# Presentation: 733779

## National Bioterrorism Hospital Preparedness Program (NBHPP)Surge Capacity

- LCDR Sumner L. Bossler Jr.
- Senior Public Health Analyst
- Department of Health and Human Services
- Health Resources and Services Administration
- Special Programs Bureau
- Division of Health Care Emergency Preparedness
- Nation Bioterrorism Hospital Preparedness Branch

## Overview

- Program initiated in 2002
- $135 Million in 2002
- $498 Million in 2003
- 62 Awardees
- 50 States, Washington, DC and Puerto Rico
- Cities of Chicago, Los Angeles and New York
- Virgin Islands
- Pacific Territories and Freely Associated Nations

## Priority Areas 

- Administration
- Regional Surge Capacity
- Emergency Medical Services
- Linkages to Public Health Departments
- Education and Preparedness Training
- Terrorism Preparedness Exercises

**Notes:**
Awardees must identify the major rural and urban priorities to be implemented in the planning process, so that both rural communities and metropolitan areas are engaged and coordinated to the fullest extent possible.  Funded Municipalities planning for a large-scale event must include the surrounding areas likely to impact municipal resources.  Conversely, in the event of an urban event, rural areas must include planning to deal with the sudden influx of potential patients into rural facilities caused by large- scale evacuation in the urban area.

## Critical Benchmarks

- 16 Total Critical Benchmarks
- Evidence based
- Sentinel Indicators

## Minimal Levels of Readiness

- Developed for each benchmark
- Serve, in some cases, as a phased-in approach to achieving the overall benchmark
- Some minimal levels are benchmarks themselves

**Notes:**
Minimal Levels of Readiness have been established as a means to ultimately achieve critical benchmarks.  Applicants will note that some minimal levels of readiness are the actual benchmarks themselves, due to the fact that the benchmark is the minimum standard that must be achieved to demonstrate readiness.  For other benchmarks, minimal levels of readiness will represent a phased approach to ultimate attainment of the critical benchmark.  

All critical benchmarks must be achieved by the end of the project period (August 31, 2007).  Certain Minimal Levels of Readiness may be able to be achieved within a twelve-month budget period; others will be phased in over a number of budget periods.

HRSA recognizes some awardees will be able to demonstrate that the Minimal Level of Readiness has been met for certain benchmarks.  If the Minimal Level of Readiness has been achieved, awardees will submit the required documents as outlined. Awardees will then propose further activities that will enhance the current capabilities of the awardee.

## Sentinel Indicators

- Developed for each benchmark
- Will serve as a baseline for quantitative data
- Asking for retrospective report with applications and yearly updates from then on

**Notes:**
In addition to adding Minimal Levels of Readiness, HRSA has added a set of National Bioterrorism Hospital Preparedness Program (NBHPP) sentinel indicators.  These indicators relate directly to the critical benchmarks.  For all but one of the critical benchmarks, there is an indicator requesting data or information for that benchmark.  Awardees are asked to report retrospectively on each of these indicators in the 2004 application regarding progress made towards achieving the benchmark prior to and during the 2003 grant year.  

While it is recognized that awardees will be reporting on less than a full 12-month period, it is important nonetheless to report all progress made during the 2003 grant year up to the application date in order to demonstrate what awardees have accomplished. Awardees should be assured that reporting retrospectively will in no way negatively impact on the financial awards that states receive.

Data for each of the indicators should be presented at the end of the description of activities listed for the associated benchmark.  Awardees will be asked to report progress on these indicators annually.

## Critical Benchmarks:Surge Capacity

- 2.1: Beds
- 2.2: Isolation Capacity
- 2.3: Health Care Personnel
- 2.4: Advanced Registration System
- 2.5: Pharmaceutical Caches
- 2.6: Personal Protective Equipment
- 2.7: Decontamination
- 2.8: Behavioral Health
- 2.9: Trauma and Burn Care
- 2.10: Communications and Information Technology

**Notes:**

This system must address all components of the awardees health care system.  Under the authorizing legislation, priority must be given to biological events before using these funds for chemical, radiological, nuclear or explosive incident planning.

Preparedness planning must address not only enhancing the surge capacity of individual health care entities, but also establishing mutual aid agreements among them.  Where appropriate, the applicant should develop and implement intra-state or multi-state regional workplans to maximize economies of scale in planning for an overwhelming terrorist incident or other public health emergency.  Awardees must consider and include off-site options for increasing bed capacity such as mobile facilities, temporary facilities appropriate to an austere environment, large convention halls, armories, and State fair grounds.  Additionally, the plan must account for the operational and physical needs of special populations; notably people with physical disabilities, geriatrics, and the mentally ill to the extent possible.  

## Critical BenchmarksSurge Capacity

- 2.1: Beds
- 2.3: Health Care Personnel
- 2.6: Personal Protective Equipment
- 2.7: Decontamination

**Notes:**
Critical Benchmarks 2-1 and 2-3 are essential elements of this guidance, taken together, they define the order of magnitude of surge capacity for beds and healthcare workers, respectively, (i.e., 15-20% above baseline service levels) that almost certainly would be needed to counter a major public health emergency.  Remembering that this is not an attempt to define full hospital preparedness, as mentioned previously, one can envision terrorism scenarios that will prompt even greater burdens upon the healthcare system.  However, HRSA believes that these Critical Benchmarks will move our nation’s healthcare system toward establishing the level of surge capacity, which realistically can be achieved during this upcoming Project Period. 

## Critical Benchmark #2.1:Beds

- Establish a system that allows the triage, treatment and initial stabilization of 500 adult and pediatric patients per 1,000,000 awardee jurisdiction (1:2000), above the current daily staffed bed capacity, with acute illnesses or trauma requiring hospitalization from a chemical, biological, radiological, nuclear or explosive (CBRN&E) incident.

**Notes:**
The surge bed ratio was derived from a variety of sources:  National Disaster Medical System (NDMS) projections, data from established Trauma regions/systems, and systems developed for Mass Causality Incidents (MCI) in other countries (e.g., Israel).  With the understanding that there were no health care specific Bioterrorism specific models at the time, excluding the DOD (NBC-CREST), the ratio of “500 patients per million (1,000,000) population (1:2000)” is based on much of the currently available models of health care delivery and extrapolations from those systems of care.  The majority of the examples of MCI models were based on ranges 100-300/per million expanded to 300-600/per million (NDMS) or in the case of the Israeli system 15-20% above current capacity.  Since all CBMs must be measurable for programmatic evaluation, ranges previously mentioned provide too much inconsistency and are difficult to quantify from the perspective of planning.  Therefore, the number is fixed at a set ratio of 500 per 1,000,000.  This represents the best available combination of data and expert judgment.

## Critical Benchmark #2.3: Health Care Personnel 

- Establish a response system that allows the immediate deployment of additional health care personnel in support of surge bed capacity noted in Critical Benchmark # 2-1.  The number of health care personnel must be linked to already established patient care ratios noted by the awardees Patient Care Practice Acts based on 24 hours operations
- This benchmark must describe how these personnel are recruited, received, processed and managed through the incident in accordance with the awardee system noted in CB #2.1.

**Notes:**
The nature of the healthcare needs and the shortage of personnel in a bioterrorist or mass casualty incident may make established role delineation impractical.  Therefore, divisions of responsibilities for various aspects of patient care and administration should be based on knowledge, experience, special talents, and to some level, the interests of individual staff members.  In this way, each healthcare provider’s particular abilities and skills are fully utilized, enhancing operational efficiency.  Non-medical personnel, such as environmental or administrative personnel, must be drawn on to lessen the clinical staff’s burden.  Volunteers should be used, if available.” 

“Potential types of health care personnel who will need to be available include physicians, nurses, emergency medical technicians, dentists and pharmacists who may not have current inpatient care experience or who are still in training.  To ensure that these resources operate in conjunction with the supporting hospitals, planners must consider distributing some of the hospital’s regular staff amid the temporary personnel.  This is advantageous because it provides a base of personnel that have current operational information and skill sets.”

## Critical Benchmark #2.6: Personal Protective Equipment 

- Each awardee must ensure adequate personal protective equipment (PPE) per awardee defined region, to protect current and additional health care personnel, during a chemical, biological, radiological or nuclear incident.  This benchmark is tied directly to number of health care personnel the awardee must provide (CBM # 2.3) to support surge capacity for beds (CBM # 2.1).

**Notes:**
It is strongly suggested that when deciding what level of PPE to provide, awardees address issues of handling a highly infectious respiratory disease or any other communicable disease prior to addressing the “all hazards” PPE.  Contingency plans for chemical and radiological terrorism preparedness may be proposed after biological terrorism preparedness is fully addressed as required under the authorizing legislation.

It is important that equipment purchased under this priority area is interoperable with equipment purchased with funds from the DHS State Homeland Security Grant Program (SHSGP) for first responders.

## Critical Benchmark #2.7: Decontamination 

- Ensure that adequate portable or fixed decontamination systems exist for managing adult and pediatric patients as well as health care personnel, who have been exposed during a chemical, biological, radiological, nuclear or explosive incident in accordance with the numbers associated with CBM # 2.1 & # 2.3.
- All decontamination assets must be based on how many patients/providers can be decontaminated on an hourly basis.  The awardee should plan to be able to decontaminate all patients and providers within 3 hours from the onset of the event.

## Contact Information

- Sumner L. Bossler Jr.
- Lieutenant Commander,
- United States Public Health Service
- Division of Health Care Emergency Preparedness
- Special Programs Bureau
- Health Resources and Services Administration
- Office: 301-443-1095
- Fax:     301-480-0334
- Email: sbossler@hrsa.gov
- Website: www.hrsa.gov/bioterrorism/index.htm