Respiratory Surge Capacity and Capability Improvement Pilot Project – Phase II (ReSCCIPP – PII) Mitigating Gaps in Mechanical Ventilatory Capacity in New York City Hospitals Lew Soloff, MD New York City Department of Health and Mental Hygiene Healthcare Emergency Preparedness Program Web: www.nyc.gov/health/bhpp 1 Traditional Surge System 3 Components Stuff Structure Staff Focus has typically been on “stuff” 2 Critical issues in local healthcare planning seen in NYC • Short supply of health care professionals – May require reduction of services to essential non-elective levels to free personnel and equipment • If need for mechanical ventilation overwhelms staffing capacity, non-critical care professionals will be enlisted to assist in patient care, but will require training 3 Critical Care Surge Capacity • Staff, space (ICU space), and ventilator supply are limiting factors • Ventilator purchase is one method/ strategy to augment critical care capacity • DHHS Pandemic Influenza Plan (Nov. 2005), along with CDC 2006 pandemic influenza funding, provided framework and unique opportunity 4 Ventilator Logistical Issues During an Emergency • Adequate supply of ventilator circuits, heat and moisture exchangers, suction equipment and pulse oximeters must be available • Oxygen supply may be limited by events that destroy commercial infrastructure or hospital supplies (storm, flood, earthquake) – Ventilators capable of operating from compressed gas and a variety of electrical sources are preferred • Operate for 4-6 hours when electric and gas supplies are unavailable • Non-invasive mask ventilation should be avoided due to contamination in pandemic event 5 Assessing New York City (NYC) Ventilatory Capacity, 12/2005 – 11/2006 Objectives Methods Estimate Shortfalls in NYC Critical Care Capacity Conducted NYC Hospital Survey; Linked Results to CDC Planning Models Make Informed Ventilator Pilot Purchase Evaluated Ventilators With Respiratory Therapy Input; Conducted Initial Purchase Determine Effectiveness of Selected Ventilator; Plan for NYC Stockpile Evaluate Acceptability of Ventilators and Training in Hospitals 6 NYC DOHMH Critical Care Capacity Survey Results, December 2005 (N=65 Hospitals) Result Implication 2,688 full-featured mechanical ventilators Shortage of ventilators expected during influenza pandemic 1,385 full-time equivalent respiratory therapists Citywide shortage in respiratory therapists; need to cross-train staff 3 (5%) hospitals familiar with ventilators in the U.S. Strategic National Stockpile (SNS) No clear advantage to use or stockpile vents in the SNS 49 (76%) hospitals willing to store, Most hospitals willing to build maintain & train staff on new vents hospital-based cache 60% of ventilators in average daily Maintaining essential medical services will require vents for nonuse during 2004-2005 flu season pandemic illnesses Source: NYC DOHMH 2005 Critical Care Capacity Survey 7 Ventilator Assessment Objectives • Estimate shortfalls in New York City hospital critical care/ventilatory capacity • Make informed ventilator pilot purchase • Determine effectiveness of selected ventilator in hospital setting prior to making a larger stockpile purchase 8 Issues Informing Choice of the Versamed iVent 201 as the NYC Surge Ventilator • Easy to use • Adequate alarms to include loss of power source, high and low pressure and disconnect • Evaluation of which ventilator to purchase included critical care physicians, respiratory therapists and local disaster management teams • It was determined that ventilators used for transport often do not offer the parameters needed for prolonged ventilation 9 The Because every breath is impertent. 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Glee I.p-In-dele end redJeelhe reed Ier new new qulernenl end Llee ene- rneehlne eerIer nI :dluelI:ne rrnn1 EHE end EU renand end 10 Respiratory Surge Capacity and Capability Improvement Pilot Project – Phase I (ReSCCIPP – PI) • Results of our survey, in context with projected gaps in citywide ventilatory capacity, supported the development of a citywide ventilator stockpile. • The effective use of stockpiled ventilators by hospitals would require – staff familiarity with ventilators – effective training materials – an understanding of citywide plans to supplement existing hospital resources 11 Hospital Feedback During ReSCCIPP - PI • 24 selected hospitals provided feedback on ventilators over 9 months – Total 498 patients – Total 23,774 hours of ventilator use in varied settings: • • • • • Transport ED/ICU Pediatric Adult Chronic care 12 ReSCCIPP – PII Project Objectives • Supplement existing NYC ventilatory capacity • Continue to evaluate the use/acceptability of these ventilators in multiple hospital settings • Increase familiarity with the surge ventilators purchased by NYC for a surge event • Develop a closer working relationship between DOHMH and NYC hospital respiratory therapy departments • Continue to evaluate Versamed’s training and supporting materials that will be provided to respiratory therapists in a “train-the-trainer” format 13 Deliverable I: Receipt of Versamed iVent 201 ventilators and related DME • Delivery will take place as part of a logistics and delivery drill • Location of delivery at hospital determined by information provided for receipt of SNS assets • Responsibility of hospital to move ventilators from point of delivery to Respiratory Therapy Department in timely manner • Deliverable documentation: Ventilator receipt documentation; this documentation must be provided to DOHMH within 8 hours of delivery as part of drill • Reimbursement: $2,000 • Tentative deadline: Date of drill (early to mid August 2008) 14 Deliverable II: Training of Staffed Respiratory Therapists • Versamed will conduct a train-the-trainer course on the use of the iVent 201 on-site at each hospital • This course is designed to facilitate training of other respiratory therapy department staff on the iVent 201 • At least 4 full-time respiratory therapists based at/staffed by your hospital must receive this course • Deliverable documentation: Training sign-in sheets and certificates of completion • Reimbursement: $2,500 • Tentative deadline: October 3, 2008 15 Deliverable III: Evaluation of Ventilators • Completion of Patient Encounter Evaluation Forms for each iVent 201 patient encounter • Participation in bi-monthly conference calls with DOHMH • Completion of Final Project Evaluation Form • Deliverable documentation: Submission of all completed Patient Encounter Evaluation Forms on at least the 3 designated submission dates; DOHMH record of participation in bimonthly conference calls; submission of Final Project Evaluation Form for your hospital • Reimbursement: $6,500 • Tentative deadlines: November 28, 2008 (1st submission milestone for Patient Encounter Evaluation Forms); May 29, 2009 (Final Project Evaluation Form) 16 Deliverable IV: Just-in-Time Training of Non-Respiratory Therapist Hospital Staff • Using quick-reference cards and a training CD provided by Versamed, develop and conduct training of at least 20 non-respiratory therapy staff on the use of the iVent 201 • Trainings must be conducted by the hospital respiratory therapists who completed the train-the-trainer course provided by Versamed • Deliverable documentation: Sign-in sheets from training sessions; signed certification sheet of staff basic competency with the iVent 201 • Reimbursement: $4,000 • Tentative deadline: April 30, 2009 17 Where We Are in the Process • The 21 selected hospitals have been notified • Delivery of ventilators and DME to all hospitals will occur on the same day in August at a date TBD with Versamed—this will be part of a functional exercise involving multiple agencies • Versamed will schedule dates for training of respiratory therapists with each hospital • Patient Encounter Evaluation Forms and materials for just-in-time training will be forwarded to hospitals • Next conference call regarding ventilatory delivery will occur in late July/early August 18