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Koenig_and_Schultz_s_Disaster_Medicine_Ch_3.pdf

Surge Capacity

Donna Barbisch, Josef Haik, Ariel Tessone, and Dan Hanfling

“On March 11th, 1918 – an Army private reported to the camp hospital before breakfast. He had a fever, sore, throat, headache . . . nothing serious. One minute later, another soldier showed up. By noon, the hospital had over a hundred cases; in a week, 500 . . . Over 11,000 peo- ple would die in Philadelphia alone that October . . . In 31 shocking days, the flu would kill over 195,000 Americans. It was the deadliest month in this nation’s history”.1 It was not only happening in the United States, it was hap- pening all over the world.

Developing the capacity and capability to handle a rapid increase in demand for patient care and public health services related to disasters or significant events impacting the healthcare commu- nity has become known as medical surge. The need for surge capacity is characterized by a mismatch between patient care needs and the capability and/or capacity to fill those needs during a catastrophic medical event. Figure 3.1 demonstrates a national response. Health and medical needs rise sharply after an event. Local response rises to meet the demand but becomes exhausted and begins to degrade after 24 hours. Preincident capacity for routine services is reduced in the immediate aftermath of a disas- ter. National and other external resources are activated and arrive after approximately 72 hours. The gap in requirements or needs compared with the capability is the surge requirement.

Significant effort has been placed on developing concepts to build medical surge capacity. The World Health Organiza- tion (WHO) identifies capacity building within the public health infrastructure as a global responsibility for all countries. In the 2005 Global Health Report, WHO outlined core capacity require- ments that all countries must meet to detect, assess, notify, and report events covered by the International Health Regulations.2

Capacities identified in the Global Health Report include

■ Components such as building or strengthening national pub- lic health institutes

■ Ensuring that national surveillance and response systems use internationally recognized quality standards

■ Strengthening human resources capacity through training programs in intervention epidemiology, outbreak investi-

gation, laboratory diagnostics, case management, infection control, social mobilization, and risk communication

■ Using WHO indicators to conduct regular assessments of core capacities to monitor progress and assess future needs

The complexities and interdependencies of the healthcare environment present considerable challenges in developing a viable and cost-effective, sustainable medical surge solution. Limited evidenced-based data exist on the efficacy of proposed interventions. Standard healthcare practice based on individual care does not transition easily to population-based best out- comes decision making; the approach to surge requires a change in perspective on healthcare management. Understanding the essential elements in developing surge capacity and developing a system to balance the rapidly increasing demands given the limited resources available is critical. A comprehensive approach will build resiliency into the healthcare system and optimize outcomes when patient care needs exceed capacity. A focus on resiliency in healthcare management will not only facilitate best outcomes during the event, it will develop the ability to maintain nonevent-related essential services during the surge and promote rapid recovery in the aftermath of the disaster to restore pre-event healthcare services. A comprehensive surge system consists of well-balanced capacity and capability in personnel (staff), sup- plies and equipment (stuff), and physical structure and manage- ment infrastructure (structure).3–4 This 3S Surge System will be described in detail in this chapter.

OVER V IEW OF THE PROBLEM

When the numbers or types of patients overwhelm the medical system’s capability, existing competence, or capacity, the time- sensitive ability to manage healthcare resources must surge to meet demand to optimize patient outcomes. In certain situations, some patient care capacity or capability may be underutilized whereas others are exhausted and overwhelmed. Balancing needs and resources to affect best outcomes is challenging.

Incidents requiring surge capacity fall into a spectrum of scenarios that may have low-complexity/high-numbers such as

33 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 06:57:16.

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34 ■ D O N NA BA R B I S C H, JO S E F HA I K, AR I E L TE S S O N E, A N D DA N HA N F L I N G

Event

Pre-Incident Capacity

O pe

ra ti

on al

R es

po ns

e L

ev el

Initial Local Surge

2 12 24 36 48 60 72 5 days 7 dayshrs

Adapted from SBCCOM Biological Warfare Improved Response Program

National and Other External

Support

Health and Medical Needs

Days to months (pandemic influenza)

Figure 3.1. Medical surge.

some blast events, high-complexity/low-numbers such as motor vehicle collisions, or high-complexity/high-numbers as is pro- jected in a pandemic influenza (Figure 3.2). “Complexity” in this context refers to the degree of difficulty in treating patient injuries. Many low-complexity/high-numbers events are charac- terized by a significant number of minor injuries that stress emer- gency triage capability. The event is localized and the majority of patients can be treated as outpatients. In high-complexity/low- numbers events there are fewer patients, but each patient requires intensive medical attention stressing critical care resources. In the preparation for mass burn events for example, although the numbers traditionally are relatively low (e.g., in Israel only ∼9% of all terror and warfare injuries are burn related) the complex- ity of the injuries and the durations of stay are usually higher. Following detonation of an improvised explosive device, burn surge may move into the high-complexity/high-numbers cate- gory. In highly specialized treatment areas, required personnel, supplies, and accompanying expenses (e.g., imaging and labo- ratory studies) are increased compared with other mass trauma incidents or infectious outbreaks.5 Hick et al., addressed the issue of specialized evaluation or interventions, a category under which most major burn patients will fall.6

In high-complexity/high-numbers events, such as pan- demic influenza and other infectious diseases, the projected

requirements stress multiple geographical areas simultaneously across a wide region of the healthcare community. Mutual aid agreements and the promise of support from governments and other entities capable of directing resources may be unavail- able. Communities may be “on their own” to manage the surge in healthcare requirements. These complex events may be par- ticularly challenging due to the shift in some systems toward managing fragile patient populations as outpatients with home health services that may include oxygen therapy, dialysis, and even in-home ventilatory support.

In prolonged or escalating events, an integrated approach is essential to coordinate and share resources. Even under “normal” conditions, some nations face extreme shortages of emergency resources. This includes developed countries like the United States where diverting patients to other hospital emergency departments due to crowding is common.7 As disasters esca- late it is imperative to recognize that medical and health needs will exceed healthcare resources.

In the management of surge, a transition is necessary from individual-based care to a population-based best outcomes approach. Healthcare professionals will be faced with ethical dilemmas in determining how to allocate scarce resources (see Chapter 5). Population-based triage protocols require shifting resources to achieve the “greatest good for the greatest number.”

Increasing Numbers (capacity)

Motor Vehicle Collision

Increasing Complexity or Acuity (capability)

Pandemic Influenza

Normal

Burns

Humanitarian Disasters

Figure 3.2. Spectrum of incidents requiring surge capacity.

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 06:57:16.

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SU RG E CA PAC I T Y ■ 35

This means that individual patients with little to no chance for survival may receive “comfort care” only and not be allocated resources for resuscitation.8 Developing guidelines to support a shift in focus from optimizing individual to population outcomes is essential.9

Existing guidelines for building surge capacity (particularly over a prolonged time period) are limited. The State of California developed comprehensive surge capacity standards and guide- lines in 2007–2008 with the input of a broad group of stakehold- ers from both government and the private sector. These experts addressed issues of worker liability, reimbursement, development and operation of alternate care sites, and surge plan templates for healthcare facilities and communities.10

The U.S. national planning effort has identified medical surge as one element of a Target Capabilities List.11 The list, a compan- ion to the U.S. National Preparedness Guidelines,12 is contained within guidance from the Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (known as “ASPR”). ASPR provides resources to eligi- ble jurisdictions for medical surge capacity and capability to sup- port, but not supplant local jurisdictions. Department of Health and Human Services also houses the Centers for Disease Control and Prevention (CDC), Public Health Emergency Preparedness Cooperative Agreement Program.

The Target Capabilities List is intended to cross-reference capabilities in the health and medical arena. The list of health and medical capabilities is not all inclusive; this can lead to criti- cal points of failure when it is used as a sole planning document. The CDC and ASPR programs provide funding linked to surge capacity planning. The original U.S. Hospital Preparedness Pro- gram (HPP) focused on increasing hospital surge capacity by 500 beds per million population. The 2007 HPP identifies priorities associated with bed tracking, medical evacuation and facility management, rapid distribution and administration of medical countermeasures, effective utilization of mobile medical assets, interoperable communications systems, advanced registration of volunteer healthcare professionals, fatality management, alter- nate care sites, and decontamination and personal protective equipment.

The programs provide funding linked to objectives; however, the measurement of the objectives is highly subjective. The 2007 HPP provided funding of $415,032,000 to eligible jurisdictions13

and the CDC awarded more than $896,000,000 for public health preparedness to improve national preparedness and strengthen medical surge and mass prophylaxis capabilities.14 The public health emergency preparedness focus was on chemical events, laboratory readiness, improved coordination of public health and medical services, increasing proficiency of volunteers, and increasing the numbers of skilled and experienced physicians.

In 2004, the U.S. Government Accountability Office reported that public health response capacity was improving but much remained to be done.15 To date, limited evidence-based data exist to determine whether the large amount of money expended in an effort to improve U.S. capabilities related to public health emergencies represent an investment that will improve out- comes.

Barbisch and Koenig describe a comprehensive approach to providing appropriate capacity or capability that takes into consideration the required supplies and equipment (stuff), the personnel (staff), and the physical space and management sys- tem (structure) to form a Surge System.16 The system must be developed with evidence-based practice guidelines to achieve a

seamless and scalable capability that will optimize outcomes in any given scenario whether of short or prolonged duration.

Defining Surge Capacity

The complexities surrounding surge capacity start with the myr- iad of definitions related to medical surge. In its broadest context, Webster’s dictionary defines surge as “a sudden rise to excessive or abnormal value.” Capacity is defined as the “facility or power to produce, perform, or deploy capability.” In its generic form, it can be said that surge capacity is the ability to rise suddenly to an excessive or abnormal value to produce, perform, or deploy a capability. Surge definitions have evolved from a number of dif- ferent perspectives. Surge can be defined relative to a practice set- ting, such as hospital, laboratory, emergency department, home health, and so forth; event type, such as blast, chemical, pandemic influenza, and so on; or magnitude of the requirements, such as daily surge or disaster surge. Daily surge is encountered regularly in chronically crowded emergency departments and some would argue that it is a predictable and manageable event and there- fore the term could be considered a misnomer.17 Disaster surge involves complex issues not encountered in daily situations. Dis- aster surge requires a shift from focus on best outcomes for the individual patient to a population-based best outcomes model.18

Medical surge, in general, refers to an increase in patient flow above the norm and is characterized by an imbalance between resources and needs.

Kelen and McCarthy define surge as “a sizable increase in demand for resources compared with a baseline demand.”19

Related to healthcare, surge implies this increase in demand is for medical or public health resources. In addition to influx (volume rate), surge is further composed of the following com- ponents: event (type, scale, and duration) and resource demand (consumption and degradation). They define surge capacity as “the maximum potential delivery of required resources, either through augmentation or modification of resource management and allocation.” Barbara et al., describe a tiered system of surge capacity focused on geographical integration. Barbara’s model differentiates between capacity and capability, identifying capac- ity as the ability to evaluate and care for a markedly increased volume of patients that exceeds normal operating capacity, and capability as the ability to manage patients requiring unusual or specialized medical evaluation or care.20

The U.S. Targets Capability List defines medical surge as “rapid expansion of the capacity of the existing healthcare system in response to an event that results in increased need of person- nel (clinical and non-clinical), support functions (laboratories and radiological), physical space (beds, alternate care facilities) and logistical support (clinical and non-clinical equipment and supplies).”21

The California Department of Public Health describes healthcare surge by stating that following a significant emer- gency or circumstances, “the healthcare delivery system has been impacted, resulting in an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources, and/or emergency medical services.”22

The multitude of efforts to define medical surge is indica- tive of the challenges in describing a comprehensive approach to managing the overwhelming medical needs in an escalat- ing event. The common element in existing definitions refers to patient care needs exceeding medical and health resources at a

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36 ■ D O N NA BA R B I S C H, JO S E F HA I K, AR I E L TE S S O N E, A N D DA N HA N F L I N G

Stuff

Staff

• Link Existing Personnel • Volunteer Coordination

Facilities • Hospitals • Clinics/Procedure Facilities • Mobile (tents & trucks) • Buildings of Opportunity

• Supplies and Equipment • Minimum of 72 hour

Expendable Supplies

The system must coordinate and balance across all domains

Structure

Figure 3.3. S-3 Surge System logistics management challenges.

given point in time. What is left to be determined is a consensus on how to meet those needs.

CURRENT STATE OF THE AR T

Prepared for What?

In developing a resilient strategy to manage healthcare surge, the first objective is to gain an understanding of “prepared for what?” Because of the variety of events that could require a rapid increase in healthcare resources, it is critical to develop a com- prehensive approach to “what” needs the preparations address. If the definition of “what” is limited to individual care associ- ated with a specific event, or a specific capability, there is a risk of increasing capacity in one area and unintentionally disabling capacity in another as the event evolves. Consider a hospital plan that redirects home health staff into the hospital to increase the hospital’s capacity to manage individual care. Although the shift in personnel may increase the in-hospital care capacity, if the needs continue to rise and the hospital must discharge patients to home healthcare, the overall system’s patient care capacity will be reduced due to insufficient numbers of personnel working in the home health environment. Planning for one area without con- sideration of the impact in another area creates critical points of failure that reduce overall healthcare system surge capacity. The planning must be comprehensive, community based, and coordi- nated at the regional, national, or international level depending on the type and size of the event.23 Hence the “what” can be defined as optimizing a population-based best outcome, scalable system.

Outcomes-based Planning

A lack of consensus exists on what is or what should be measured and what “population” is being served. Evidence-based data on the efficacy of proposed solutions to prepare for peak events at all levels (local, regional, national, or international) are incomplete. How can it be determined that plans will achieve the goals? Is the purchase of ventilators or a list of volunteers an adequate measurement of medical surge? It is not how much equipment is

available, but rather how well the population is served that must be measured. Is it best outcome for the patient, the provider, the institution, or the population as a whole? The objective in medical surge must be best outcomes for the entire population.

Outcomes-based planning is a multidimensional process that starts with an accurate assessment of overall surge requirements, a realistic measurement of overall capability and capacity, and the potential impact to the overall system as a result of the inter- ventions. Identifying the type of patient care required is not enough. A determination of how much care will be needed and how quickly it must be provided to be effective must be con- trasted with what can reasonably be accomplished considering the available resources. Once the needs are identified, the time- line of delivery is critical and must match the rapidly escalating requirements.

Because surge capacity can be applied to numerous diverse scenarios with overwhelming requirements in both impact and complexity, solutions must transition from individual-based best outcomes to population-based best outcomes as limitations in resources escalate. Triggers to shift from an individual patient to a population-based focus are ill defined. Furthermore, in a prolonged event such as a pandemic, there may be multiple shifts back and forth between baseline operations and periods of time when allocation of scarce resources demand a population-based approach.

Koenig and Backer coined the term “crisis standard of care” to describe the clinical practice in the setting of a catastrophic disas- ter.24 The shift to improving population-based outcomes occurs when healthcare needs exceed currently available resources. The mismatch occurs when any of the 3Ss of a surge system (staff, stuff, and structure) are insufficient (Figure 3.3). The lack of, or limited numbers of, qualified personnel (staff) in public health and specialty service (e.g., trauma, burn, or surgical services) or generalists in large-scale events can impact surge capacity. Limitations in surge capacity may be due to supply or equip- ment (stuff) shortages such as specific antidotes, respiratory equipment, or monitors. The mismatch can also be due to limi- tations in the physical space available for patient care and related services (structure) such as the number of functional hospitals or alternate care sites in an area, the capacity of the laboratory

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SU RG E CA PAC I T Y ■ 37

infrastructure to process specimens, or the mismatch of facil- ities designed for specific needs such as critical care or burn care, or nonacute and long-term care facilities. The most critical element is the system itself, which is used to manage all of the resources. Ventilators without personnel to operate them or a mass care arena without pharmaceutical support lack the ability to improve outcomes. Effective surge capacity requires a systems approach and a process to transition between differing surge numbers and complexity levels.

Given the interdependency of the various elements of the healthcare environment, a significant challenge exists. A rapid increase in demand superimposed on existing healthcare short- ages, just-in-time inventory, projected breakdowns in the supply chain, personnel shortages and capability mismatch, and the dire consequences of limitations in healthcare make the concept of healthcare surge capacity extraordinarily complex. If not consid- ered, these interdependencies can lead to critical points of failure resulting in a total systems breakdown. Proposed solutions in one area often create cascading untoward effects in other practice set- tings or parts of the surge system. Surge concepts are generally defined relative to the needs of a specific practice setting such as a hospital or the public health community, or specific elements within those communities: emergency departments, intensive care settings, home health, hospice, and so forth. Other surge concepts have been developed relative to the type or cause of injury or illness, for example trauma, burn, and infectious dis- eases. If uncoordinated, multiple entities can be competing for the same resources rather than complementing each other.

Consider the assumptions used to decide where to manage a critical care patient when both the emergency department and the critical care unit of a hospital are filled to capacity. There is an understanding in both environments that the patient will not get optimal care if the appropriate stuff, staff, and structure are unavailable and if the system is not coordinated to provide all of the patient’s necessary services. In some cases, patients are placed in hallways without essential requirements while awaiting appropriate care environments. The practice begs the questions: Which environment will create the best outcomes for the patient, for the other patients, for the staff, and overall for the hospital? Depending on the goal, the answer may change. In a true scarce resource environment, the goal will be to optimize outcomes for the entire population of patients rather than for each individual patient.

Challenges associated with complex issues that have incom- plete, contradictory, and changing requirements can be char- acterized as “wicked problems.”25 Defining best outcomes in wicked problems requires understanding the environment and assumptions of all stakeholders, acceptance of differing perspec- tives, and a comparison of the impact of actions that may not be optimal for each individual stakeholder, but deliver best out- comes for the community at large. Using the wicked problems approach, enduring processes can be developed to link the seem- ingly disparate influences in the health and medical environment with the desired outcome.

Assumptions in Surge Capacity Planning

Contributing to the challenges in developing evidence-based planning are commonly held assumptions in healthcare such as that the number of hospital beds is a reflection of capability or that stockpiling ventilators is a measure of readiness. Beds and ventilators are important elements of the “stuff” component of

the 3S Surge System; however, equipment does not take care of patients by itself.

Some experts suggest that field and mobile hospitals are too little, too late and cost ineffective because they arrive from 2 to 5 days after impact, well after the last casualties are evacuated in sudden impact disasters.26 Additional reports indicate that field hospitals may undermine efforts to restore services to baseline because they divert staff, supplies, and patients away from regular services in the aftermath of the disaster.27 Any plan to use field hospitals should clearly identify the types of services provided as well as the time required before the capability is operational. In addition, these resources should be as self-sufficient as possible so as not to drain resources from existing local supplies. Oper- ational plans must also specify at what point the field hospital mission will be completed because it is often uncertain when to withdraw these outside resources, particularly if their presence has provided a higher level of care than the affected population was receiving at baseline.

Measuring capacity and capability requires a review of the continuum of healthcare and the throughput of patients from the time they enter the healthcare system until they are no longer in need of care. It is incorrect to assume that if there are sufficient hospitals or hospital beds, the healthcare system is prepared. Projections for pandemic influenza suggest 30% of the U.S. pop- ulation will be ill; 50% of those will need outpatient services; more than 10% will require hospitalization; 1.6% will require intensive care; 0.8% will require mechanical ventilation; and 2% will die.28 Historical data from 1918 suggest the majority of ill- nesses will occur in a 1-month period. Figure 3.4 provides the numbers for a 1918 and a 1957-like pandemic. Several questions arise. What is “hospitalization” if hospitals are not available? How many victims will actually receive hospital care? If not managed in a hospital, where will care take place? Who will provide the care? Will appropriate triage occur to dedicate scarce resources to those who are expected to live? If not, will more suffer and die?

Using assumptions that not only project level of care but cor- relate the level of care with what will realistically be available is critical. Data on the influenza pandemic of 1918 within the U.S. show that the death rate escalated from 14/1,000 to 44/1,000 in October. It then immediately declined to 24.9/1,000 in the fol- lowing month, returning to nearly baseline in less than 2 months (Figure 3.5). With a surge in requirements of the magnitude seen in the 1918 pandemic, traditional healthcare will be unavail- able. Planning therefore should address how to optimize patient outcomes by using nontraditional care.

Finally, developing realistic planning focusing on the number of lives that can be saved or the impact on positive outcomes is critical. The assumption that everyone can be saved is false. Peo- ple will die in catastrophic events. The focus should be on maxi- mizing lives saved and minimizing morbidity given the available resources. Resources should be directed to the portion of the population who, with appropriate intervention, has the most likely chance for recovery. Plans must be not only theoretical, but based in reality.

DYNAMIC CAPABILITIES IN SURGE CAPACITY

Defining Surge Requirements

Defining evolving requirements is critical when managing an event. Several predictive models can assist planners in describing

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38 ■ D O N NA BA R B I S C H, JO S E F HA I K, AR I E L TE S S O N E, A N D DA N HA N F L I N G

Severe (1918-like)Moderate (1957-like)

6,000996Deaths

2,400216Mechanical ventilation

4,800429ICU care

30,0003,000Hospitalization

150,000 (50%)150,000 (50%)Outpatient medical care

300,000 (30%)300,000 (30%)Illness

50% of ill persons will seek medical care* Hospitalization and deaths will depend on the virulence of the virus

Population: 1,000,000

* CDC

Figure 3.4. Medical Planning Assumptions.

the magnitude of the event. The Humanitarian Assistance in Disaster Situations: A Guide for Effective Aid recommends all countries should give high priority to the preparation of their own health and medical personnel to respond to the emergency needs of the affected population and that regional coordina- tion planning should be a priority.29 The first step in plan- ning is to define projected needs or requirements. The fol- lowing models provide communities with the ability to project needs.

THE HOSPITAL SURGE MODEL

The Hospital Surge Model estimates the hospital resources needed to treat casualties arising from biological (anthrax, small- pox, pandemic influenza), chemical (chlorine, sulfur mustard, or

sarin), nuclear (1 KT or 10 KT explosion), or radiological (dis- persion device or point source) attacks.30

PANDEMIC INFLUENZA ESTIMATE MODEL

FluSurge is a spreadsheet-based model which provides hos- pital administrators and public health officials estimates of the surge in demand for hospital-based services during an influenza pandemic. The FluSurge model estimates the number of hos- pitalizations and deaths from an influenza pandemic (whose length and virulence are determined by the user) and com- pares the number of persons hospitalized, the number of per- sons requiring intensive care, and the number of persons requir- ing ventilator support during a pandemic with existing hospital capacity.31

U.S. Crude Death Rates 1917–1919

per 1,000 population*

0 5

10 15 20 25 30 35 40 45 50

Ja n

Feb M ar Apr

M ay Ju

n Ju

l Aug

Sep t

Oct Nov

Dec

1917 1918 1919 *Total Population

1917 103,265,913 1918 103,202,801 1919 104,512,110

Vital Statistics Rates in the United States 1900-1940, P 130 http://www.cdc.gov/nchs/data/vsus/vsrates1900_40.pdf

Figure 3.5. U.S. Crude Death Rates 1917–1919.

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SU RG E CA PAC I T Y ■ 39

MASS EVACUATION TRANSPOR TATION MODEL

The Mass Evacuation Transportation Model is designed for use before a mass casualty event or disaster to estimate the time required to evacuate patients and other evacuees from healthcare facilities and other locations and transport them to receiving facilities.32

At the international level, most programs focus on the coor- dination of resources at the local area of the disaster or those flow- ing into the impacted region. The United Nations’ International Search and Rescue Advisory Group provides guidance relative to assets such as country specific Urban Search and Rescue teams.33

Several evaluation tools exist. These include the Global Disaster Alert and Coordination System, a joint initiative of the United Nations and the European Commission. This system provides near real-time alerts about disasters around the world and tools to facilitate response coordination, including media monitoring, map catalogues and a Virtual On-Site Operations Coordination Center.34 The Pan-American Health Organization supported the development of a Supply Management System database to facil- itate the receipt, inventory, classification, and rapid distribution of key humanitarian supplies and equipment such as medicines, food, clothing, and blankets.35

While these templates exist, most have not been validated with respect to time sensitive delivery of resources. In many cases, the time to mobilize outside assistance exceeds that necessary to have a positive survival benefit and resources intended for response do not arrive until the recovery phase. Further research is required to develop evidence based approaches to identify which actions will deliver capability and capacity in an effective and timely manner.

According to the London Regional Resiliency Flu Pandemic Response Plan, the UK Department of Health will initiate a national ‘FluLine’ with access to algorithms that can assist in identifying protective actions for the general public. The UK plan advises symptomatic people to remain at home and “self care.” The logistical support for managing self care in the home is not identified. Primary Care Trusts (PCTs) mobilize general practitioner and primary care resources supporting and moni- toring the development of integrated health response arrange- ments, specifically antiviral collection points, the management of excess deaths, and social issues. The PCTs are also responsible for developing arrangements to maintain and support patients in a community setting and for ensuring that health plans account for the needs of vulnerable populations, closed communities such as care homes, military bases and prisons and other establishments that may require special planning.36

Within the US, many templates exist that primarily focus on the provision of necessary staffing, supplies, equipment and pharmaceuticals coupled with the structure and processes to inte- grate requirements to support a large scale disaster response. Due to their closer proximity, local and state resources will arrive to the disaster region before national assets. However local resources are limited and may be depleted by the event itself. This high- lights the critical need for contingency planning. Local planners must recognize the need to meet surge requirements without the benefit of outside resources for a minimum of 72 hours. Examples of the type of planning and the resources available can be broken down into local, regional, national, and interna- tional efforts. The following are sample initiatives from the US system. Portions of these models may be applied to global pre- paredness efforts depending on country-specific resources and conditions.

Local Surge Planning and Coordination

Metropolitan Medical Response System The Metropolitan Medical Response System (MMRS) is a

locally managed emergency preparedness and response system that is integrated into state and federal programs. It is active in over 120 of the largest metropolitan regions in the United States. Originally formed in 1996 in the wake of the 1995 Oklahoma City bombing and the Tokyo Sarin gas attacks to focus explic- itly on the traditional first responder approach to biological and chemical terrorist events, the program has evolved to be inclu- sive of all response disciplines, and has become a useful adjunct for support of surge capacity planning in local jurisdictions. The federal government provides funding linked to comprehensive plan development which is evaluated through a series of com- munity wide exercises. These focus on medical surge response, mass prophylaxis distribution, chemical/biological/radiological/ nuclear (CBRN) and other hazardous material responses and decontamination, medical supplies management and distribu- tion, emergency public information and warning, interoperable communications, isolation and quarantine, fatality management and information sharing and collaboration. The MMRS inte- grates emergency response partners within communities and their surrounding regions to develop the collaboration that is critical in events of significant magnitude. Many MMRS com- munities have stores of personal protective equipment and caches of pharmaceuticals oriented towards CBRN response that com- plement other stocks of supplies and equipment. In summary, “the Metropolitan Medical Response System (MMRS) program assists designated localities to develop and maintain plans, con- duct training and exercises, and acquire pharmaceuticals and personal protective equipment to achieve the enhanced capabil- ity necessary to respond to a mass casualty event during the first crucial hours of such an event, until significant external resources arrive and become operational.”37

An expansion model related to the MMRS was initiated in Washington DC in 2007 designed to provide the tools to manage multiple capabilities within the region and identify timely inte- gration of capabilities. The Seamless Emergency Medical Logis- tics Expansion System (SEMLES) established a program within the DC Department of Health to translate concepts into an inte- grated operational reality. The model provided a cost effective and integrated approach to synchronize parallel systems to cre- ate critical surge capacity for rapid and sustained response. The process requires extensive inter-organizational collaboration in assessing existing medical emergency capability, projecting needs in a variety of disasters and catastrophic events, and analyz- ing capability gaps. The program established a hub within the Department of Health to link resources into a modular expansion capability as needs grow. Regardless of the resource: prehospital, hospital; non-hospital healthcare; health related; or infrastruc- ture support; SEMLES enables connectivity to optimize capabil- ity. It builds on MMRS to integrate all existing local, regional, and federal programs. Despite inevitable organizational, finan- cial and political obstacles, SEMLES coordinates and synchro- nizes programs to provide a template to optimize surge capacity38

(Figure 3.6).

Alternate Care System Development: The Stratification of Care Model

Increasing attention has been given to the need to broaden surge capacity planning to include the full spectrum of patient

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• 1000 patient triage external to hospital

• 50 patient minimal care • 8 patient critical care • Isolation / quarantine capable • Mobile -can deploy anywhere

in region

Within 4 hours

Within 8 hours • Alternate Care Sites • 1000s in minimal or holding

capacity

Buildings of Opportunity, i.e. gymnasiums, hotels, convention centers

Seamless Emergency Medical Logistics Expansion System SEMLES Operations

Mobile deployable assets Available in 30 minutes

•8 critical care

• MMRS • EMAC

Regional synchronization

Optimize healthcare facility capacity DC: • 2904 staffed beds

*without federal beds

Federal Assets •PHS •NDMS •DoD

OperationalOperational HUBHUB

I. II.

III.IV.

VI.

Figure 3.6. Modular/Phased Immediate and Sustained Capability.

care delivery capabilities in a disaster impacted community. Much of this work started with a focus on alternate care facility planning for extension of hospital-like services in an unregu- lated, non-healthcare setting. Examples include the establish- ment of Federal Medical Shelters (FMS) in the US during the responses to the multiple Florida hurricanes in the summer of 2004, Hurricanes Katrina and Rita (2005) and Hurricanes Gustav and Ike (2008). The initial concepts for such planning came from work conducted by the US Army Soldier Biological Chemical Command (SBCCOM), Biological Warfare Improved Response Program (BW-IRP) in the late 1990’s. These efforts focused on a combination of out-of-hospital capabilities divided between Neighborhood Emergency Help Centers (NEHC) and Acute Care Centers (ACC).39,40 The NEHC is intended to function as a com- munity care station that provides functions including victim triage and distribution points for medical countermeasures. The ACC, similar to the FMS concept, serves as an out-of-hospital medical treatment facility for lower acuity patients not requiring a hospital critical care setting, but not well enough to be man- aged at home. Additional work in this arena continues to evolve, focusing on the spectrum of care delivery options and broad- ening the focus to a stratification of care model as elucidated in the Mass Medical Care with Scarce Resources: A Community Plan- ning Guide publication in 2007.41 Pandemic influenza planning has galvanized many communities to adopt such an approach to surge capacity planning, largely based on this theoretical framework.42

The US CDC adopted the framework for surge capacity planning, emphasizing the importance of coordinating public

health and healthcare related planning for pandemic influenza under the umbrella of a Community Alternate Care Site (ACS), comprised of community partners who are essential to deliv- ering care in the setting of a surge response to disaster (Table 3.1). The components of an ACS are built around the strati- fication of care model, with an important emphasis on devel- oping consensus based community wide agreement on the use of triage algorithms, particularly those that relate to the ethical and legal implications of allocating scarce resources in a disaster event.

Healthcare Facility Surge Capacity The implementation of surge capacity strategies in healthcare

facilities requires a graded approach using a variety of strategies. There are a number of steps that healthcare facilities can take to expand capacity over discrete time frames. There are several steps that can be taken to augment the delivery of care for an increased volume of high acuity patients. Space to deliver care, clinical staffing availability, and the critical use of supplies must all be considered. A continuum of surge capacity implementa- tion may be subdivided into conventional, contingency and crisis surge implementation.43 In turn, these respective levels of surge will be accompanied by an equivalent conventional, contingency or crisis care process to maintain the standard of care. Such an approach is based upon the recognition that not all disaster events will require the same degree of response, thus requiring a scaled approach to surge capacity implementation in the hos- pital. Examples of methods to support conventional care that are outside the normal operations of daily patient care delivery

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Table 3.1: Community Alternate Care Site Partners

Ambulatory Surgical Centers

Call Centers

Emergency Departments

Emergency Management

Emergency Medical Services

Faith Based Organizations

Home Health Agencies

Hospice Agencies

Hospital Administration

Law Enforcement

Legal Counsel

Local Government

Long Term Care Facilities

Medical Examiners Office

Non Profit Organizations

Pharmacies

Private Community Physicians

Public Health Department

Schools and Universities

Special Needs Agencies

Urgent Care Centers

Veterans Affairs Health Centers and Community Based Outpatient Clinics

include doubling of beds in single patient rooms and canceling elective surgical procedures. The other end of this spectrum, the delivery of crisis care, might involve the placement of patients in non-conventional treatment settings. In order to maximize the level of care delivered in a crisis care environment, there are a number of steps that can be taken to prepare to man- age an influx in patients requiring critical care services.44,45,46

Within the context of a surge response to a disaster event, the delivery of “emergency mass critical care” takes place in a crisis care environment. The pool of available critical care resources is limited by the disaster event, or because the total number of patients requiring such care exceeds that capacity that is nor- mally available. A deliberate framework for planning to care for patients under these circumstances must be developed prior to the onset of an event. The framework must contain clearly delin- eated plans for the stepwise expansion of critical care services outside of the normal intensive care setting. These services must provide the highest level of care that can be sustained over an extended period of time. Essential components of emergency mass critical care include the use of mechanical ventilation; the administration of intravenous fluids, vasopressors, medications to treat specific disease conditions, and adequate sedation and analgesia; and other select practices that are known to reduce the adverse consequences of critical illness. Some experts recom- mend that hospitals with intensive care units should prepare to

deliver such care for a daily critical care census that is three times their usual capacity, for up to 10 days of care delivery. Further research is necessary to validate this recommendation.

Examples of Local Level Resources and Tools

Hospital and Healthcare Facility Surge Options Hospitals and other healthcare facilities must have plans to

expand their capacity to manage a surge in the number of patients needing care during a disaster. The California Department of Public Health developed a comprehensive program of standards and guidelines, operational tools, and training materials to facil- itate planning for healthcare surge.47 Figure 3.7 reflects basic requirements for staffing when establishing an Alternate Care Site.

The US-based Joint Commission identified the following examples as options for consideration.48 Detailed planning is required to integrate the comprehensive stuff, staff and structure to meet standard of care requirements in crisis care.

SHUTTERED HOSPITALS

Hospitals that have been closed may offer an option for surge capacity. The process of opening a facility that has been closed requires considerable attention to environmental safety. Plan- ning is critical as the cost of improving the facility may be more than the cost of replacement. Recently closed facilities offer the most viable expansion solutions.

FACILITIES OF OPPOR TUNITY

“Facilities of opportunity” are nonmedical buildings that can offer healthcare facility surge opportunities. Examples include veterinary hospitals, convention centers, exhibition halls, empty warehouses, airport hangars, schools, sports arenas, or hotels. Considerations such as staffing, ease of patient care, sanitary facilities, and food service should be considered. Facilities such as day surgery centers and other existing healthcare facilities may provide options for expansion with minimal cost and effort.

MOBILE MEDICAL AND POR TABLE FACILITIES

Mobile and portable facilities build on the military model of independent hospital facilities. Many models exist commercially that may offer expansion capability. As with other options, a cost benefit analysis along with assessment of the ability to deliver care in a timely manner is critical in developing the capability.

In 2007, the state of California engaged in a program to develop three mobile field hospitals designed to provide surge capacity of 200 beds each within 72 hours after activation.49 The program provides facilities and an equipment package designed to maintain operations for 72 hours. Personnel are organized from existing resources within California. Each Mobile Field Hospital includes emergency/triage facilities, an operating room with two suites, two Intensive Care Units with a total of 20 crit- ical care beds, 180 ward beds, mobile radiology, laboratory and pharmacy supply units. Locations for the care of special patient populations include pediatric care units, obstetrics/gynecology units, orthopedic and neurology units and a negative pressure isolation ward for highly contagious patients. The units require contractor support to maintain operations such as food services, potable water service, waste water removal, trash removal, med- ical waste removal, showers, toilets, laundry facilities, oxygen

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Acceptance and Assignment of Augmented Staff During Healthcare Surge

Released

Credential Verification

Staging Area for Resources

Orientation

Released for possible future

callback

Search for Assignment AssignmentVolunteer Point of

Arrival Registration

Unaffiliated and registered prior to event volunteers arrive

Registration Information (contact, competencies, available) obtained or confirmed if registered prior to event

Individual credentials verified as necessary

Orientation and briefing provided

Update Available assignments

Available Assignments

TaskDeploymentAssignment Briefing

Temporary Release or Return to Staging Area

Incident Badging Incident transportation, training, supervision

If match for future shift

If immediate

match

If no assignment

If accepted

assignment

If false credentials

If credentials

verified

Figure 3.7. Considerations for Staff Support.

cylinder refill service and fuel delivery service for power gener- ation systems. The program was designed to support services as needed to restore or replace available hospital capability during a disaster or public health emergency.

Local Staff Support Options Staffing for surge capacity presents many challenges. Unin-

vited but well-meaning volunteers may converge on the disaster region. Often there is no plan to integrate these spontaneous volunteers into the local command and control structure and their management consumes resources that were programmed for the response. In addition to anticipating this group of vol- unteers, a better approach is to establish systems to coordinate volunteer resources prior to rather than during an event. Even with pre-event initiatives, there are difficulties related to confirm- ing current qualifications, identifying sufficient providers who are not already committed to other responsibilities, and compli- ance with existing country-specific regulations. For example, in the US, multiple entities may have requirements for credentialing personnel including states and local healthcare facilities. These initiatives are focused on identifying health personnel who may be mobilized to help support the surge in demand for patient care service delivery. State based registry systems are being estab- lished under the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) program. Addi- tional federal resources are being developed within the Medical Reserve Corps (MRC) program to identify local volunteers in the medical and public health arenas who can contribute their skills during times of disaster response. Nevertheless, signifi-

cant controversy surrounds credentialing and management of volunteers. For example, Schultz and Stratton argue that all of the currently available credentialing options have serious limita- tions that would make it difficult for hospitals to use the health care workers provided by such entities. Most of these systems require significant time to activate and implement. In addition, they don’t all provide volunteers with skill levels that hospitals can utilize. Hospitals require highly trained professionals within hours of a disaster. These two authors suggest a hospital-based credentialing system that is shared among local facilities within one jurisdiction. All credentialed healthcare providers at each hospital are listed in a database and this information is dis- tributed to all facilities. Immediately after a disaster, hospitals can consult the database to verify the credentials of volunteers in the area. This system would permit rapid credentialing of qualified volunteers in the first hours and help to maintain hos- pital function.50

Expanding scope of practice under disaster conditions is another option under development. The State of California is developing guidance with the support of professional member organizations to identify professional skills sets that could be used during crisis care to expand capability in resource constrained environments. For example, State of California paramedics are trained to give injections, but not normally permitted to adminis- ter vaccinations. If regulatory relief and training were provided, prehospital personnel could assist with mass vaccination pro- grams during exposures and outbreaks.

State Medical Assistance Teams are also being developed across the US to provide support within states rather than

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deploying to other states as has been the traditional focus. Mutual aid agreements may allow these resources to deploy to other states with approval of State leadership.

STATE MEDICAL ASSISTANCE TEAM (SMAT)

The North Carolina State Medical Response System devel- oped a deployable State Medical Assistance Team (SMAT). Their level one team is designed to provide medical care in disasters or during special events, deploy a 150-bed alternate care facility, support a Strategic National Stockpile receiving site, establish drug distribution and immunization sites and establish a field medical station capable of treating 250 patients within a twenty- four hour period. The team deploys with 12 to 54 members depending on the requirements of the emergency.51

CalMAT TEAMS

California Medical Assistance Teams (CAL-MAT) are a state of California volunteer resource designed to respond across Cal- ifornia during a state of emergency. California has three teams designed to deploy within 12 hours of notification and operate without resupply for 72 hours.52

Regional Support

Emergency Management Assistance Compacts Another important source of surge response within the US

is that provided by formal State to State requests and offers of support. After the delays in delivery of assistance experienced during Florida’s Hurricane Andrew in 1992, the Southern Gov- ernors Association created a mechanism by which states could assist one another in times of disaster. This was the origin of the Emergency Management Assistance Compact (EMAC), a congressionally ratified organization that provides form and structure to interstate mutual aid. Through EMAC, a disaster impacted state can request and, when approved by the provid- ing state, receive assistance quickly and efficiently. These process resolves two key issues: liability and reimbursement.53 EMAC is a model that illustrates how to manage the response at the low- est level possible. It provides a process to request personnel and equipment more quickly that may be available through Federal programs.

Medical Reserve Corps The MRC is a community-based program developed by the

US federal government. It is designed to organize and engage volunteers to prepare for and respond to emergencies. The MRC supplements existing emergency and public health resources. The MRC identifies specific, trained, credentialed personnel and prepares them to respond to local disasters.54

U.S. National Planning for Surge Capacity

National Disaster Medical System The National Disaster Medical System (NDMS) is a nation-

ally driven, top down program designed to provide resources to local jurisdictions upon their request, in the event of a disaster. It was established in 1984 as a partnership between the Depart- ments of Defense, Veterans Affairs, Health and Human Services, Federal Emergency Management Agency, and private hospitals. The program evolved from the Contingency Hospital System

designed to provide medical care for military personnel return- ing from overseas conflicts. Originally focused on transport of patients and bed capacity at definitive care sites, the program expanded in 1997 to include deployable teams designed specif- ically for domestic emergency medical response. Lead respon- sibility resides in Department of Health and Human Services. The Homeland Security Act of 2003 transferred oversight for the NDMS to the Department of Homeland Security, however this authority was transferred back to the Department of Health and Human Services by the Pandemic and All Hazards Preparedness Act of 2006.55

NDMS constitutes the primary federal response mechanism for management of mass casualty events in the United States, with focus placed on three discrete areas of response (Chapter 9). The first is the provision of deployable teams designed to provide basic emergency healthcare support in the disaster affected area. The teams mobilize under federal authority to provide support as requested.56

The second component of NDMS is that related to patient transport and the provision of medical evacuation out of a dis- aster affected area. Transport management and coordination is a responsibility of the Department of Defense with the assistance of the Department of Veterans Affairs. This includes commu- nicating onsite organization, coordination and transportation of evacuated patients from a mobilization center near the inci- dent site (e.g., a designated airport facility) to a reception site (e.g., an airport in a non-affected region of the country). DoD (USTRANSCOM) estimates that dedicated assets will be able to transport 81 critically ill or injured patients over a 54-hour time- frame. A Civil Reserve Air Fleet (approximately 1400 aircraft including 45 Boeing 767s) provides additional transportation support. The conversion of civilian aircraft to a configuration capable of supporting the transport of disaster casualties takes a minimum of 60 hours. Additional private sector assets are under contract to assist in patient evacuation including those provided by the HHS private ambulance contract and the availability of approximately 800 civilian rotor wing assets.57

The third major component of NDMS is the provision of definitive care. About 1800 hospitals have signed agreements guaranteeing a minimal number of staffed and available beds for patient placement in the event of a catastrophic event requiring evacuation of patients out of a disaster stricken region. Theo- retically, this provides a nationwide capacity for placement of approximately58 100,000 patients in unaffected regions of the US. For a widespread disaster that extends beyond a region or State or one that involves contagious or contaminated patients who cannot readily be transported to remote areas, this system would be problematic.

National Disaster Medical System Teams59

Table 3.2 contains a list of NDMS teams. A snapshot of capability of the most common teams includes:

DISASTER MEDICAL ASSISTANCE TEAM (DMAT)

DMATs are the basic team of the NDMS. As of 2009, there are 55 DMATs located across the United States, although only 24 are deemed to be operational, with demonstrated ability to deploy between 6 and 12 hours after activation. They are expected to arrive on site within 48 hours and maintain opera- tions for 72 hours without resupply. Teams consist of 35 people who are capable of providing primary and acute care, triage,

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Table 3.2: National Disaster Medical System Response Teams

55 Disaster Medical Assistance Teams (DMATs)

4 National Medical Response Teams (NMRTs)

5 Burn Teams

2 Pediatric Teams

1 Crush Medicine Team

3 International Medical/Surgical Teams (IMSuRTs)

3 Mental Health Teams

3 Veterinary Medical Assistance Teams (VMATs)

11 Disaster Mortuary Operational Response Teams (DMORTs)

1 Joint Management Team (JMT)

3 Nurse/Pharmacist National Response Team

initial resuscitation and stabilization, advanced life support and preparation of sick or injured for evacuation. DMAT members are capable of providing ambulatory care for up to 250 patients per 24-hour mission cycle, with limited laboratory point of care testing and bedside radiology services. They have the means to stabilize and hold 6 patients for extended treatment for up to 12 hours, and can support an additional 2 critical care patients for up to 24 hours. They can provide sustained ward care for 30 non-critical inpatients at NDMS designated facilities, and can augment staffing at alternate care facilities and assist with mass medical countermeasure distribution.60

DISASTER MOR TUAR Y OPERATIONAL RESPONSE TEAM

(DMORT)

DMORTs provide technical assistance and support for recov- ery, identification, and processing of deceased victims. Teams include medical examiners, coroners, funeral directors, patholo- gists, forensic anthropologists, medical records technicians and transcribers, fingerprint specialists, forensic odontologists, den- tal assistants, x-ray technicians, and other personnel. Stand-alone capability is available through Disaster Portable Morgue Units (DPMU).

VETERINAR Y MEDICAL ASSISTANCE TEAM ( VMAT)

VMATs are designed to support veterinary services during disasters or emergencies. Their capabilities include support in assessing the medical needs of animals; medical treatment and stabilization of animals; animal disease surveillance; zoonotic disease surveillance and public health assessments; technical assistance to assure food and water quality; and animal decon- tamination. The teams are organized to support the specific event and include various members of the veterinary health manage- ment community.

NATIONAL MEDICAL RESPONSE TEAM (NMRT)

An NMRT is a 50-member specialized team designed to pro- vide medical care following a nuclear, biological, or chemical incident. The team is capable of providing mass casualty decon- tamination, medical triage, and primary and secondary medical care to stabilize victims for transportation to tertiary care facili- ties in a hazardous material environment.

INTERNATIONAL MEDICAL SURGICAL RESPONSE TEAM

(IMSURT)

IMSuRTs are designed to support the US State Department. They were implemented in response to attacks directed against the US embassies in Nairobi, Kenya and Dar es Salaam, Tanzania in August 1998. IMSuRTs provide worldwide deployable medical and surgical treatment capability.61 They are supposed to deploy within 3 hours of notification. IMSuRTs are the only NDMS team with surgical operating room capability designed to provide emergency surgery, treatment, and stabilization. They deploy with all necessary equipment but are not designed to function in austere environments.

Strategic National Stockpile The Strategic National Stockpile (SNS) is a program cre-

ated in 1999 by the U.S. federal government designed to supple- ment and re-supply state and local governments with medical materiel supplies (Chapter 16). It contains antibiotics, medi- cal supplies, antidotes, antitoxins, antiviral medications, vac- cines and other pharmaceuticals. The SNS program coordinates governmental and non-governmental capabilities including the National Veterinary Stockpile, commercial business vendor man- aged inventory (VMI) process, and commercial carriers. The purpose is to integrate critical medical supplies for distribu- tion in emergencies. The program also coordinates with the research and development community to acquire medical coun- termeasures for CBRN threats and to expedite access to drugs that are not commercially available for non-research purposes. The SNS maintains 12-hour push packs that are strategically located across the US near major transportation hubs as well as forward placed caches of chempacks that are integrated into local hazardous materiel response programs. A Technical Advi- sory Response Unit (TARU) is also available to support local authorities in receipt and coordination of distribution of the SNS. The SNS also maintains Federal Medical Stations designed to provide for 250 non-acute and special needs patients over three days. The medical stations increase in 50-bed increments and contain supplies for first aid, pharmaceuticals and house- keeping.62,63

VENDOR AND STOCKPILE MANAGED INVENTOR Y

In addition to the 12-hour push packages (Chapter 16), ven- tilators and vaccines, are stored and managed under a man- aged inventory program. This consists of either Vendor Man- aged Inventory (VMI) or Strategic Stockpile Managed Inventory (SMI). When specific supplies are known to be needed in order to support the medium to long term objectives of a disaster surge response, VMI or SMI will be used to supplement the initial shipments. VMI is maintained by the primary corporate vendor under contract with the federal government. VMI and SMI supplies are designed to arrive 24 to 36 hours following the initial receipt of the push packages. The process to request SNS assets requires a request from the affected state’s public health authority through the governor’s office to HHS. The request is evaluated and upon authorization will be released for shipment. HHS maintains authority for the SNS materiel until it arrives at the designated receiving and storage site where upon it is trans- ferred to state and local authorities. State and local authorities will then begin the breakdown of the 12-hour Push Package for distribution. A Technical Assistance Response Unit (TARU), a team of medical logisticians, will deploy to assist state authori- ties in the breakdown and distribution of the stockpile.

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Table 3.3: Federal Medical Station Types

Type I: Under development to provide advanced intensive care and operating room services

Type II: Under development to provide specialty care (e.g., infectious disease isolation)

Type III: Provide basic low acuity care in a ward like setting

Type IV: Provide medical shelter for patients with chronic medical conditions

CHEMPACKS

Unlike most biological incidents, treatment must be near immediate after a chemical agent release. To address this con- cern, the US government developed a forward deployed element of the SNS in 2003 in order. Healthcare facilities and other entities voluntarily participate in The Chempack Program and receive a cache of medications configured for either hospital or out-of- hospital usage.64 The Food and Drug Administration’s (FDA) Shelf Life Extension Program was developed to address the finan- cial challenges of maintaining the program. The program was initially managed for the Department of Defense beginning in 1986, to permit select medications to be stored and used over a longer period of time than determined by the labeled expiration date.65

FEDERAL MEDICAL STATIONS (FMS)

The FMS is a federal resource designed to deploy and deliver primary healthcare services anywhere in the US. The team includes approximately 100 personnel primarily from the US Public Health Service (USPHS). The FMS provides resources for 250 stable primary care patients for three days using supplies from the SNS. FMS also may be used to support mass ambula- tory vaccination services, prophylactic medication administra- tion and prehospital triage and initial stabilization for up to 250 mass casualty patients. Facility requirements are the responsibil- ity of the local jurisdiction and include an approximately 40,000 square feet structurally intact building with electricity, heating, air conditioning, ventilation, and clean water services, bathroom and showering facilities, billeting for staff, and contracted sup- port for food, potable water, laundry, ice, medical oxygen filling, and biomedical waste disposal. They also require assistance of a 10-person set-up team. The FMS can be expected to arrive 48–96 hours from the time of request to delivery inside the continental US and takes an additional 12 hours to assemble. At the time of this writing, there are four types of FMS in various stages of development (Table 3.3).

THE CITIES READINESS INITIATIVE

In the context of biological terrorism response, the US gov- ernment initiated the Cities Readiness Initiative (CRI) to support cities in increasing their ability to deliver antibiotics and med- ical supplies to their population with 48 hours of the decision that such mass medication distribution is required. The program began in 2004 and was expanded to prepare 72 cities across all 50 states. The CRI facilitates the development of Points of Distri- bution (POD) and the policies and processes to implement mass distribution. In several jurisdictions, the United States Postal Service is the key partner involved in the distribution of phar- maceuticals, relying on mail carriers to deliver antibiotics to the homes of selected zip codes.

Additional Staff Surge Capacity

The US Public Health Service Commission Corps The US Public Health Service Commissioned Corps

(USPHS) is one of seven uniformed services within the United States. It provides public health leadership and service for federal government agencies and programs and is the medical arm of the US Coast Guard. The USPHS consists of approximately 6,000 full-time public health professionals from all disciplines.66 It has developed teams designed to augment state and local resources during emergencies.67

RAPID DEPLOY MENT FORCE (RDF)

The USPHS has five Rapid Deployment Force (RDF) teams, each with 105 multidisciplinary staff. They are designed to deploy within 12 hours of notification. The teams have numerous over- lapping responsibilities providing capabilities such as mass care in the FMS, and reinforcing staffing at Points of Distribution and Casualty Collection Points. The RDF is also capable of conduct- ing community outreach and assessments.

APPLIED PUBLIC HEALTH TEAM (APHT)

The APHT is designed to provide assistance in public health assessments, environmental health, infrastructure integrity, food safety, vector control, epidemiology, and surveillance. Their goal is to deploy within 36 hours of notification.

MENTAL HEALTH TEAM (MHT)

The MHT is designed to provide assistance in assessing stress and suicide risks within the affected population, manage respon- der stress, and provide therapy, counseling, and crisis interven- tion. Their goal is to deploy within 36 hours of notification.

US Department of Defense Surge Capacity Resources

The US Department of Defense (DoD) has a mission of Defense Support to Civil Authorities (DSCA). While the DoD has a wealth of capability, the assets are aligned with specific, primarily war fighting missions. Availability of assets is subject to national security priorities. All requests for DoD support are channeled through the National Response Framework processes. As the lead federal agency, the DHS has the responsibility for determin- ing what agency has the ability to supply appropriate assets to the affected area. DoD acts in support of domestic emergencies and never in a lead role. They do not provide support with- out requests from DHS with the exception humanitarian assis- tance of immediate response to imminently life-threatening local situations.68

Burn Surge

Although a subset of overall surge systems, the issue of surge capacity for burn casualties has some unique features and deserves special attention. A review of the detailed planning in burn surge can assist in defining critical points of failure in surge planning. Burns surge has historically been a challenge. Figure 3.869 demonstrates the number of burn patients in sev- eral events. Burns fall into the high-complexity/low-numbers spectrum under normal circumstances but can escalate rapidly given different types of scenarios. Resources for the management of burn casualties are limited and, in many countries, a system of regional burn centers exists. Specially trained staff, burn-specific

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• Café fire, Volendam, January 2001* – 245 casualties, mean TBSA 12% – of 182 admitted, 112 in ICU – 10 died, 78 transported abroad

• Night club fire, Rhode Island, February 2003** – 215 victims, 96 died at scene, 4 later – 64 sent to trauma center – 151 transported to 15 other facilities

• Matsa typhoon, 118 chemical burn casualties***

*Welling L. Burns. 2005;31:548-54. **Mahoney EJ. J Trauma. 2005;58:487-91. ***Ma B. Burns. 2007;33:565-71.

Figure 3.8. Burn-related Disasters.

supplies (stuff), and specialized units (structure) are necessary to optimize outcomes for burn patients. In addition, a manage- ment system to distribute large numbers of casualties with burns is essential.

The first step in preparing for a burn surge event should be the identification of resources available for reallocation from traditional uses including: nonburn-specialized staff who can take part in the management of burn patients (e.g., general surgeons, anesthesiologists, intensivists, general surgery nurses, intensive care nurses, postoperative unit nurses); structure: hos- pitalization capability in departments other than burn units (e.g., plastic and general surgery, intensive care units, post operative units); and stuff: medical equipment, supplies, and medications (particularly large volumes of intravenous fluids and airway equipment).

The second step should be to define the systems compo- nent, that is, which of these resources should be used in each phase of the management of the event? Burn surge, as in other trauma, has three management phases – the first is the man- agement at the scene or scenes of the incident; the second is hospital or alternate care facility management, such as further resuscitation and surgical interventions as indicated; and the third is the rehabilitation phase. During the planning phase, it is critical to define outcomes-based triage criteria by which patients would be distributed to nontraditional burn treatment areas. The first patients to be assessed are not always the ones that require hospitalization in a burn unit.

Kelen and McCarthy state “staffing for maximum known demand is not economically sound, because the physician or provider would be idle for considerable periods during lower demand times.”70 In addition, even if there were no fiscal con- straints, until new learning technologies such as virtual reality are perfected, it would likely be difficult to provide adequate training to an unlimited number of staff. In resource-constrained envi- ronments, a number of small interventions can be reserved to the highest skilled providers, in this case, the burn surgeon if available. In the initial phases, estimation of burn size and initi- ation of fluid resuscitation, escharotomies where indicated, and the decision regarding admission to a burn unit or other care location should be conducted by an experienced burn provider. Ideally, a burn surgeon should perform daily evaluation of the wounds, decisions regarding the need for surgery, and the surgery itself. In the rehabilitation phase, a different type of specialist can provide services in consultation with a burn surgeon. In general, other physicians (e.g., general surgeons, emergency physicians,

and anesthesiologists) can perform additional medical interven- tions. Thus, nonburn specialists with basic surgical skills can create surge capacity for burn patients by augmenting personnel resources. Although adjustments may need to be made in a scarce resource environment, if resources are sufficient, the following guidelines are useful in the hospital or definitive alternate care site setting

1) In the acute care phase patients should be divided into major burn patients and nonmajor/minor burn patients. Because every patient with more than 20% total body surface area (TBSA) burns requires fluid resuscitation and because escharotomies can be mandatory even in small deep burns restricted to one location, these are not optimal criteria for determining whether patients are in the “major” burn cat- egory. Rather, the criteria for a major burn patient should be – impending respiratory failure of need for mechanical ventilation; inhalation injury; hemodynamic, septic or other shock states; special body areas burned (e.g., genitalia, deep facial burns); greater than 30% TBSA; major accompanying trauma (e.g., head trauma or visceral injury); single- or mul- tiorgan failure; underlying medical conditions that indicate major systemic diseases (e.g., ischemic heart disease, diabetes with target organ damage, malignancy); or disability (e.g., paraplegia, loss of hearing). All other patients are designated nonmajor/minor burn patients.

2) Nonmajor/minor burn patients can be managed with the resources of general and plastic surgery departments by the departments staff (physicians and nurses) with regular patient to caregiver ratio. Ideally, a burn specialist should perform daily patient assessments (a ratio of up to one burn physician to 30 patients is the goal).

3) Major burn patients should be managed in a burn unit or in an intensive care unit. Postoperative units are an alternative if burn unit capacity has been exceeded.

4) The ideal burn nurse to patient ratio for major burn patients is 1:1. Intensive care, general, and plastic surgery nurses can be trained to care for burn patients if staff surge capacity is needed. In this case, one of three nurses should be a burn nurse (daily dressing changes are usually performed in teams of three, therefore a team of three nurses can treat three patients). Taking all that into account, optimally each patient requires 4.2 full-time nursing equivalents 1.4 of which are specialized burn nurses. Another requirement should be that in each shift there will be at least one burn nurse per three patients. This requirement does not change the num- ber of full-time nurses needed; however, it does require that patients are grouped into threes.

5) Exact guidelines for the rehabilitation phase are difficult to establish. Almost all major burn patients will require rehabilitation before discharge (and all will require reha- bilitation after discharge). Because most major burn patients will be hospitalized for acute care for a few weeks, there is time to coordinate rehabilitation services.

Other Considerations

Staff Augmentation of staff with expertise in burn care is a critical

element for creating surge capacity. Planning should account for the fact that some personnel will be unable (e.g., due to injury,

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death, or lack of transportation infrastructure) or unwilling to report to work during a disaster. Therefore, double or triple the number of personnel expected to be needed should be provided. To prepare nonburn specialists (e.g., plastic surgery and general surgery nurses) to assist in a burn disaster, basic burn training coupled with a rotation in a burn unit at least every 2 years is desirable. Nurses from other departments who have experience in treating ventilated patients should also be considered for pre- event training in burn management. Surge plans should specify staff members who can be allocated to assist during a burn disas- ter. These staff members should be aware of their responsibilities and trained prior to the event. Just-in-time training after an event occurs may be a useful adjunct if additional personnel are required.

Outpatients Most patients with injuries limited to burns can be managed

as outpatients. Professional triage that complies with Ameri- can Burn Association guidelines can identify patients who do not need acute care services thereby preserving staff, stuff, and structure for more severely injured patients. Community medi- cal services should be capable of treating patients with burns of up to 15%–20% of TBSA in nonspecialized body regions.

Transfer Because burn events fall under the “high-complexity/low-

numbers” end of the spectrum, highly specialized multidisci- plinary teams will be needed to manage patients from these types of disasters. If possible, patients should be transferred to an appropriate facility from the scene(s). In some cases, however, severely burned patients may require rapid transfer to a tertiary medical center after initial stabilization at a nonburn facility.

In addition to transferring patients out, resources can be brought in to augment capacity at a burn center. Local, regional, national, and even international resources may be needed in mass burn disasters. Local resources are most easily allocated and should be used first. A regional system should be in place for resource sharing. Physicians and nurses can be allocated for short periods of time based on a daily assessment of patient needs. National disaster management plans should state which backup resources are available and detail logistics for their movement to a burn center.

Duration of stay must be considered. Burn patients usually remain hospitalized well into the recovery phase of a disaster, especially when combined injuries are present. For example, in Israel 25.6% of terror-related burn casualties are still hos- pitalized 1 month after their admission.71 Two major effects of this prolonged duration of stay are continuous demand for resources including personnel, hospitalization facilities, med- ical equipment, and medications; and shifts in management strategies (e.g., increased referrals or outpatient treatment) must be initiated to maintain capacity to care for nonevent-related patients.

Building Resiliency and Sustainable Surge Capacity

The responsibility to develop surge capacity does not always fall clearly within a single entity. Each part of the system (e.g., healthcare facilities, emergency medical services, public health, and all levels of government involved in providing healthcare) must develop surge capacity that enables maintaining its own

critical functions during a disaster while simultaneously avoid- ing adding undue stress on other functions. In addition, the overall system of patient care needs surge capacity. A review of the patient care requirements from event through recovery is useful in determining how to build system resiliency and sustainable surge capacity. An outcomes-based, scalable sys- tem with capability across the continuum of care is needed along with the appropriate stuff, staff, and structure to sup- port the surge. In addition, a process is necessary to transition between individual-based care and population-based best out- comes.

Healthcare can be divided into five basic elements that pro- vide or support the continuum of care:72 1) emergency medical services (initial nonhospital care); 2) hospital care; 3) nonhos- pital healthcare (e.g., clinics, physician offices, nursing homes, home health, hospice, and rehabilitation facilities); 4) nonhospi- tal health and medical assets (e.g., public health assets, laboratory, pharmacy, radiology, occupational health, and medical supply); and 5) assets that are not health or medical, but support health and medical operations (e.g., communications, power, water, security, and transportation). Catastrophic events will require increased capacity across all elements. Depending on the sce- nario, surge capacity may only be needed for a portion of these elements at any given time.

A solution for high-complexity/low-numbers events can pro- duce the intended individual-based outcomes for those events but may fail the efficacy test for population-based outcomes in a high-complexity/high-numbers event. A transition strat- egy must be incorporated in the planning. As was identified in burn surge, a large part of the treatment can be provided by nonburn-specialized personnel, under the supervision of burn personnel.

With a clear understanding of patient throughput, incre- mental surge policies and procedures to provide capability and capacity in a timely and cost effective manner can be developed. A field or mobile hospital may represent significant capability if fully equipped and staffed with the appropriately trained per- sonnel; however, if it cannot be fully operational until days after the event, it may not be useful or cost effective. If it uses per- sonnel already engaged in other critical capability areas, it may not benefit the overall affected population. Only when the plans include a balanced and achievable 3S Surge System will the field hospital be a true asset.

Recommendations for Further Research

Evidence-based data on efficacy of interventions and best out- comes in surge capacity are limited. Modeling events that have not occurred can assist in validating assumptions. There are numerous areas of research and investigation that can add to the evidence-based data for operational planning, education of providers, and investigation into nontraditional methods of providing care. Additional research is required in healthcare management, finance, and the legal and ethical issues surround- ing surge capacity.

Realistic timelines as to how quickly resources can be deliv- ered must be developed. Further modeling of a balanced 3S approach will assist planners in developing achievable plans. A need exists for the development of triggers and transition strategies to assist in reallocation of resources as events esca- late through the spectrum of scenarios. Further studies on the

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efficacy of interventions and their impact on individual-based versus population-based outcomes are needed.

The business of healthcare management and services pro- vided should be reviewed to identify fiscal and legal issues. The California Standards and Guidelines developed in 2008 provide a good launching point to address the full spectrum of manage- ment.

Finally, a need exists to review current practices and to develop the evidence to support interventions that will improve outcomes. In May 2006, the Society for Academic Emergency Medicine convened a consensus conference entitled “The Sci- ence of Surge.” The proceedings of this multidisciplinary, multinational meeting are available at http://www.blackwell- synergy.com/toc/acem/13/11. This early work raised important issues surrounding the concept of surge capacity. The develop- ment of realistic and sustainable solutions to create surge capacity for catastrophic disasters will require much additional research.

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