十九页，共一百零三页。VentilatorCharacteristicsRuggedLightweight(<10kg)EasytouseGasconsumption-lowBatterylife-longEasytotrigger<$10KVendorsupportandlongevityMaintenanceTraining第八十页，共一百零三页。CriticalFactorsInaMCI–manypatientswillneedventilationexceedingnotonlyequipmentbutstaffcapabilitiesLikelythatcriticalcareRRTwillsupervisenon-criticalcareRRTandothersincareoftheventilatedpatientsTheventilatormusthaveadequatealarmsandmonitoringTheventilatormusthaveasimpleinterfaceandbeeasytouse第八十一页，共一百零三页。SpecificDevices第八十二页，共一百零三页。Concerns EducationandtrainingUniversalresponseDecentralizationofsuppliesandequipmentOperabilityinMCIenvironmentsSafetyAgecapabilityCompensationLegalprotectionCommunicationsVulnerablePopulationsVolunteerism第八十三页，共一百零三页。FEHVR第八十四页，共一百零三页。MedicalReserveCorpsMission:

Toaugmentlocalcommunityhealthandmedicalserviceswithpre-identified,trainedandcredentialedvolunteersduringemergencymedicaloperationsandvitalpublichealthactivities.Purpose:

TheFloridaMedicalReserveCorps(MRC)Networkwasestablishedforthepurposeofeffectivelyfacilitatingtheuseofhealthprofessionalvolunteersinlocal,state,andfederalemergencyresponsesineverycountywithinFlorida.第八十五页，共一百零三页。LicensureRenewalStatementIfyouarerenewingtoactivestatus,wouldyoubeavailabletoprovidehealthcareservicesinspecialneedssheltersortohelpstaffdisastermedicalassistanceteamsduringtimesofemergencyormajordisaster?□Yes第八十六页，共一百零三页。OtherIssues第八十七页，共一百零三页。DisasterImplicationsCommunitiesFood,Water,ShelterPowerEconomicandSocialDisruptionChildSafetyDomesticAnimalsPersonalPropertyDamage第八十八页，共一百零三页。DisasterImplicationsPatientPopulationsFood,Water,ShelterPowerformedicalequipmentMedicationsRenalDialysisIncreasehospitalsurge!第八十九页，共一百零三页。HealthcareImpactsRoadClosuresHospitalClosures/EvacuationWorkforceShortageResourceManagementHVACWater,FoodSanitation第九十页，共一百零三页。SuppliesManagementSurroundingIssuesJust-In-TimeInventoryAccessEquipment&SuppliesVentCircuitsAerosolandHumidityMedicationsOxygenSuppliesOtherMedicalSupplies第九十一页，共一百零三页。InfrastructureSupport MutualAidAgreementsVendorAgreementsHospitalAgreementsGovernmentAgreementsLocal(i.e.–City,Municipality,County)RegionalState/Inter-StateFederal第九十二页，共一百零三页。InfrastructureSupport Workforce&StaffingPersonalPlanPPEPlantFacilitiesSecurityPlansFacilitySafety第九十三页，共一百零三页。CommunicationDevicesPhones:cell,satellite,landbased800mgHz/MEDRadiosPagersOverheadpagingsystemsDispatcherEmailHAMRadio第九十四页，共一百零三页。SpecialPopulationsThisisaneverydayissueforhospitalsonasmallscale.Weneedtoplantosupportlargenumbersofpersonswhoarehardtoreachorhavedisabilities.第九十五页，共一百零三页。DeadlyMisconceptions“Itwon’thappenhere”Itwon’thappentome”“Someoneelsewilltakecareofit”第九十六页，共一百零三页。第九十七页，共一百零三页。Q&A?ThankYou!第九十八页，共一百零三页。AcknowledgementsThe2008-2009FloridaStateWorkingGroupVentilatorCapabilityTeammembersare:JohnWilgis,MBA,RRT-FloridaStateWorkingGroupVentilatorCapabilityTeamChair,Director,EmergencyManagementServ