3-S System.
It is not beds or ventilators alone that provide patient care. Effective management requires integration of all healthcare system components. A 3-S System’s approach addresses this challenge by integrating policies, procedures, and the Stuff, Staff, and Structure to provide realistic planning and response, creating the capability to adequately manage the crisis.2
The proliferation of large-scale events over the course of the past two decades highlights the need for planning to surge in a resource constrained environment. Increasingly, the delivery of healthcare to large numbers of victims has been a central feature of the response. Events caused by natural disasters, as well as those related to terrorist actions, contribute to a fundamental focus on integrating the provision of healthcare into overall response efforts.
In general, events fall into two distinct categories based on how the incident evolves. One event type is characterized by a slow, steady, and progressive rise in patient demand for healthcare services, such as might be seen in an emerging infectious disease or biological event. These events may be obscure and are often characterized by unusual and unclear etiologies. They develop gradually over time, plateau at some point, and then slowly recede, allowing a return toward the baseline delivery of healthcare services. The other type of medical surge event is defined by the suddenness in which its impact occurs. These events may be anticipated, as in a hurricane or cyclone, or unexpected as in an explosion or earthquake. They generate a rapid, but not usually sustained, demand for healthcare services. The need for medical services peaks much faster in these incidents than in the slow-onset event.
Most commonly, the need for medical surge is associated with a sudden-onset event, such as a blast, earthquake, or tsunami. In a sudden impact event, there is usually an awareness of the incident and the immediate need for increased medical response capacity and capability. The medical community surges to respond but resources often become exhausted within a relatively short time period. The timeline for flow and integration of external support and resources is variable and should be factored into plans. A distinct strategy for shortening the timeline includes efforts focused on pre-event planning and selective positioning of resources. While the sudden impact event is relatively finite in nature, the secondary impact of improper management can have a profound effect on the total number of casualties. An example of such an occurrence is the cholera outbreak in Haiti, resulting from the arrival of United Nations (UN) troops from Nepal that carried cholera into the country. This unfortunate consequence resulted in 657,117 cases and 8,096 deaths as of May 22, 2013.3 The return to baseline demand for medical services is dependent on the magnitude of the event and the capability of the community to restore services.4 Figure 3.2 depicts a timeline for a sudden onset event.
Surge Capacity in a Sudden-Onset Event.
The 1918 pandemic is an extreme example of a slow-onset event requiring a surge in medical services. Individuals begin presenting to the medical community with generalized complaints, an unknown etiology, and symptoms that developed over hours and days. A slow-onset event can continue for weeks to months. It may also affect multiple geographic regions, which can limit deployment of external resources from these areas to the location where the disease first appeared. Public health may be overwhelmed with demands to monitor or restrict travel (see Chapter 17) or report symptoms.
Figure 3.3 depicts a slow-onset timeline reflecting the escalation of casualties presenting to the medical community, the follow-up response of local medical resources, the point at which the local resources are exhausted, and the gap between exhaustion and when external resources may become available. The system may not return to baseline for months to years. The 2014 Ebola outbreak also illustrates these concepts, although to a lesser degree.
Surge Capacity in a Slow-Onset Event.
State of the Art
Definitions and Perspectives
In its broadest context, surge is defined as representing a sudden rise in some measurable entity to excessive or abnormal values. However, detailed approaches to interpreting this definition differ based on geographical/political areas of responsibility (local, regional, national, or international) and on the specific mission of the healthcare entity (hospital, prehospital, pharmacy, mental health, special populations, and public health). In addition, medical surge can be further defined as requiring both a medical surge “capacity” and surge “capability.” Medical surge capacity is the provision of services that are normally available from an entity to a greater percent of the population. Development of medical surge capacity recognizes that the response to a sustained or sudden increase in demand for healthcare services requires a certain concomitant rise in available surge resources including hospital beds, hospital staff, equipment, supplies, and pharmaceuticals needed to support such care. Medical surge capability is the provision of new or expanded services that an entity does not normally offer, such as burn or trauma care. This concept recognizes the need to expand capabilities to manage patient care needs, particularly those that may require unique services not generally available in locations other than specialty centers.
At the global level, the World Health Organization (WHO) approaches medical surge from a broad perspective and with regard to international laws and independent jurisdictions. Their guiding document is the International Health Regulations of 2005.5 The WHO Emergency Response Framework uses a grading system designed to: 1) inform and identify the extent, complexity, and duration of operations; 2) initiate action to re-purpose support resources; and 3) support implementation of disaster policies and procedures. Should an event occur, local WHO Country Office (WCO) staff will respond immediately, forming an initial Emergency Response Team (ERT) within the country. However the process of identifying the scale and urgency of an event, as well as the appropriate international response and authority of member nations, can take hours to days. Once the public health consequences are determined, WHO follows a two-phase surge process over 3 months to grade and manage an international response to the emergency. Phase 1 deployments occur within 72 hours to supplement the WCO; phase 2 occurs within 2 weeks of grading the emergency. Grading occurs within 24 hours of completing a risk assessment for a sudden-onset event, and within 5 days of performing a risk assessment for a slow-onset event. Figure 3.4 depicts the WHO international grading system.
WHO International Grading System.
An overview of the U.S. framework for medical surge is contained in the Department of Health and Human Services Medical Surge Capacity and Capability Handbook.6 This guidance provides organizational clarity to develop surge planning across multiple jurisdictions. It classifies groups into six tiers that range from an individual operating unit through local, regional, state, and federal efforts. Other countries and states have their respective guidance on medical surge, proposing how the jurisdictional and overlapping needs and resources can be coordinated.
When considering medical surge guidelines within specialties or practice areas, interdependencies between different healthcare groups can create cascading untoward effects in other parts of the surge system. One group’s surge strategy may conflict with that of another. Consider a hospital plan that redirects home health staff to the hospital in an effort to increase the hospital’s capacity to manage individual care. This shift in personnel may initially increase the in-hospital care capacity. However, as the need for in-patient care continues to rise, patients will require discharge to home healthcare. However, due to insufficient numbers of personnel working in the home health environment, the overall system’s patient care capacity is actually reduced. Planning for one area without consideration of the impact in another area creates critical points of failure that reduce overall medical system surge capacity. Resources such as qualified healthcare staff are mostly a fixed asset, even if one includes those who come from outside the affected disaster area in support of the response. Hospitals, public health agencies, and specific elements within communities (emergency departments, intensive care settings, home health services, and hospice facilities) must consider each other as they optimize their planning priorities. Other surge concepts have been developed to address specific types or causes of injury and illness. Examples include trauma, burns, and infectious diseases. 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 intensive care unit of a hospital are filled to capacity. Members in both environments understand that the patient will not get optimal care if the appropriate 3-S resources (Staff, Stuff, and Structure) are unavailable and if the system is not coordinated to provide all necessary services. In some cases, patients are placed in hallways without provision of all essential services while awaiting appropriate care environments. The practice raises several questions: Which environment will create the best outcomes for the patient, for the other patients, for the staff, and for the hospital? Depending on the goal, the answers 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.
Detailed surge plans are complex and challenging to implement. Specific elements of the plan can be incomplete or ill defined, particularly as it relates to the availability of actionable information that warrants a surge response effort. For example, deciding when a given healthcare organization or health system is truly overwhelmed can be difficult to ascertain. The importance of situational awareness is critical to supporting the administrative decisions needed to move toward implementing surge response plans. Yet, the communication of information that results in actions is often subject to the effects of the ensuing disaster event, and therefore may be impeded. The disrupted communication capability that frequently occurs after a disaster leads to incomplete information, and time-sensitive critical decisions must be made in a vacuum. Understanding that a health system has reached appropriate trigger points for action poses a vexing challenge, particularly when the event is unfolding and information is limited or inaccurate.
Such challenges that occur in planning for and managing medical surge are categorized as “wicked problems,” that is, those associated with complex issues that have incomplete, contradictory, and changing requirements.7 Defining best outcomes in wicked problems requires: 1) understanding the environment and assumptions of all stakeholders; 2) acceptance of differing perspectives; and 3) comparing the impact of actions that may not be optimal for each individual stakeholder, but deliver best outcomes for the community at large. Using the wicked problems approach, enduring processes can be developed to link the seemingly disparate influences in the health and medical environment with the desired outcome.
With these challenges in mind, identifying the underlying issues can be accomplished by measuring capacity and capability across the continuum of healthcare. A simple view of this approach is to consider the throughput of patients from the time they enter the healthcare system until they return to health. Using this strategy, it is clear that simply having the current level of hospital capacity (or current number of hospital beds) does not ensure the healthcare system is prepared. As an example, based on the U.S. Center for Disease Control and Prevention (CDC) influenza planning tools, projections for pandemic influenza suggest: 1) 30% of the U.S. population will become ill; 2) 50% of those will need outpatient services; 3) more than 10% will require hospitalization; 4) 1.6% will require intensive care; 5) 0.8% will require mechanical ventilation; and 6) 2% will die.8
Figure 3.5 provides the numbers for a 1918 and a 1957-like pandemic. Comparing this information with historical data from 1918 suggests the majority of illnesses will occur in a 1-month period. Data on the influenza pandemic of 1918 within the United States show that the death rate escalated from 14 per 1,000 to 44 per 1,000 in October. It then immediately declined to 24.9 per 1,000 in the following month, returning to nearly baseline in less than 2 months as shown in Figure 3.6.
Pandemic Influenza Planning Assumptions Using CDC Planning Tool FluAid.
United States Crude Death Rates, 1917–1919.
If this surge event occurred in the United States during 2014, the projected supply of healthcare resources would not be sufficient to meet the population’s medical needs in the peak month. This raises several questions. 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?
It is critical to use assumptions that not only project the level of demand for care, but also correlate such demand with what will realistically be available. With a surge in requirements for medical resources similar to the magnitude seen in the 1918 pandemic, traditional healthcare will be unavailable. Therefore, planning should address methods to optimize patient outcomes using nontraditional approaches. One model, the Seamless Emergency Medical Logistics Expansion System (SEMLES) originally designed for the Washington, DC, Department of Health in 2003, demonstrates a cost-effective and integrated approach to surge planning. The concept synchronizes parallel systems to create critical surge capacity for a 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 analyzing capability gaps. The program establishes a hub within the health department that links resources into a modular system that can expand capability as needs grow. Components of this modular system include prehospital EMS, hospitals, outpatient medical care providers, and infrastructure support agencies. Regardless of the resource, SEMLES enables connectivity to optimize capability. Despite inevitable organizational, financial, and political obstacles, SEMLES coordinates and synchronizes programs to provide a template to optimize surge capacity. (See Figure 3.7).9
Seamless Emergency Medical Logistics Expansion System (SEMLES).
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 timeframes and 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. Examples of methods to support conventional care that are outside the normal operations of daily patient care delivery include doubling of beds in single patient rooms and canceling elective surgical procedures. At the other end of this spectrum, the delivery of crisis care might involve the placement of patients in non-conventional treatment settings, referred to as alternate care sites. In addition, some experts recommend 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.
The identification and utilization of alternate care sites can support overall surge capacity. While many potential facilities exist, several offer clear advantages. The U.S.-based Joint Commission identified the following examples as options for consideration.
Hospitals that have been closed (shuttered hospitals) may offer an option for surge capacity. The process of opening a facility that has been closed requires considerable attention to environmental safety. Planning 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.
A second option, “facilities of opportunity,” are nonmedical buildings that can serve to enhance healthcare facility surge. 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.
Lastly, 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. A major problem with such facilities is not just acquisition costs, but the ongoing expense generated by maintenance. These facilities may remain unused for decades and the cost for maintaining them in a continuous state of readiness is substantial.
Staff Support Options
Staffing for surge capacity presents many challenges. Uninvited 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 volunteers, 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 confirming current qualifications, identifying sufficient providers who are not already committed to other responsibilities, and compliance with existing country-specific regulations. For example, in the United States, 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.
In the United States, state-based registry systems have been established under the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) program. Additional 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, significant controversy surrounds credentialing and management of volunteers. For example, Schultz and Stratton argue that all of the currently available credentialing options have serious limitations that would make it difficult for hospitals to use the healthcare 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 distributed 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 hospital function.10
In addition to utilization of local responders, many countries have organized deployable medical teams. In the United States, the National Disaster Medical System (NDMS) is a nationally driven, top-down program designed to provide resources to local jurisdictions upon their request, in the event of a disaster. 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. 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.
Disaster Medical Assistance Teams (DMATs) are the basic unit of NDMS and have demonstrated the ability to deploy between 6 and 12 hours after activation. They are expected to arrive on site within 48 hours and maintain operations for 72 hours without resupply. Teams consist of thirty-five people who are capable of providing primary and acute care, triage, 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 six patients for extended treatment for up to 12 hours, and can support an additional two critical care patients for up to 24 hours. Other teams with different missions also exist, such as Disaster Mortuary Operational Response Teams and Veterinary Medical Assistance Teams. Additional groups support the care of burn, pediatric, and mental health patients.
Medical Supply Surge
Options for managing increased demand for medical supplies and equipment exist and include optimizing utilization for the population instead of the individual. But scarce resource allocation protocols are only effective for a limited time. At some point, resupply is necessary. Strategies for eventually providing increased supply usually involve stockpiles.
An example of this approach is the Strategic National Stockpile (SNS), a program created by the U.S. federal government designed to supplement and resupply state and local governments with medical materiel supplies. It contains antibiotics, medical supplies, antidotes, antitoxins, antiviral medications, vaccines, and other pharmaceuticals. The SNS program coordinates governmental and nongovernmental capabilities including the National Veterinary Stockpile, commercial business vendor managed inventory process, and commercial carriers. The purpose is to integrate critical medical supplies for distribution in emergencies. The program also coordinates with the research and development community to acquire medical countermeasures for Chemical, Biological, Radiological, and Nuclear (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 United States near major transportation hubs as well as forward-placed caches of chempacks that are integrated into local hazardous material response programs. A Technical Advisory Response Unit (TARU) is also available to support local authorities in receipt and coordination of distribution of the SNS.
In addition to the 12-hour push packages, ventilators and vaccines are stored and managed under a managed inventory program. This consists of either vendor managed inventory (VMI) or strategic stockpile managed inventory (SMI). When specific supplies are required 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.
Considerations in Development of Surge Capacity
Another framework to organize and conceptualize surge suggests categorizing surge into conventional capacity, contingency capacity, and crisis capacity.11 In crisis capacity, the degraded resources force the practice environment into provision of crisis care using previously determined scarce resource allocation protocols. A key goal of the framework was to aid in phased implementation of surge capacity plans (see Figure 3.8).
Continuum of Surge Response and Implications for Provision of Medical Care under Increasingly Austere Conditions
At the individual level, a review of patient care requirements from the moment an event begins through recovery is useful in determining how to build system resiliency and sustainable surge capacity. Barbisch and Koenig describe an outcomes-based, scalable, time-sensitive system applicable across the continuum of care that will provide appropriate capacity or capability. It takes into consideration the 3-S System as previously mentioned to support the full spectrum of needs for patient care.12 The 3-S system terminology was further endorsed by Hick et al. in 2009. However, in doing so, they changed the terminology to Staff, Space, and Supplies.13 Early surge models often focused on critical supplies (Stuff) like ventilators or hospital beds while overlooking the critical need for Staff and Structure. In addition, surge planning that emphasizes the needs of only one group, such as trauma or burn patients, would overlook the secondary impact on other practice areas. As an example, the cross-training of hospital staff caring for patients in non-acute areas to also provide burn care in support of burn center personnel may seem reasonable. However, it is highly likely that during a large-scale surge, these same staff would also be overwhelmed with an increase in volume of non-acute patients and so be unavailable.
Patient care delivery requiring integrated surge planning can be divided into five basic elements: 1) emergency medical services (initial triage and treatment); 2) hospital care; 3) out-of-hospital healthcare (clinics, physician offices, nursing homes, home health, hospice, and rehabilitation facilities); 4) out-of-hospital health and medical assets (public health assets, laboratory, pharmacy, radiology, occupational health, and medical supply); and 5) assets that are not health or medical, but provide operational support (communications, power, water, security, and transportation). Catastrophic events require increased capacity across all elements. Depending on the scenario, surge capacity may only be needed for a portion of these elements at any given time. Critical issues arise when any one of the elements is mismanaged or managed in a vacuum.
Appropriate triage at the onset of the event is critical. Mismanagement of fragile populations (populations with functional or access needs) increases the risk for poor outcomes secondary to the primary event. This designation applies to those victims of disaster that are extraordinarily vulnerable members of society due to socioeconomic standing, chronic disease state, age, and other characteristics. Triage is critical to ensure that these unique populations have access to support services such as pharmacy, dialysis, and oxygen therapy. Without appropriate support, populations with functional or access needs can easily become secondary casualties.14 Development of robust community-based surge strategies that address the delivery of care to the medically fragile is an important component of developing a community’s approach to surge capacity and capability planning. A key component that contributes to this community-based approach includes the utilization of home healthcare services. Assuring the delivery of home healthcare will be an important strategy to prevent patients who might otherwise not need hospital-level care from using these critical resources. With a clear understanding of patient care requirements and the ability to develop a cohesive plan for patient throughput, implementation of surge policies and procedures will likely improve outcomes in a timely and cost-effective manner under catastrophic disaster conditions.
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