Form Approved
OMB No. 0990-0391
Exp. Date 05/31/2018
(Major incident-specific collections: Up to two times a year, in cases of a major public health emergency [e.g., severe flu season], the voluntary panel participants will receive a survey based on the ongoing collection survey that addresses healthcare issues specific to that emergency [e.g., practices used to treat patients, resources running low]. Questions in this instrument will vary based on the major incident. Questions will include none, some, or all of the questions in the ongoing collections survey, plus incident-specific questions that gather more details about the specific incident.)
SYSTEM TEST: A PULSE For U.S. Hospitals' Stress Level |
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Background: On a daily basis, we know that the healthcare system is often stretched beyond its conventional capacity and capability. Surge capacity occurs across a continuum that is often based on resource availability and demand for health services. One end of the continuum is defined by conventional responses - the maximal utilization of service usually provided in healthcare facilities; at the other end of the continuum is crisis care, when the care provided is the best possible given very limited resource availability. When disaster events or incidents occur, Hospitals and Emergency Departments may be further challenged with even more resource imbalances than their normal conventional or contingency status. To that end, it is useful to periodically query frontline clinicians to assess how stressed their current healthcare delivery setting is. The USCIIT Program for Emergency Preparedness (USCIIT-PREP) asks for your responses to the questions below.
Individual site data are not reported; only AGGREGATED DATA BY REGION are reported.
Please DO NOT forward this email.
Please complete by [DATE AND TIME]
Please provide your participant information
Institution
City
State or Territory
HHS Region (Automatically completed)
I would like to receive the results of this query:
Yes
No
Your Primary Role
What is your primary practice setting?
ED and ICU
Emergency Department (ED)
Intensive Care Unit (ICU)
Other (please select and define below, free text box will appear
Are your patients primarily pediatric?
Yes
No
Base Questions: None, some, or all of these questions will be included or removed based on the emerging public health need.
Variable Questions, based on participant response to question: What is your primary practice setting?
Emergency Department (ED) Setting
TODAY, is the ED bed capacity in the primary hospital that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
TYPICALLY, is the ED bed capacity in the primary hospital that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
At the time that you are responding to this poll, what is the number of ICU patients in the ED waiting for ICU beds?
Intensive Care Unit (ICU) Setting
TODAY, what is the ICU (Med-Surg) bed capacity in the primary unit that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
TYPICALLY, what is the ICU (Med-Surg) bed capacity in the primary unit that you serve:
Under capacity
Appropriate balance
Over capacity
On diversion
At the time you are responding to this poll, is the number of patients requiring mechanical ventilation in your unit (demand versus supply):
Under capacity
Appropriate balance
Over capacity
On diversion
At the time you're responding to this poll, what is the total number of patients in your ICU on invasive mechanical ventilation?
At the time you're responding to this poll, what is the total number of patients in your ICU?
Resources
In your primary role setting, are you experiencing any of the following resource shortfalls? (If information not available, please leave blank)
Staffing
Supplies
Space
Other type of resource shortfall
No resource shortfalls
Major Incident-Specific Questions: A series of questions specifically developed to address the needs of the incident will be included on each implementation of a major incident-specific survey. The following sections display questions for two types of incidents. Only one major incident will be covered per survey.
Sample Severe Flu Questions
In the hospital(s) you work at locally, has the impact of the flu on the health care system:
Worsened
Stayed the same
Lessened
Are the EMS systems having difficulty finding open/available hospitals above normal baseline?
Yes
No
Have Emergency Department volumes increased from baseline?
Yes
No
Are hospitals implementing surge strategies?
Yes
If yes, which strategies: __________________
No
Have hospitals cancelled elective admissions/surgeries/procedures?
Yes
No
How many hospitals are on diversion?
Is the hospital you primarily practice at overwhelmed?
Very
Somewhat
Not at all
Have clinical standard protocols been changed?
Yes
If yes, which protocols: __________________
No
Are additional ventilators needed?
Yes
If yes, how many: __________________
No
Have communities implemented alternate care or triage sites?
Yes
No
Please list any comments or concerns regarding severe flu you have at the current time:
__________________________________________________________________________________________________________________________________________________________________________________________
Sample Severe IV Solution Shortages
Has your facility recently experienced, or is currently experiencing, difficulty in obtaining intravenous (IV) normal saline?
Yes
If yes, which product(s): __________________
No
Has the IV normal saline supply adversely impacted clinical care?
Yes (Check all that apply.)
Medication errors
Delayed treatment
ED or facility diversions
Other(specify/describe)_______________________________________
No
Has your facility implemented any contingency measures due to the limited amount of normal saline?
Yes (Check all that apply.)
Substitution
Conservation
Cancellation of treatment
Other (specify/describe)_______________________________________
No
Not applicable (facility is not experiencing a shortage)
If your facility is conserving its saline consumption, which conservation method(s) are being utilized? (Check all that apply.)
Recommending oral hydration over IV
Decreasing IV flow rates
Increasing time per IV bag
Other (Please describe:_______________________________ )
Not implementing saline conservation
Has your facility recently experienced, or is currently experiencing, a difficulty in obtaining any other intravenous (IV) fluids?
Yes
If yes, which product(s): __________________
No
Has your facility engaged alternate suppliers or other facilities for normal saline products?
Yes
For sizes greater than 1000 cc IV bags
For 1000 cc IV bags
For sizes less than 1000 cc IV bags
Other saline products: ________________________________
No
Unknown
Please list any comments or concerns regarding saline supply you have at the current time:
__________________________________________________________________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0391. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/msword |
| File Title | Form Approved |
| Author | DHHS |
| Last Modified By | Bonny Bloodgood |
| File Modified | 2015-10-01 |
| File Created | 2015-10-01 |