Maurice A. Ramirez, DO, CNS, CMRO

Suge Sort and Support at Boca Raton Community Hospital

Dr. Shultz enjoyed another homecoming today as Surge, Sort and Support was presented at Boca Raton Community Hospital. BRCH was the launching point for the most successful of DEEP Centers prior programs and is always a receptive and attentive audience for these fantastic programs.

Mary once again was the perfect coordinator, even providing Dr. Ramirez a tour of the ER and Disaster Response supplies. Of course the facts learned about BRCH-ER were incorporated into the exercises Dr. Ramirez presented as he customized live on stage.

The interest in surge issues and Psychological First Aid was not limited to hospital disaster planners. A strong contingent of community clergy was in attendance and participated in every discussion and exercise.

Local Emergency Management representatives fresh from the "Mass Migration" exercise also attended the morning sessions.

As aways, Dr. Shultz was presented the "science behind the numbers" for disaster surge predictions, reinforced by Dr. Ramirez presenting the "untold pandemic predictions." Even veterans like Mary admitted to a chill when facing the "worst case scenario."

Boca Raton Community Hospital is one of the best prepared facilities the Surge, Sort and Support team has visited this month. Kudos and keep it up!

Surge Sort and Support at Homestead Hospital

Well not exactly at Homestead Hospital. Homestead Hospital is about to celebrate the move to the big and beautiful new facility so Homestead Hospital met us at the  First National Bank Building near the hospital for a wonderfully interactive installment of Surge Sort and Support.

The day's award for resilience goes to Raul who is so dedicated to his personal and professional preparedness that he attended Surge, Sort and Support after working all night as a nursing supervisor.

Keeping "Banker's Hours" allowed us as a teaching team the luxury of beginning our  training at 9:30am rather than 8:30am. A day packed with information meant we expected to end at 5:30pm rather than 4:30, but the energized attendees kept our pace energized and kept us enthralled in the Baptist Homestead Hospital experience.

It was gratifying to see veterans of Hurricane Andrew and other more contemporary disasters taking notes on such concepts as Support Centers, Family Centers and Continuous Integrated Triage.

Of particular interest was the concept of using the Family Center as a "Reunification and Discharge Center." In this model, not only is a large proportion of the surge diverted to a location outside the secure decon envelop of the hospital. This model also utilizes this location as a place to reunite patients with friends and family providing an opportunity to provide patient education in the presence of the patient's support system. Studies on aftercare patient education has long shown that education combined with simultaneous family education results in the highest degree of patient compliance and success.

Dr. Shultz and I throughly enjoyed our day with the team from Homestead Hospital. Thank you for the opportunity to share this time with you.

Surge Sort and Support at Jacksonville University

Today we had the great pleasure of spending time with the fine students of the Jacksonville University School of Nursing. These fine young people are embarking on careers of service in both civilian and military nursing. It was truly invigorating for Dr. Shultz and I to interact with such wonderful young people.

Perhaps owing to the unfortunate weather related events which occurred earlier today or perhaps it is the nature of the Jacksonville University students, but this has been the most interactive class in the past 37 training sessions. The Jacksonville University School of Nursing has a Disaster Track and eight of the "Disaster Nurses" attended and contributed their perspectives to the interactive sessions.

Given that this was a training session for fresh minds, unbiased by years of mis-information about disaster preparedness, the exercises presented unvarnished numbers for surge and an unapologetic insistence on the paramount importance of rapid and efficient Continuous Integrated Triage leading to an increased throughput created by the dedication of resources to "choke points" in patient care and information flow.

The senior students ended the day with plans to celebrate their coming graduation and the end of final examinations.

Congratulations to the graduates of the Jacksonville University School of Nursing and congratulations to Jacksonville University on their fantastic student body.

Surge Sort and Support at Memorial Hospital Tampa

Perhaps owing to the fact that the top Disaster Medical Response Team in the nation is stationed there, or perhaps because the Super Bowl is coming in the not too distant future, but what ever the cause, Florida's Tampa/St. Petersburg is fast becoming the metropolitan with the greatest number of disaster prepared hospitals.

Today Memorial Hospital hosted another Surge Sort and Support class, the 6th in nine months. Representatives from 4 hospitals and 3 emergency rooms were in attendance. As the scope of the patient surge from even a small terrorist event was described, the attendees furiously scribbled notes and sought out instructors for further discussions. Additional area training was even requested to assist in full healthcare readiness.

The concepts of alternate treatment areas and increasing surge capacity by increased throughput using Continuous Integrated Triage brought requests from the area's hospitals for more and greater depth of training in the use of Family Centers and Hospital Based Support Centers.

Dr. Shultz invited the audience to participate in a discussion of panic in the the next terrorist attacks or Katrina style disaster.

The Memorial Hospital team were great hosts as always and we again extend our thanks and admiration for their efforts in support of their community and colleagues.

Surge Sort and Support at St. Joseph's Womens Hospital

Dirk Palmer and the team at the family of St. Joseph's hospitals once again hosted a stellar audience for Surge Sort and Support. It is always gratifying be "back by popular demand" in any venue, but particularly when the message is so critical to community health and so well received.

St. Joseph's is the among that small 4% of hospitals in the Institute of Medicine reports who have achieved an operational level of Disaster Preparedness. The teams in attendance, in the midst of avian flu planning, enjoyed the detailed review and reconciliation of the varied statistics for the size of the coming pandemic.

The newest iteration of Continuous Integrated Triage and the implications of the latest NIMS Implementation Plan for Hospitals and Healthcare were the hot topics for discussion with the faculty during each break.

As always, the afternoon focus on the needs and stressors for responders and hospital staff was the most popular part of the day.

The progress in preparedness made by St. Joseph's in the months since our last visit was most wonderful to see and heartening to us as Preparedness Educators.

Congratulations St. Joseph's and thank you for having us back.

   

Surge Sort and Support at Cedars Miami

Today Dr. Jim Shultz and I had the great pleasure and honor of presenting the Surge, Sort and Support course at Cedars Miami. For us this was a great homecoming as Cedars is located next door our main offices.

As we expected, the Cedars team was receptive and enthusiastic! The constant applause enlivened Dr. Shultz to a point seldom seen even for him. Even a veteran professional speaker such as myself was moved to the edge of tears as I gave the emotional closing to a Cedars family who had made us their own.

As always, the morning began with a review of the Disaster Life Cycle and the Footprint of Disaster. Dr. Shultz reviewed the science and I provided the narrative stories to drive home the scope of the challenge. Surge capacity and Surge throughput are the themes of the mid-morning and the tidal wave of humanity Dr. Shultz presents focused the group on the need to plan for more than just the patients.

Sort (aka Triage) was yet another opportunity to introduce the newest iteration and integration of triage systems, “Integrated Triage.” The audience was enthralled as they listened to the first full scale application of Integrated Triage in New Orleans following hurricane Katrina. They then listened to the auctioneer like pace as the actual triage evaluation process was presented in real time.

Support finished out the morning with the introduction of Psychological First Aid, the Hospital Based Support Center and the Family Center. These new tools for the care and treatment of the survivors of disaster are now a part of Integrated Triage.

The afternoon, as always, focused on the responders. The aspects of Psychological First Aid turned inward on the responder and the healthcare professional began the afternoon. The ever present resilience toolbox finished the day by providing each participant with a sampling of the resources available to ensure their individual resilience.

Thank you Cedars for your hospitality and dedication.

Surge Sort and Support at VA Miami

Today it was my privilege to contribute the care of the guardians of our freedom. Today Dr. James Shultz of Miami University - Miller School of Medicine's Disaster and Extreme Event Preparedness (DEEP) Center and I presented Surge Capacity and Disaster Psychological First Aid training to the men and women of the Miami Veterans Administration Medical Center.

The morning began with a wonderful overview of the state of the VAMC system disaster preparedness and the leadership role of Miami VAMC in that national preparedness. Following this review by the VAMC administration, Dr. Shultz blew the audience away with his review of the science behind the numbers for patient surge in extreme events. I followed with a review of the real numbers of hospital beds, surge capacity and predicted pandemic flu impact. The first session ended with an interactive terrorism based surge event exercise.

• 955,768 registered  hospital beds in the United States (AHA 2005 survey)
  • 96% average occupancy at peak of cold/flu season (AHA 2005 survey)
  • Need 20% surge (191,154), but only have 4% (38,231) (HHS Pan Flu Plan)
  • Alternately HRSA recommends surge of 500 beds per 1 million (150,000)
  • Short between 111,769 and 152,923 beds
• 105,000 Ventilators in United States (Michael Olsterholm – NEJM)
  • 18% Out of Service for Maintenance and Repair (18,900)
  • 67% used on Chronic Vent Patients (70,035)
  • 105,000 less 18% (18,900) and less 67% (70,035) means 16,365 Vents for Acute Care
• 300 million people in the United States as of October 1, 2006 (US Census Bureau)
  • In a pandemic expect 33% to become ill (100 million)
  • Half will require hospitalization (50 million)
    • Only 955,768 beds total and only 38,231 available
  • Half of hospitalized will suffer ARDS and qualify for intubation (25 million)
    • Only 105,000 ventilators and only 16,365 available
  • Half of the ARDS patients will die in the United States (12.5 million)
    • Approx. 500 million will die world wide (more than the entire US population)
  • CDC Numbers:  50% of 33% = 16.5% Hospitalized
                           50% of 16.5% = 8% ARDS
                           50% of 8.25% = 4% Die

The second session of the morning featured Dr. Shultz introducing Integrated Triage which combines aspects of MASS triage, START/JumpSTART triage and Behavioral Triage. Theory was made reality by my signature story of triaging 5387 patients in the Louis Armstrong International Airport in New Orleans, Louisiana following hurricane Katrina. The session ended with an interactive triage exercise based on the first session's terrorism exercise.

The last session of the morning demonstrated the interconnection of medical and psychological first aid in every aspect of disaster medicine and disaster response. The final morning exercise reviewed the response of the group to the terrorism exercises of the morning and related them to the provision of psychological first aid.

Following a brief lunch, Dr. Shultz and I reviewed the special situations of surveillance, isolation, quarantine, decontamination and the SARS experience. The definitions of disaster, catastrophe and resilience were reviewed:

• Disaster = Needs > Resources
• Catastrophe = Needs > Ability to Respond
• Resilience = Resources > Needs - aka - Mastery Against Adversity

The rest of the afternoon was devoted to the well being of the audience. With 2007 being the Year of Resilience (unofficially), the concepts of individual and organizational stress were reviewed with the SARS experience illustrating the stressors anticipated for the coming pandemic flu.

The program ended with a review of the resilience toolbox, a set of resources to help the audience build their own resilience and ensure that Resources will always exceed Needs.

Attendees are invited to click on "Comment" to submit questions and comments to Dr. Shultz and myself. Please subscribe to this blog by email or RSS Feed to be kept up to date on answers to your questions and the questions of others from this and future presentations. If you subscribe by email, you will receive a free copy of The Original My Medical Records personal medical records software and a copy of the Integrated Triage flowchart.