Patient Surge

One of the fundamental objectives of any emergency preparedness program is the ability to respond to surges in demand for health care. Within the realm of health care, proactive emergency preparedness necessitates planning for large-scale emergencies that affect large numbers of persons. Occasionally these events may provide some advanced warning and gradually grow in magnitude. Examples include flooding, hurricanes, or pandemics. However, much of the time, disasters provide little to no advanced warning, as is the case with tornados, explosions, or transportation incidents.

The study of medical surge capacity as a science is relatively new, and it has mostly centered on the disciplines of disaster medicine, emergency management, public health, and the military. However, the study and measurement of surge capacity presents many challenges, and it still has yet to be clearly and precisely defined. One general description of surge capacity is the “ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system.” The Joint Commission defines surge capacity as “the ability to expand care capabilities in response to sudden or more prolonged demand.” The Health Resources and Services Administration (HRSA) defines surge capacity with numeric benchmarks, such as the ability to triage, treat, or reach a disposition of 50 cases per million population for burns, trauma, toxic chemical exposure, or radiation and 500 cases per million population for infectious diseases. Another benchmark established by the Task Force on Mass Casualty Critical Care suggests that hospitals planning to provide emergency mass critical care (EMCC) should establish the capability to triple their typical Intensive Care Unit (ICU) census for up to 10 days without external support.

Currently it is difficult for individual health care organizations and regional health care coalitions to determine exactly what steps must be taken in order to define and ensure adequate surge capacity for large-scale events or how surge plans should be tailored to the size and scope of the event. Best practices in establishing surge plans, decision-triggering benchmarks, and operational procedures should be informed in part by optimal clinical outcomes in population-based care. To ensure optimal patient outcomes during the response to a large-scale mass casualty incident (MCI), surge capacity must be operationalized effectively across the community health care system, including all institutional and community-based providers. Institutional-based providers include hospitals, long-term care facilities, residential behavioral health facilities, and hospice. Community-based providers include Emergency Medical Services (EMS), public health departments, public and private clinics, urgent care facilities, pharmacies, dialysis centers, outpatient surgery centers, general and specialty private medical practices, and home health agencies.

Maintaining excess capacity for patient surge runs counter to cost-efficient business practices, and hospitals of all sizes face numerous challenges to their ability to meet surge demands. Large hospitals, especially those with specialized tertiary care services, anchor the community health care system, and consistently operate at 95% to 110% capacity already, which greatly limits a hospital’s ability to manage a large influx of critical patients. Community health care systems in rural areas are comprised of smaller hospitals, as well as smaller or nonexistent local public health departments, and may struggle with limited resources and outside support, limited and outdated communication technology, reliance on volunteers, poorly equipped emergency medical transport units, and greater distances from other mutual aid and supportive resources.

Historical perspective

Medical surge planning is a component of a more global Emergency Operations Plan (EOP), which in turn is developed under the auspices of a Comprehensive Emergency Management (CEM) program. The concept of CEM dictates that disaster management initiatives incorporate all four phases of emergency management (mitigation/prevention, preparedness, response, and recovery); maintain an “all-hazards” emphasis, engage, integrate, and coordinate with all stakeholders; identify and address all vulnerabilities; and be scalable to the size and scope of the event. Surge planning must consider both the facility-specific issues (hospitals, nursing homes, hospice, and behavioral health), as well as those pertaining to the community-wide health care system, including public health departments and community-based providers.

Institutional-based providers must be cognizant that whatever event is creating the surge may be affecting the community health care system as a whole. Therefore, participation of the entire emergency response system, as well as local and state offices of emergency management, can play a key role in helping to source additional resources. Coordinating with community stakeholders such as public health and emergency management during the planning phase provides for efficient flow of information, such as bed availability, the reporting of infectious disease outbreaks that may have implications for the overall community, and resource availability during the response and recovery phases. Other community-based agencies, such as mental health services, public health, and EMS agencies, may need to share important information that would be protected under the Health Insurance Portability and Accountability Act (HIPAA). Sharing clinical data, particularly data that have been redacted of all personal information, can support real-time awareness needed to help inform decision makers, particularly during epidemics.

Surge triggers and crisis standards of care decisions are based on critical data points. Monitoring these key indicators that govern the change from individual-based to population-based health care is most likely to be gathered, analyzed, and shared through the community’s Emergency Operations Center (EOC) during an incident. Public health should work with emergency management to ensure that appropriate data are shared to the level needed for response. Based on the typical functions of an EOC, this is the single physical location where representatives from all stakeholders within the community health care system are colocated, which facilitates the exchange of key information and the request for desired resources.

Current practice

Surge “Capability” Versus Surge “Capacity”

In the development of a surge plan, it is important to delineate between two terms that are often used interchangeably: surge capability and surge capacity . Capability is the ability to achieve a desired goal; in this case to optimize patient outcomes for the greatest number of people. Capacity is the measure of all the organizational strengths, attributes, and resources, such as additional beds, space, staffing, and supplies available to achieve that goal. In order to measure the hospital’s surge capability, its surge capacity should be viewed as a rate or throughput (e.g., number of patients that can be triaged and treated in the first hour, 12 hours, etc.).

Consider, for example, whether or not the hospital has the ability to handle a surge of 100 patients. Even if the hospital has the flex space, extra beds, cardiac monitors, etc., its measure of surge capacity is expressed by how quickly the patients can be triaged and treated and to what level of acuity. Therefore, the overall capability is a reflection of any rate limiting factor, such as lack of staffing, specialized skills, or equipment, etc.

Homeland Security Presidential Directive 8 (HSPD-8) dictates that federal, state, local, and tribal entities and their private and nongovernmental partners should adopt a capability-based planning approach in their EOPs. Therefore, capability-based planning is the foundation for federal preparedness initiatives including the Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program documents, such as the National Guidance for Health Care System Preparedness and the U.S. Homeland Security Exercise Evaluation Program (HSEEP) programs.

A capabilities-based approach (or the ability to meet an objective) provides a common standard for comparing, connecting, and guiding the dissimilar elements of an organization toward the achievement of the end objective. Whereas an objective-based approach (capacity), when used alone, may inaccurately suggest a level of performance that may not be attainable. This unpredictability is best met by planning to accomplish those objectives that the organization is actually capable of achieving, as demonstrated in full-scale exercises or past real-world performance.

If a new level of capability is desired, then the preparedness initiatives to attain that new capability must be developed, tested, and proven through a disaster preparedness cycle.

Figure 35-1 illustrates the cycle followed for building and improving disaster preparedness programs such as surge capacity. This process should be repeated, at least annually. High-impact or high-probability events (such as large mass gatherings or frequently occurring events) may require the cycle to be repeated more frequently.

Surge plans must be flexible and scalable to meet the demands of all types and sizes of incidents. The Institute of Medicine has established three basic levels of surge capacity: conventional, contingency, and crisis. Each level of surge is defined by prescribed data points of real-time situational information. This information gathered through attentive situational awareness and monitoring provides benchmarks or triggers that should prompt decision makers to declare which phase of surge the facility or community is experiencing.

The conventional level of surge would be what a facility experiences on a regular basis, perhaps during flu season or even from a multivehicle accident, and it is typically handled in-house with the staff and supplies on hand. Management strategies for conventional surge utilize the physical spaces within the facility, staff, supplies, and operational processes (systems) that are typically used in normal day-to-day operations within the institution. These are the resources that are used during a major MCI. Figure 35-2 shows a typical no-notice MCI.

The contingency level of surge requires some minor changes in operations, and some resources may be replaced with equivalent alternatives, which may result in minor impacts to standards of care. Situations that require patient triage and rationing of specialized equipment, such as ventilators, fall into the contingency level. Management strategies for surge levels involve utilizing the normal spaces, staff, supplies, and systems in a manner that is not consistent with normal daily operations, in order to provide care that is functionally equivalent to usual patient care. These in-house resources may be temporarily utilized in a different manner during a major MCI or on a more sustained basis during a disaster (when the demands of the incident exceed community resources).

Crisis levels of surge require health care leaders to enact crisis standards of care and dictate a shift from individual-based care to population-based care strategies. An event that is large enough in size and scope to cause a fundamental change in the community health care system and significantly changes the standards of patient care will force the community or facility into the crisis level of surge operations. The massive tornados in Joplin, Missouri, in 2011 and Moore, Oklahoma, in 2013, as well as Hurricane Katrina’s impact on New Orleans and the Gulf Coast in 2005, certainly created this level of impact. Major earthquakes in urban areas, pandemics, and biological attacks also have the potential for this type of impact. Crisis levels of surge require innovative use of resources that are not consistent with usual standards of care, but do provide sufficiency of care in the context of a catastrophic disaster (i.e., provide the best possible care to the largest number of patients given the circumstances and available resources).

Developing useful indicators and triggers

Surge situations by their very nature will most likely occur as part of a highly stressful situation, and both institutional and community-based health care providers will undoubtedly be affected by that stress. To provide guidance for decision makers in the middle of a crisis, surge plans should include benchmarks or triggers, to indicate when the declaration should be made as to what level of surge is currently happening. Given the number and variety of data sources, it can be challenging to identify useful benchmarks because precise numeric benchmarks are not clearly defined and easily recognized (e.g., a single case of anthrax or 10 serious patients from a vehicle crash). In many disaster situations, vague and inaccurate information, along with other real-world dynamics, may create situations that are difficult to interpret and define (e.g., an outbreak of severe gastrointestinal symptoms or unknown number of casualties from a reported tornado). Oftentimes the courses of action are not as clear-cut or significant data analysis may be required before action can be taken.

Instead of developing a cumbersome and exhaustive list of possible indicators and triggers, the Institute of Medicine suggests that it may be helpful to consider the following four steps. These steps are relevant for both slow-onset and no-notice events, applicable to all types and sizes of health care facilities, and should be considered for the transition from conventional to contingency care, to crisis care, and in the return to conventional care.

1.

Each facility or agency should identify key response strategies and actions necessary to respond to an incident (e.g., timely issuance of the disaster declaration if advance notice is possible or the recognition of the disaster, opening or staffing the EOC, multiagency coordination, establishment of alternate care sites, and surge capacity expansion).
2.

Facility leaders should identify potential indicators that inform decisions to initiate these actions; indicators may include a wide range of data sources (i.e., bed availability, public health surveillance, or notification by EMS crews on the scene).
3.

Next, decision makers should determine the trigger points or benchmarks for taking these actions. Pre-scripted triggers may be derived from certain indicators or data points. However, the data may not be sufficiently clear to support a clear decision. When pre-scripted triggers are inappropriate because the real-time information is vague or insufficient, it is important to determine and train staff on a process for identifying nonscripted triggers (i.e., who in the crisis leadership team needs to be notified/briefed, who provides the assessment and analysis of the information that is available, and who makes the decision to implement the next set of strategies).
4.

Each facility or agency should utilize its emergency management or crisis leadership team to determine the tactics that should be implemented at each corresponding decision trigger point. Pre-scripted triggers or decision benchmarks should lead to appropriately pre-scripted tactics, which will support a rapid, preplanned response.

Obviously, it is impossible to predict every type of disaster scenario, but following these steps can help in identifying key sources of information that act as indicators to help determine whether or not the available information supports decisions taken to implement (trigger) specific strategies and tactics.

Decision benchmarks or triggers should be based on the key response strategies and actions that are outlined in both the facility-specific and community-wide EOPs. One primary trigger for progression from the conventional to contingency care phase would be the activation of a facility’s EOP, especially if doing so enhances the patient-surge capacity that cannot be achieved in the conventional phase. ^,^,These types of triggers are usually tailored to the size and resources of that facility. Each facility and community should identify what the various decision benchmarks or triggers should be within their respective EOPs (e.g., on-site fire requiring evacuation within the facility, three-alarm fires in multifamily structures, second-alarm or greater EMS response, any triggers for notification of medical director or crisis leadership team, or preestablished supply consumption rates).

Regional health care coalitions that include all institutional providers, public health departments, and other community-based providers support higher levels of situational awareness, information sharing, and resource management. With preestablished lines of communication that deliver accurate, real-time situational awareness, stakeholders can be alerted when more than one coalition facility declares a disaster, when disaster victims are taken to more than three hospitals, or when staff, space, or supply shortages are anticipated. This type of real-time intelligence should also be factored in as a data point or decision trigger. The Local Emergency Planning Committee (LEPC) and Regional Health Care Coalition are both ideal venues for stakeholders to discuss, plan, exercise, and review this type of plan.

Triggers or decision benchmarks to escalate from the contingency to the crisis care phase tend to correlate to the exhaustion or overwhelming of operational resources at a level or rate that requires community-wide or regional coordination for resource allocation strategies.

While it may be an individual facility that finds itself in the crisis care phase, it is critical that the regional health care coalition and emergency management Agency become involved in order to manage the resource demands regionally and ultimately ensure that as consistent a level of care as possible is provided. Another benefit to regional collaboration among stakeholders is the likelihood that most of these triggers for lack of resources will be consistent across all facilities within the region.

Establishing decision triggers or benchmarks is a process that requires a great deal of planning and coordination. Decision makers must be able to assess, analyze, and validate incoming data in order to make an informed decision. Some triggers will be based on actionable intelligence; others may be based on predictive data. Data monitoring from more than one source generally yields information that is predictive and may include monitoring of weather or epidemiologic data. Actionable data may include regional hospital bed capacity or emergency department (ED) wait times.

The Components of Surge

Even though a single definition or measurement standard for surge capacity has yet to be developed, there is a general consensus on its key components; often referred to as the “4 S’s” for “staff,” “stuff,” “space,” and “systems.” Staff refers to personnel or manpower; stuff consists of supplies and equipment; space entails both on-site areas as well as off-site alternate care facilities; and systems comprise integrated management policies and processes. ^,^,

Staff includes clinical personnel, such as nurses, physicians, pharmacists, respiratory therapists, and allied health providers, as well as nonclinical personnel, including cafeteria, housekeeping, clerical support, security officers, and physical plant engineers.

Health care stuff or supplies include durable equipment, such as cardiac monitors, defibrillators, intravenous (IV) pumps, ventilators, blood glucose monitors, wheelchairs, and beds. Stuff also includes consumable supplies, such as medications, blood, oxygen, sterile dressings, IV fluids, catheters, syringes, sutures, and personal protective equipment, as well as food and water for staff, patients, and visitors.

The terms “space” and “structures” are often used interchangeably. Hospitals tend to be the first structures that come to mind in health care, although institutional-based providers include extended care facilities, behavioral/mental health, and hospice facilities. Community-based providers, such as community health clinics, laboratories, outpatient surgical centers, dialysis centers, private medical practices, and public health departments, also compose the structure component of surge capacity. A more global view of “structure” also includes “buildings of opportunity” that can be utilized as alternate care facilities, such as community centers, schools, hotels, churches, or other large public assembly venues. Within the contingency level of surge, “space” can also refer to areas within the hospital that can be utilized in a different capacity to support patient triage or care (e.g., large atriums, conference rooms, hallways, and covered parking areas).

“Systems” for health care surge include integrated policies and procedures that link departments within the health care facility such as establishing the Hospital Incident Command System or opening the EOC and enacting the EOPs, Continuity of Operations plans (CoOPs), and Crisis Communications plans. Even though the term systems typically refers to management processes, it can also be extrapolated to include backup infrastructure systems (electric, medical gases, water, sewer, IT, communications, and security) that are critical to continuity of operations during a disaster. Additionally, systems can refer to policies and procedures that can link the health care facility with community-based providers, including public health departments, EMS, home health care, pharmacies, and physician offices.

Each level of surge operations has associated management strategies related to the 4 S’s.

Staffing Strategies

Conventional staffing strategies involve the redistribution of staff that are credentialed and privileged at the institution before the event. During a disaster, staff members could be assigned in their usual area or assigned to other areas within the facility while remaining in assignments that are consistent with the typically assigned duties and scope of practice. The next step can be to utilize specialized clinicians in the roles of general care providers. For example, if all elective outpatient procedures have been canceled, those staff members can either be reassigned to other parts of the hospital or to provide general levels of care to patients now filling that area as surge space.

Contingency staffing strategies include augmentation of existing staff with outside personnel who have a similar level of credentials and are preprivileged or able to be privileged quickly from a partner hospital, staffing agencies with existing contracts, Medical Reserve Corps, and state or federal medical response teams. Contingency staffing may also include adding additional noncritical responsibilities to clinical providers. Figure 35-3 shows a Disaster Medical Assistance Team (DMAT) assisting with the evacuation of a patient.