On Sept. 11, 2001, within minutes of the terrorist attack at the World Trade Center, St. Vincent's Hospital Manhattan in New York City activated its emergency external disaster plan. At the level 1 trauma center, which is less than a mile away from ground zero, staff canceled elective surgeries; secured additional medical equipment; assembled hundreds of physicians, nurses and other personnel; and freed up more than 130 beds in anticipation of casualties.
Ten miles from the Pentagon, in Falls Church, Va., Inova Fairfax Hospital, another level 1 trauma center, coordinated care and pooled resources, becoming the incident command center for the five hospitals in the Inova system. Patient by patient, hospitalists in Inova's department of medicine identified those who could be safely discharged, and nonemergent surgeries were canceled. Inova freed up 23% of its beds and canceled hundreds of surgeries in about four hours.
Unfortunately, Inova Fairfax and St. Vincent's are in a minority of hospitals with the ability to respond to a major emergency. According to a report from Trust for America's Health, over half of states scored five or fewer points out of a possible 10 on key indicators of health emergency preparedness.
Robert Rosenbaum, MD, chairman of the emergency management committee at Christiana Care Health System in Delaware, said that solving the complicated problem of surge capacity-a hospital's ability to expand resources to meet the patient care demands of mass casualty events-can be overwhelming. “It involves issues so enormous that knowing where to begin is not easy,” he said.
According to Gregory R. Ciottone, MD, director of the disaster medicine section in the Division of Emergency Medicine at Harvard Medical School in Boston, two types of disasters must be considered when addressing surge capacity: a biological event, and everything else.
“If you have to respond with lights and sirens, it's everything else,” Dr. Ciottone said.
A short-lived event, like Sept. 11, requires a robust group of first responders and short-term surge capacity at hospital emergency and operating rooms. A flu or other pandemic, however, requires a sound public health system and facilities that can manage surge capacity over a period of months. Because no sudden event triggers this type of surge, hospitals need to recognize the signs.
“In our plan, we have check points,” Dr. Ciottone said. “For example, a number of patients presenting with flu can trigger steps that will change the way our hospital goes about everyday business, from normal operations to stopping elective surgery and redefining bed usage, to pushing general primary care medicine into surrounding areas-like university treatment centers, cafeterias, gyms-and utilizing the hospital as an intensive care unit for ventilated flu patients.”
Dr. Rosenbaum suggests starting with a hazard vulnerability analysis (HVA) of the local environment. “You have to look at each threat and determine the likelihood and the potential impact of it happening. Preparedness is a moving target,” he said. Earthquakes in California and floods in coastal areas are examples, and terrorism is the newest threat.
“Although the probability for a terrorist event is low, except in a few high-risk areas, the [potential] impact is high,” Dr. Rosenbaum said.
Mantra for emergency preparedness
HVA is the first step in what has come to be an accepted four-phase planning approach. “Mitigation, preparation, response and recovery has become the mantra for emergency preparedness,” Dr. Rosenbaum said.
Mitigation. By conducting HVAs, hospitals can recognize and eliminate or minimize hazards.
Preparation. A hospital emergency incident command system (HEICS) provides a hospital-specific model for emergency management by detailing who does what when.
“It's important to build in redundancy,” Dr. Rosenbaum said. “You must plan for inevitable system failures. Drill, exercise, practice-look for flaws. Every system within your hospital has to be part of preparedness.”
Response. Internal surge capacity is developed by creating plans to open areas not normally used for acute patient care. Christiana, for example, determined that its physical therapy gym could be used as a negative pressure isolation area in the event of a massive disease outbreak.
“With less than $5,000 worth of equipment, we can create an isolation room for 25 to 30 patients, which can be set up in less than an hour,” Dr. Rosenbaum said.
And hospitals will also need to respond to people who aren't hurt.
“During the 9/11 attacks, our biggest surge problem was with the families of those injured,” said Dennis Greenbaum, MD, chairman of the department of medicine at St. Vincent's Manhattan. The gyms and auditoriums of a nearby university became a gathering place for victims' families.
“It wasn't in our disaster plan at the time, but it is now,” Dr. Greenbaum said.
Recovery. Once the immediate impact of the hazard has been met, hospitals must work toward reopening beds and normalizing operations, or redefining what normal is. This includes recovery time for the staff. At Christiana, a volunteer group of almost 100 medical and support people are available to help staff surge capacity units.
Working with partners
No hospital can address a nonlocalized event alone. “You have to work with other hospitals and public service agencies-ambulance, fire, police,” Dr. Rosenbaum said. “Hospitals need to know how [these agencies] work, and to be included in their plans.”
San Diego, for example, has a disaster council that represents all health care interests, including hospitals, the Veterans Administration, and military facilities, said Irving Jacoby, FACP, professor of emergency medicine at the University of California, San Diego (UCSD), and the hospital director for emergency preparedness and response at UCSD Medical Center.
And it's important to develop these relationships ahead of time, according to Christopher Cannon, director of the Yale New Haven Center for Emergency Preparedness and Disaster Response in New Haven, Conn. “Define who your partners are, who will take the lead, what your role is,” he said.
Inova Health System, for example, formed a hospital alliance among its five hospitals and nine other area hospitals. An electronic bedboard and a staff management system allow all 14 hospitals to post and view information about bed capacity and emergency room status.
The role of the hospitalist
Hospitalists play a key role in helping to address surge capacity, according to Dan Hanfling, MD, director of emergency management and disaster medicine for Inova. “They're the ones who'll know who can be sent home to clear beds. . .and will be asked to take in patients and victims,” he said.
Becoming involved in emergency planning is the best way hospitalists can help ensure preparedness in their hospitals, Dr. Jacoby said. Hospitalists and residents should know their roles outside as well as inside the hospital and participate in disaster exercises. Hospitalists can also help determine how to take care of patients in nontraditional treatment areas during a patient surge, Dr. Ciottone said.
Most important, hospitalists and other staff shouldn't assume that they'll be able to handle the fallout of a sudden catastrophe. Good planning is crucial.
An ideal plan, according to Joseph A. Barbera, MD, co-director of the Institute for Crisis, Disaster and Risk Management at George Washington University in Washington, D.C., should provide very clear processes and procedures that can:
- 1. Ensure all patients can be adequately cared for during an internal emergency, such as a fire, flood or tornado strike, including evacuation and communication plans.
- 2. Ensure that the medical staff can optimally care for mass casualties and treat unusual casualties, such as severe nerve agent intoxication.
- 3. Ensure access to real-time information from senior personnel at the scene to effectively develop risk stratification for large numbers of victims.
“Emergency science is every bit as scientific as the practice of medicine,” Dr. Barbera said. “Internists working in a hospital can be critical in promoting a realistic plan with the right priorities, a plan that makes sense for health care providers, and helping to sell it to the medical staff.”
Sheila Dyan is a freelance writer in Cherry Hill, N.J.
Potential strategies for increasing hospital surge capacity
- Discharge patients early; establish discharge holding area
- Convert outpatient procedure beds into inpatient beds
- Use hallways or create alternate treatment areas
- Partner with local health department, emergency management agency, or the American Red Cross to create emergency treatment capacity outside the hospital
- Consider other local facilities, such as schools and armories
- Use automated surveillance and tracking systems
- Link information from physicians, clinics and hospitals to the public health system and the first-responder community
- Implement communication systems to allow rapid dissemination of information to key players and planners in a mass casualty event
Source: “Optimizing Surge Capacity: Hospital Assessment and Planning, “ Agency for Healthcare Research and Quality (AHRQ).
- Agency for Healthcare Research and Quality. Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. November 2006. AHRQ Publication No. 07-0001.
- Greater New York Hospital Association. General Emergency Preparedness for Providers: Guidelines/Protocols/Checklists.
- Joint Commission on Accreditation of Healthcare Organizations. Standing Together: An Emergency Planning Guide for America's Communities. September 2005.
- Nevada Hospital Association. Regional Hospital Surge Capacity Plan. June 2006.