PanFlu Essential Healthcare Services Tabletop
The PanFlu Essential Healthcare Services Tabletop (TTX) was provided to six counties in the state of Indiana in June and July 2009, with over 200 participants. Our purpose in conducting this TTX was to assist hospitals and healthcare providers in the testing and evaluation of their Strategic Plan for Delivery of Essential Healthcare Services in the face of the demands associated with pandemic influenza. The project received support from the Centers for Disease Control through the Indiana State Department of Health. The exercise required participants to explore and measure their capabilities to sustain essential healthcare services during weeks 1, 3, and 5 of a simulated 12 week influenza pandemic wave. The participants identified their essential healthcare services that would be continued, discontinued, or altered in response to the ever-increasing patient loads experienced with each successive exercise module.
There were two pre-exercise scenario injects. The first inject, given 10 days prior to the exercise start date, provided a scenario and asked the hospitals/county participants to identify an appropriate Incident Command System (ICS) structure with qualified personnel and back-ups. The second inject, 7 days prior, increased the severity of the scenario and asked participants to review their plan(s) and share their plan(s) with appropriate healthcare service providers and community stakeholders.
On exercise day, the Module 1 scenario introduced confirmed cases of a novel virus in Indiana with a World Health Organization (WHO) Alert Phase of 5, and a significant number of worried well and sick reporting to the hospital emergency departments (EDs) and healthcare providers. Participants discussed surge triage triggers and implementation, traffic issues and security needs, and then based on these factors, the resulting impact on continuation of their essential healthcare services. After Module 1, the participants took part in a working lunch where they considered ethical issues surrounding three different scenarios. The scenarios focused on hospital visitation policies, staffing absenteeism, and ventilator allocation. Participants identified the primary ethical issues that would be considered in arriving at a recommended solution(s) and various other issues including who the decision-makers would be, and how decisions would be communicated to affected parties. Laws, policies, and regulations surrounding the ethical issues were identified as well, allowing the participants to recommend potentially beneficial changes.
The Module 2 introduced an increase to a WHO Alert Phase 6, a large increase in patients needing triage and hospitalization, an escalation of security concerns, and significant absenteeism among nursing staff. Participants determined their nursing staff demands/needs by completing an Excel spreadsheet that would reveal staffing requirements based on bed counts, patient:nurse ratios, and work shifts. Participants also identified supply strategies to include ordering, storing, reuse, and to respond to security issues in triage lines. Finally, they determined the impact of the scenario events on their essential healthcare services and identified what they would continue, discontinue, or alter.
The third module continued to increase patient loads exacerbating bed and staffing shortfalls, contributing to "community panic". Staff availability was reduced by 30%. Participants reviewed their ICS structure from the pre-exercise injects, and replaced members as controllers removed them from the exercise. Participants also identified community stakeholders and agencies that would provide assistance during pandemic efforts. Most importantly, participants again discussed what essential services would be kept unchanged, discontinued, or altered.
As participants worked through the exercise scenario, they could observe their nurse staffing needs as compared to their nurse staffing capabilities based on the decisions they made regarding bed counts, patient:nurse ratios, work hours per day/week, and number of part-time nurses they had available. The software used during the exercise allowed participants to quickly analyze their staffing decisions and make adjustments (charts on the left are examples of the visual depictions that were provided to show the impact of their decisions).Participants could also see the results of increasing the number of available hospital beds (surge beds) versus the number of patients who required hospitalization. Shortfalls for nursing staff or available beds could then be analyzed.Consequently, numerous ethical issues were raised and then discussed regarding courses of actions that participants suggested to help resolve these problems. While this exercise looked specifically at nurses and respiratory therapists, this exercise could be applied to any of the hospital staff positions.
The exercise planning team consisted of individuals from diverse backgrounds at Purdue University including the Purdue Homeland Security Institute (PHSI) and Healthcare Technical Assistance Program (HealthcareTAP), with helpful advice and recommendations from local planning committees, and staff members at the Indiana State Department of Health (ISDH). The exercise was enhanced by several video clips depicting potential real-world situations. Assumptions for severity of the exercise pandemic were derived with help from ISDH and were similar to those occurring in the 1918 influenza pandemic. Additionally, methodologies from the CDC Flu Surge 2.0 models were combined with county populations to predict numbers of those who would be sick, those needing hospitalization and ultimately, death rates.
The exercise was very successful. Many county hospital and healthcare providers, as well as emergency management personnel, and key decision makers were in attendance and assembled to work through various challenging scenarios. Members from state agencies were present and contributed to the overall success with their inputs and observations. We were also fortunate to have two members from the Centers for Disease Control and Prevention (CDC) observing one of the exercises. To the question of "How satisfied were you with the TTX overall", the average response of all participants was 4.7 out of 5.
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- Crane Naval Surface Warfare Center
- Department of Homeland Security
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- Indiana Department of Homeland Security
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- Indiana State Department of Health
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