PLANNING CONSIDERATIONS

Infectious Disease: Stable Covid-19 Isolation Patients : A TMTS designated for a cohort of stable isolation patients with a respiratory infection will have its own special considerations. Assume that all stable patients may need respiratory treatments, aerosolize/airborne risks, and a minimum 1-week to 2-weeks (https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html) recovery times. TMTS should have an established protocol for specimen collection to aid in the disposition of recovering patients. CDC recommends two negative nasopharyngeal swabs each obtained greater than 24 hours apart. A robust means of communications between clinical and non-clinical staff should be established at time of set-up. No visitors should be allowed.
Staffing considerations include clinical and logistic staff to rotate 12 hour shifts for up too 2 weeks. A Physician or Nurse Practitioner must be present at all times. Direct patient care providers will need enough PPE for entry and exit for each clinical shift at a minimum and a secure space for donning and doffing PPE.
All other staff should be kept separated and minimal use of PPE unless they need to enter the clinical area. Pharmaceuticals for anti-bronchospasm (e.g. albuterol) and fever (e.g. acetaminophen) is best distributed to each patient with instructions for usage as needed by the clinical providers. Protocols need to be in place for the transfer of a patient requiring higher level of care.
Protocols need to be developed for the discharge and tracking of the recovered patient. For safety purposes, all staff and patient care areas should adhere to most updated guidelines from CDC and/or Public Health, e.g. 6 feet social distancing.
TMTS Administrator and Logistics should work out the type of spacing needed to accommodate these guidelines. CDC disinfection guidance should be adhered to during the daily use of TMTS where needed and demobilization phase of the TMTS (https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/cleaning-disinfection.html).
Need to Plan/Train/Drill: The need for a TMTS will be driven by a worse-case scenario event. It is imperative that the TMTS process be deliberated and tested at the community level beforehand. The set-up and operation of a TMTS is not intuitive. Essentially, a space not designed for medical care needs to be adapted into a suitable environment to provide medical care to displaced patients, provide for their families, and support the medical and non-medical volunteers and staff that will provide assistance. This will not work without pre-planning with community partners and testing it by actually providing training and conducting exercises.
Legal/Jurisdiction Issues: There are numerous legal and jurisdictional issues that still require resolution. These include but are not limited to liability protection, worker’s compensation, standards of care, and allocation of scarce resources. These issues will be addressed; however, not having all the answers is no reason to not pursue a means to provide for the need for a TMTS in our communities.
MOUs/Site Determination: Sites should be pre-determined with MOU’s in place. A Site Selection Tool has been provided in this document. It should be utilized immediately upon the determination of the location of a TMTS. The tool will provide pertinent and essential site specific infrastructure information. This information will help mitigate site related problems and help those in command to obtain critical support to maximize sustainability.
Exit Strategy: Development of an exit strategy should begin as soon as the TMTS opens. The efforts to operate the station as well as the drain on local and regional resources require that planners understand that the TMTS is TEMPORARY. Even as patients may be pouring in, the exit strategy and demobilization, planning should be addressed during every operational period. The goal is to get every patient discharged or to a more stable place for care as soon as possible. The primary planning should limit the option of utilizing the TMTS to two weeks, though an outbreak/epidemic could require a longer plan.
Safety and Security: Safety and Security are the most important operational requirements of a TMTS. Without proper safety and security measures the welfare of patients and personnel could be in jeopardy. A security process should be set-up to: control access into and within the TMTS, identify and track patients, identify and track staff and visitors, and ensure the security of existing inventory and caches. A lock-down procedure should also be developed.  Work with local authorities prior to a healthcare surge event to address heightened security needs, or contact appropriate law enforcement personnel as soon as possible.
Level of Care:

Consider the need to provide focus for the TMTS mission. There are two distinct scenarios that could require the utilization of a TMTS.

EMERGENT:requiring a rapid deployment in response to a sudden catastrophe i.e.: earthquake. Scope of care will be fluid and based on responder medical skill level, organizational capacity of leadership, supplies and equipment, and the clinical needs of victims.
STRATEGIC: to serve a specific clinical need i.e.: palliative care in the wake of an epidemic. Scope of care could be more focused allowing for judicious use of specialized healthcare providers, specific equipment, supplies and pharmaceuticals.

The TMTS should have the minimum capability to provide both in-patient and out-patient healthcare services with the caveats of:  healthcare provider capability will be varied; and skilled providers/ equipment/ supplies will be limited. Likewise, common diagnostic tools will not be available on site (such as; X-Ray, CT Scans or blood work).  Though over time, and with sufficient support for obtaining resources many of these shortfalls can be overcome. For instance, point-of-care bedside testing for common lab tests can be done with minimal equipment. A courier service to private/community laboratories or hospitals could provide for more advanced testing.

Patient care areas can be organized in terms of triage categories. This would include: Red, Yellow, Green and Black. Also, it is best to have a separate secure area for pediatric patients and for those who may be receiving palliative care

It is most important to be flexible and able to scale up or down in any given area to accommodate the unpredictable arrival of patients with a variety of needs. Likewise, the needs of patient’s families will need to be addressed.
Assignment of TMTS roles: A clear chain of command with appropriate medical authority needs to be established as soon as possible. A sample organization chart has been provided in this guide that will assist with these designations. Medical Director. This is a challenging and difficult role, those best suited should have a background in Command and Medical Operations. All medical orders must be provided by a physician.

It is also recommended that daily operations be assigned to a TMTS Administrator. This role is best suited for a RN with charge nurse or supervisory experience or a physician with management experience.

These and other positions are delineated in the guide with accompanying Job Action Sheets.

Job Descriptions: TMTS personnel will be functioning in an unusual environment. It is crucial that every individual is provided an orientation to the environment. This includes a safety briefing, job action sheet, any event specific information, emergency procedures (for both clinical events and situational events). Further, all personal should be provided with debriefing opportunity and instructions on what to do if they encounter any health issues as a result of participation.
Staffing/Volunteer Management: Ensuring that staff/volunteers have appropriate credentials is a priority. Verification can be done through ILLINOIS HELPS or the Department of Professional Regulation. Non-medical individuals should be vetted as well. All must have a government issued ID and background checks pursued.
Just-in-time Training: The novel concept of operations of the TMTS and lack of familiarity with equipment on hand requires the provision of guidance to responders. This should include an explanation of: the command structure, current situation and patient census, the role the responder is expected to fill, strategies for problem identification and resolution, resources for operating equipment and obtaining supplies, documentation, debriefing or follow-up requirements. On-site training may also need to include; PPE (personal protective equipment), Fit testing, infection control procedures, and safety guidelines.
Documentation: Sample documents have been included in this guide. Paper records are the best option for a TMTS. A plan to store medical records should be developed. Also a patient valuables tracking system should be developed and a secure found for safe keeping of personal valuables.
Supplies and Equipment: A sample supply and equipment list is provided in this guide. This list was designed in collaboration with a team of medical experts and experienced medical disaster responders. The overall scope of the list is aimed at addressing preparedness for all hazards.  The intent is to offer support for 50 patients over a period of 10-14 days (actual support may vary based on event). The list has some specific details as well as some broad categories that will need to be addressed by local medical experts. Consider the need to provide a secure temperature-controlled environment for some supplies and pharmaceuticals. Likewise, there should be space reserved on-site for unloading and inventory storage.
Functional Needs Considerations: The needs of patients should be accommodated as best as possible. Simple things such as close proximity to a bathroom for certain patients will make patient care easier and more efficient. Patients with disabilities may require additional assistance.  Patients who speak a foreign language may require interpreters. Similarly, the pediatric area should be secure and constantly monitored. Beds for pediatric patients should be appropriate for the age and physical needs of the children.  A play area should be included if possible.
Responder Health and Safety: The TMTS may function completely with volunteers, many of whom may not reside in the local community. These individuals will require billeting, meals, showers and a separate area away from the clinical operations to rest and recuperate.
Fatality Management: A fatality management plan should be developed in the first 48 hours or sooner if necessary. Local authorities and emergency management authorities should be consulted for direction. Management of human remains will need to be coordinated with existing local and state plans.