Surge Capacity: Preparing for the worst-case scenario
John L. Hick, MD
Hamilton, Ontario
May 29, 2006
What defines a disaster?
Demand for critical resources outstrips availability thus putting patients or staff in danger
Goal is to plan ahead to ensure: More effective use of available resources Mobilization of additional resources
Outcome: ‘special incident’ doesn’t become a ‘disaster’
May depend on time / day / facility
Capacity vs. Capability
Surge Capacity – ‘the ability to manage increased patient care volume that otherwise would severely challenge or exceed the existing medical infrastructure’
Surge Capability – ‘the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions’
Barbera and Macintyre
Surge Capacity Partners EMS (and other patient transportation resources) Emergency Management Public Health Public Safety/Law enforcement Healthcare Systems
Hospitals and hospital associations Red Cross Behavioral health Jurisdictional legal authorities Professional associations inc pharmacy, medical,
nursing, mental health
Concepts and Principles
Standardization Incident Management System Multi-Agency Coordination System Public Information Systems Interoperability (eg: personnel and resource
typing) Scalability Flexibility Tiers of capacity (spillover to next level)
Off-Site Care Facilitiese.g., Procedure Centers,
Churches, Hotels, Community/Recreation Centers, Warehouses
Home
Clinics and/orPrivate MDs
Treatment/Triage
In-Home Family Care
LTC Facilities
Urgent Care Centers
Neighborhood Emergency Help
CentersMass Dispensing Clinics
Screening Centers
Homecare
Hospitals
Surge Capacity Coordination
HCF A HCF CHCF B Healthcare Facility 1st Tier
2nd TierHealthcare “Coalition”
Jurisdiction I
(PH/EM/Public Safety)
Non-HCF Providers
Medical Support
3rd TierJurisdiction Incident
Management
4th Tier
Jurisdiction II
(PH/EM/Public Safety)
Regional Coordination
5th Tier
National Response 6th Tier
Provincial CoordinationProvince A Province B
Provincial and National Response
Tiers of Response – Patient Care
Cap
ab
ilit
ies
and
Res
ou
rces
National Response
Regional / Mutual Response Systems
Provincial Response
Increasing magnitude and severity
Local Response
Tiered Response Strategy
Minimal Low Medium High Catastrophic
Facility / Community Planning Emergency
Management Plan HVA Command, control,
communications Community partners Regional partners Training Drills Review / modify
Functional Planning MCI Security Event Fire Chemical exposure Radiologic Event Infectious Disease Evacuation
Local Attractions...
Emergencies Present Themselves In 2 Ways…
Oklahoma City Bombing
September 11, 2001
Hurricane Katrina
Midwest Floods
Pandemic InfluenzaNorthridge Earthquake
The Amount of Time We’re GivenTo Pre-Organize People and Pre-Stage Equipment
Can Drastically Change Our Response Effectiveness
Anticipatedand/or
With Warning
Anticipatedand/or
With Warning
Unanticipatedand/or
Without Warning
Unanticipatedand/or
Without Warning
‘C’ first and foremost
CommandControlCommunicationCoordination
Command / Control
Who is in charge? Who has authority to declare a special
incident, evacuate, etc? Where is the EOC/Command Post? How does the EOC/CP interact with:
Community resources Other hospitals/public health
Tiered, scalable, flexible plans Use of Hospital Incident Command System
Getting Organized…
INCIDENT BRIEFING
• Date/time of start of incident
• Type of incident
• Services involved
• Current incident status
• Current resource status
• Current strategy/objectives
• Communications systems being used
• Special problems/issues
NatureNature
SizeSize
LocationLocation Time of DayTime of Day
Day of the WeekDay of the Week
InitiallyInitially
MobilizationChecklist
MobilizationChecklist
What ?Where ?When ?Who’s Involved ?Where Is It Going ?
What ?Where ?When ?Who’s Involved ?Where Is It Going ?
EmergencyOperations
Center
IncidentAction
Planning
Communication
Within ED / hospital Phone (redundant?), local cellular Paging Portable radios Alpha pagers, SMS, email, VOIP Runners
Outside facility – phone, cell, HEAR, amateur radio, internet – VOIP, email, net-based
Coordination
Within facility (for ICU, CT, etc.) Outside facility:
Transfers (including ambulances, helos) Resource requests Outside agencies
Regional Hospital Resource Center (RHRC) Coordinates hospital response and requests
within region
‘S’ - Logistics
SpaceStaffStuff
Space Get ‘em up and get ‘em out (ED, clinics) Discharges and transfers (eg: nursing home)
Discharge holding area
Board patients in halls Cancel elective procedures Convert procedure/PACU areas to patient care Accommodate vents on floor (or BVM or austere O2 flow
powered ventilators) Alternative ambulatory care areas (lobbies, clinics, etc.)
Staff
Different events = different staff needs Eg: HAZMAT vs. trauma vs. monkeypox
Scope of event = scope of staff call-in Mechanism to reach staff Support staff – eg: central supply, food,
psychosocial Labor pool unit leader Assign staff to specific areas when possible Nursing staff often limiting factor
Staffing
Personnel Augmentation
Hospital personnel Clinic personnel Non-clinical practice professionals Retired professionals (eg: HC Medical Society) Trainees in health professions Service organizations Lay public / faith-based / family members Government personnel
Stuff
Patient care supplies – look at by type of event
Pharmacy – analgesia, sedation, dT, abx PPE – masks, barrier gowns Supply and staffing issues (72h ahead) Logistics and planning sections
Surge Capability
Pharmaceuticals
Personal Protective Equipment
HCMC Security
HCMC Security
‘T’ - Operations
TriageTreatmentTransport
Triage
Primary – immediate, often scene-based (eg: EMS)
Secondary – at hospital or for in-hospital resources, re-assessment Location Supplies Personnel
Tertiary – after admission / initial care
Treatment
Where provided? (eg: will certain patients be cohorted in certain areas?)
What treatment will be provided? (resource limitations?)
What are the limiting factors? Staff Supplies Space
Transportation
Ground assets (including buses and out-of-area EMS)
Rotor-wing “Loading zones” for both ground and air units Receiving facilities Coordination of patients, records Prioritization for evacuation and method
Transportation Capacity/Capability
IN-HOUSEIN-HOUSEDistressed StaffDistressed Staff
INPATIENTINPATIENTDistressed InpatientsDistressed Inpatients Family MembersFamily Membersof Inpatientsof Inpatients
INCOMINGINCOMING
Behavioral Health Surge
MediaMedia VolunteersVolunteers OnlookersOnlookers
PsychologicalPsychologicalCasualtiesCasualties
EMS-EMS-ProcessedProcessed
MedicalMedical
Self-TransportedSelf-TransportedMedical CasualtiesMedical Casualties
Bystanders orBystanders orFamilyFamily
Members,Members,Friends,Friends,
Co-workersCo-workersof Incomingof IncomingCasualtiesCasualties
Family MembersFamily MembersSearchingSearchingfor Missingfor MissingLoved OnesLoved Ones
Injured,Injured,Exposed,Exposed,
DistressedDistressedDisaster/Disaster/
EmergencyEmergencyWorkersWorkers
Community-Based Surge Clinics Homecare Nursing homes Procedure centers Family-based care Off-site hospitals (Acute Care Center) Off-site clinics (Neighborhood Emergency Help
Centers) (assessment and clinic level care) Local / Regional referral / NDMS
Influenza calls to MDH December 2003
0
500
1000
1500
2000
2500
3000
Visits to MDH home and Flu Clinic web pages - Dec 2003
0
2,000
4,000
6,000
8,000
10,000
12,000
12/3 12/6 12/9 12/12 12/15 12/18 12/21
MDH Home Page
Flu Clinic Page
Hospital Metro Resources Routinely staffed beds 4857 Avg. daily census 4143 Surge Capacity
Census vs. staffed variance 714 Unstaffed but available beds 1068 15% of total beds staffed = 728 PACU/procedure rooms 536 Convertible rooms single to double 473 Total average overall surge capacity 2500-3519 Adjusted standard of care surge capacity 500-
1000
Metro Hospital Resources
Stepdown beds 501 (surge 190 addtl) ICU beds 416 (surge 192 addtl) PICU beds 64 (surge 20-39 addtl) ED beds 460 OR suites 295 Ventilators 533 Tabs of doxycycline 76,881
Regional Hospital Resource Center
Hospital A
Hospital B
Hospital C
Clinic coord
Healthsystem
Multi-Agency CoordinationCenter
EM EMS PH
Public HealthAgenciesEMS Agencies
JurisdictionEmergency Management
AA
B
C A
B
C C
B
Hospital Resources Metro Population 2,600,000 10% population affected by ‘pandemic’ =
260,000 patients 20% of affected patients too sick to care for
selves = 52,000 20% of those patients lack family members
that can care for them or are too sick for homecare (require IV fluids, etc.) = 10,400
Requires off-site care facilities and triage of resources
Off-site hospital Incident recognized, regional coordination
established, need for off-site care recognized Primary and secondary sites pre-selected and
screened Public health authority is authorizing/controlling entity Compact provides for first 48h:
Teams of providers (RN, MD, HCA/NA/EMT) <200 beds – 1 team >200 beds – 2 teams Each 6-8 person team has up to 50 patients
May be required when hospital infrastructure damaged, especially in smaller community
Sample Site
Sample Site Food Restrooms Staff rehab areas Secure HVAC system specs Paging /messaging
/radio Power Phone, T1 lines, etc. City owned!
Adjusting Standards of Care
The last resort ‘What do you do when you can’t surge any
more’ Gracefully, systematically change your
standard of care to one appropriate for the resources available
Staffing and staff roles / responsibilities Policy changes (eg: documentation) Resource triage decisions
Overarching Goal
Do the greatest good for the greatest number of persons you can based upon the resources available…
What are the goals? Understanding by the community of the limits of
resources and the plans when they are exhausted Evidence-based strategy for triage of resources
(based upon chance of survival, not subjective factors)
Regional, not facility-based criteria Provide support and framework for physician
decisions Provide governmental support for response efforts
including liability protection
Restrictions on Mechanical Ventilation
Do not offer or withdraw ventilator support for: Tier 1 – multi-organ failure Tier 2 – severe underlying disease conditions Tier 3 – other criteria (event driven) possible:
Sequential Organ Failure Assessment Score Age related? Other markers for poor outcomes?
What can I do?
Know your role in your institutional plan Work with your emergency preparedness committee Look at your C, S, T - have you optimized your
preparedness? Ask questions, run scenarios… KISS Job action sheets / task cards Extension of daily tasks / responsibilities Education where these differ from your plan Start small, grow big