A few years ago, I had the honor of having dinner with Sheri Fink, MD, PhD, the author of a book titled Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. In the book, Dr. Fink challenges planners to make ethical patient care decisions in high-stress situations and to make tough choices under circumstances you hope you’ll never experience, but for which you need to be prepared. Dr. Fink’s book was the culmination of a 6 year investigation into the choices made during the mass care and medical surge issues presented during Hurricane Katrina.
While this book can be life-changing for the emergency manager and hospital administrator, it is a case study about a past event; a look BACK at what was done wrong and what was done RIGHT. In the wake of this past 2017 hurricane season, perhaps it is time to take a good look into the future of your facility, community or scope of responsibility.
There were many during Katrina that uttered the words, “We never imagined…”
With the 2018-2019 hurricane season right around the corner and tornado season beginning within a week or so, we need to perhaps combine these lessons from the past with some real planning for the future and what it may hold. Of course, to be realistic, there is the somber truth that our challenges may not come from Mother Nature at all.
The Prime nightclub shooting in Orlando, Florida, overwhelmed hospitals in the area, creating a medical surge on local ERs of 102 patients with at least 49 of them being fatalities, while 53 others were casualties of different levels. The Orlando Medical Center alone admitted 44 victims, including nine who died, and carried out 26 operations by six surgeons and operating room staff.
According to the U.S. Department of Health & Human Services, Office of the Assistant Secretary for Preparedness and Response:
“Medical and public health systems in the United States must prepare for major emergencies and disasters involving human casualties. Such events will severely challenge the ability of healthcare systems to adequately care for large numbers of patients (surge capacity) and/or victims with unusual or highly specialized medical needs (surge capability).”
The term medical surge refers to a hospital’s ability to provide adequate medical evaluation and care during events that exceed the limits of the normal infrastructure of an affected community. It encompasses the ability of healthcare organizations (HCO) to survive a hazard impact and maintain or rapidly recover operations that were compromised (a concept known as medical system resiliency).
The first step is to distinguish surge capacity from surge capability.
Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients during and after an event that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.
Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:
Identify the medical need
Identify the resources to address the need in a timely manner
Move the resources expeditiously to locations of patient need (as applicable)
Manage and support the resources to their absolute maximum capacity
Fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. The integration of additional resources (whether standby, mutual aid, or state/federal aid) is difficult without adequate management systems.
Here’s an example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds), minimizing the purchase and maintenance of expensive equipment that generate no income except during rare emergency situations.
When addressing an overall medical surge strategy, we must look at the not only the HISTORIC possibilities but the FUTURISTIC possibilities that could exceed anything we have seen in the past. While a shooting of just over 40 students would be HISTORIC, a shooting on a University campus involving over 300 is possible isn’t it? This is where a cache of items such as Westcot units would establish the needed surge capacity in that community.
Medical surge capability refers to the ability to manage patients requiring unusual or very specialized medical evaluation and care. Surge requirements span the range of specialized medical services (e.g., expertise, information, procedures, equipment, or personnel) that are not normally available at the location where they are needed (e.g., pediatric care provided at non-pediatric facilities). Surge capability also includes patient problems that require special intervention to protect medical providers, other patients, and the integrity of the HCO.
Here’s an example: Many hospitals encountered difficulties with the 2002-2004 outbreak of patients with symptoms of severe acute respiratory syndrome (SARS). The challenge was not presented by a high volume of patients, but rather by the specialty requirements of caring for a few patients with a highly contagious illness that demonstrated particular transmissibility in the healthcare setting.
Protection of staff and other patients was a high priority, as was screening incoming patients and staff for illness and preventing undue employee concerns. Coordination with public health, emergency management, and other response assets was critical. The Ebola outbreak in 2014 created a similar situation.
Requirements of medical surge capacity and capability (MSCC) include a systematic approach to meeting patient needs that challenge or exceed normal operational abilities, while preserving quality of care and integrity of the healthcare system.
The MSCC management system demonstrates management processes that allow HCOs to coordinate existing resources and then obtain “outside” assistance in a timely and efficient manner. HCOs can then transition from baseline operations to incident surge capacity and capability to meet the response needs of catastrophic events and then back to baseline.
Surge response plans should not depend on the federal government to provide MSCC. Hospital and community strategies to enhance MSCC must recognize that the required emergency interventions are time-sensitive and based at the local level.
A surge event requires fast access to the needed resources. The federal government does not establish, stockpile, and control resources necessary for immediate MSCC. In addition, because most medical assets in the United States are privately owned, MSCC strategies must bridge the public-private divide, as well as integrate multiple disciplines and levels of government.
A comprehensive MSCC response plan must include “all-hazard” processes and procedures, mutual aid, and validated emergency management concepts.
It is for this reason that Integrity Medical Solutions is expanding its business and supply model to include not only peripheral products that can be packaged and cached with our current products, but we are now developing a Rapid Response Unit that can bolster that cache in the event of exceptional surge in the event of a terror attack, a major outbreak or the destruction of area facilities.
There are several types of medical surge, including:
Local medical surge, such as during the Orlando terror event
Incoming medical surge, such as what New York and New Jersey hospitals experienced during the terror events of September 11, 2001
Evacuation medical surge, such as the more than 1,000 patients evacuated from Tulane University Medical Center after Hurricane Katrina on August 27th, 2005
As such, preparedness can be divided into three levels:
Infrastructure, the physical structures
Organization, the plan for the hospital response
Individual, the personal preparedness plans for an event
A CBRN medical surge involves the complicating factor of injured patients who may be contaminated with CBRN material. Enhanced PPE, enhanced respiratory protection devices, and patient isolation pods are needed to protect first receivers, other patients, and the facility.
A well-designed and well-tested medical surge response plan may help with making difficult ethical decisions during an event. Triage priorities for incoming patients and for evacuating patients need planning to avoid confusion and delay during an event. In other words, by contacting us today to discuss your possible needs in the future, you might just be giving your community and responders the edge they need when the event takes place.