Metrics in the Science of Surge

Metrics are the driver to positive change toward better patient care. However, the research into the metrics of the science of surge is incomplete, research funding is inadequate, and we lack a criterion standard metric for identifying and quantifying surge capacity. Therefore, a consensus working group was formed through a "viral invitation" process. With a combination of online discussion through a group e-mail list and in-person discussion at a breakout session of the Academic Emergency Medicine 2006 Consensus Conference, "The Science of Surge," seven consensus statements were generated. These statements emphasize the importance of funded research in the area of surge capacity metrics; the utility of an emergency medicine research registry; the need to make the data available to clinicians, administrators, public health officials, and internal and external systems; the importance of real-time data, data standards, and electronic transmission; seamless integration of data capture into the care process; the value of having data available from a single point of access through which data mining, forecasting, and modeling can be performed; and the basic necessity of a criterion standard metric for quantifying surge capacity. Further consensus work is needed to select a criterion standard metric for quantifying surge capacity. These consensus statements cover the future research needs, the infrastructure needs, and the data that are needed for a state-of-the-art approach to surge and surge capacity.     

Emergency Department Surge Capacity: Recommendations of the Australasian Surge Strategy Working Group

For more than a decade, emergency medicine (EM) organizations have produced guidelines, training, and leadership for disaster management. However, to date there have been limited guidelines for emergency physicians (EPs) needing to provide a rapid response to a surge in demand. The aim of this project was to identify strategies that may guide surge management in the emergency department (ED). A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations and identified underlying assumptions from disaster epidemiology and clinical practice. The group then characterized surge strategies from their corpus of experience; examined them through available relevant published literature; and collated these within domains of space, staff, supplies, and system operations. These recommendations detail 22 potential actions available to an EP working in the context of surge, along with detailed guidance on surge recognition, triage, patient flow through the ED, and clinical goals and practices. The article also identifies areas that merit future research, including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies, and measurement of strategy impacts on throughput, cost, and quality of care.     

The Measurement of Daily Surge and Its Relevance to Disaster Preparedness

This article reviews what is known about daily emergency department (ED) surge and ED surge capacity and illustrates its potential relevance during a catastrophic event. Daily ED surge is a sudden increase in the demand for ED services. There is no well-accepted, objective measure of daily ED surge. The authors propose that daily and catastrophic ED surge can be measured by the magnitude of the surge, as well as by the nature and severity of the illnesses and injuries that patients present with during the surge. The magnitude of an ED surge can be measured by the patient arrival rate per hour. The nature and severity of the surge can be measured by the type (e.g., trauma vs. infection vs. biohazard) and acuity (e.g., triage level) of the surge. Surge capacity is defined as the extent to which a system can respond to a rapid and sizeable increase in the demand for resources. ED surge capacity includes multiple dimensions, such as systems, space, staffing, and supplies. A multidimensional measure is needed that reflects both the core components and their relative contribution to ED surge capacity. Although many types of factors may influence ED surge capacity, relatively little formal research has been conducted in this area. A better understanding of daily ED surge capacity and influencing factors will improve our ability to simulate the potential impact that different types of catastrophic events may have on the surge capacity of hospital EDs nationwide.     

The Art and Science of Surge: Experience from Israel and the U.S. Military

In a disaster or mass casualty incident, health care resources may be exceeded and systems may be challenged by unusual requirements. These resources may include pharmaceuticals, supplies, and equipment as well as certain types of academic and administrative expertise. New agencies and decision makers may need to work together in an unfamiliar environment. Furthermore, large numbers of casualties needing treatment, newer therapies required to care for these casualties, and increased workforce and space available for these casualties all contribute to what is often referred to as "surge." Surge capacity in emergency care can be described in technical, scientific terms that are measured by numbers and benchmarks (e.g., beds, patients, and medications) or can take on a more conceptual and abstract form (e.g., decisions, authority, and responsibility). The former may be referred to as the "science" of surge, whereas the latter, an equal if not more important component of surge systems that is more conceptual and abstract, can be considered the "art" of surge. The experiences from Israel and the U.S. military may serve to educate colleagues who may be required to respond or react to an event that taxes the current health care system. This report presents concrete examples of surge capacity strategies used by both Israel and the U.S. military and provides solutions that may be applied to other health care systems when faced with similar situations.     

Research Priorities for Surge Capacity

The 2006 Academic Emergency Medicine Consensus Conference discussed key concepts within the field of surge capacity. Within the breakout session on research priorities, experts in disaster medicine and other related fields used a structured nominal-group process to delineate five critical areas of research. Of the 14 potential areas of discovery identified by the group, the top five were the following: 1) defining criteria and methods for decision making regarding allocation of scarce resources, 2) determining effective triage protocols, 3) determining key decision makers for surge-capacity planning and means to evaluate response efficacy (e.g., incident command), 4) developing effective communication and information-sharing strategies (situational awareness) for public-health decision support, and 5) developing methods and evaluations for meeting workforce needs. Five working groups were formed to consider the above areas and to devise sample research questions that were refined further by the entire group of participants.     

Integrated plan to augment surge capacity

INTRODUCTION: Surge capacity is defined as a healthcare system's ability to rapidly expand beyond normal services to meet the increased demand for appropriate space, qualified personnel, medical care, and public health in the event ofbioterrorism, disaster, or other large-scale, public health emergencies. There are many individuals and agencies, including policy makers, planners, administrators, and staff at the federal, state, and local level, involved in the process of planning for and executing policy in respect to a surge in the medical requirements of a population. They are responsible to ensure there is sufficient surge capacity within their own jurisdiction. PROBLEM: The [US] federal government has required New York State to create a system of hospital bed surge capacity that provides for 500 adult and pediatric patients per 1 million population, which has been estimated to be an increase of 15-20% in bed availability. In response, the New York City Department of Health and Mental Hygiene (NYC DOH) has requested that area hospitals take an inventory of available beds and set a goal to provide for a 20% surge capacity to be available during a mass-casualty event or other conditions calling for increased inpatient bed availability. METHODS: In 2003, under the auspices of the NYC DOH, the New York Institute of All Hazard Preparedness (NYIHP) was formed from four unaffiliated, healthcare facilities in Central Brooklyn to address this and other goals. RESULTS: The NYIHP hospitals have developed a surge capacity plan to provide necessary space and utilities. As these plans have been applied, a bed surge capacity of approximately 25% was identified and created for Central Brooklyn to provide for the increased demand on the medical care system that may accompany a disaster. Through the process of developing an integrated plan that would engage a public health incident, the facilities of NYIHP demonstrate that a model of cooperation may be applied to an inherently fractioned medical system.     

Equipment,Supplies, and Pharmaceuticals: How Much Might It Cost to Achieve Basic Surge Capacity?

The ability to deliver optimal medical care in the setting of a disaster event, regardless of its cause, will in large part be contingent on an immediately available supply of key medical equipment, supplies, and pharmaceuticals. Although the Department of Health and Human Services Strategic National Stockpile program makes these available through its 12-hour "push packs" and vendor-managed inventory, every local community should be funded to create a local cache for these items. This report explores the funding requirements for this suggested approach. Furthermore, the response to a surge in demand for care will be contingent on keeping available staff close to the hospitals for a sustained period. A proposal for accomplishing this, with associated costs, is discussed as well.     

Differentiating Large-scale Surge versus Daily Surge

This breakout session at the Academic Emergency Medicine 2006 Consensus Conference examined how baseline overcrowding impedes the ability of emergency departments to respond to sudden, unexpected surges in demand for patient care. Differences between daily and catastrophic surge were discussed, and the need to invoke a hospital-wide response to surge was explored.     

State of Research in High-consequence Hospital Surge Capacity

High‐consequence surge research involves a systems approach that includes elements such as healthcare facilities, out‐of‐hospital systems, mortuary services, public health, and sheltering. This article focuses on one aspect of this research, hospital surge capacity, and discusses a definition for such capacity, its components, and future considerations. While conceptual definitions of surge capacity exist, evidence‐based practical guidelines for hospitals require enhancement. The Health Resources and Services Administration's (HRSA) definition and benchmarks are extrapolated from those of other countries and rely mainly on trauma data. The most significant part of the HRSA target, the need to care for 500 victims stricken with an infectious disease per one million population in 24 hours, was not developed using a biological model. If HRSA's recommendation is applied to a sample metropolitan area such as Orange County, California, this translates to a goal of expanding hospital capacity by 20%–25% in the first 24 hours. Literature supporting this target is largely consensus based or anecdotal. There are no current objective measures defining hospital surge capacity. The literature identifying the components of surge capacity is fairly consistent and lists them as personnel, supplies and equipment, facilities, and a management system. Studies identifying strategies for hospitals to enhance these components and estimates of how long it will take are lacking. One system for augmenting hospital staff, the Emergency System for Advance Registration of Volunteer Health Professionals, is a consensus‐derived plan that has never been tested. Future challenges include developing strategies to handle the two different types of high‐consequence surge events: 1) a focal, time‐limited event (such as an earthquake) where outside resources exist and can be mobilized to assist those in need and 2) a widespread, prolonged event (such as pandemic influenza) where all resources will be in use and rationing or triage is needed.     

The ExploreSurge Trail Guide and Hiking Workshop: discipline-specific education for public health nurses

Generic preparedness education and training for the public health workforce has increased in availability over the past 5 years. Registered Nurses also have more opportunities available for participation in emergency and disaster preparedness curricula. Discipline- and specialty-specific training and education for public health nurses (PHNs) incorporating their population-based practice, however, remains a largely unexplored area that is not accessible except for sporadic local venues. The Public Health Nursing Surge Curriculum provides 50 hr of nursing continuing education and activity-based aggregate focused learning experiences that are completed within a 12-month period, including an in-classroom seminar. The Public Health Nursing Surge Curriculum was developed on a foundation of 25 competencies linking PHNs and their population-based practice to surge capability. The curriculum was built in partnership with statewide public health directors of nursing over a 12-month period and is evaluated by a 3-level process to include self-rated confidence in performance. The curriculum's use of a blended learning methodology enables staff-level PHNs to master individual competencies toward surge capability within the public health response system.     

Ability of regional hospitals to meet projected avian flu pandemic surge capacity requirements

INTRODUCTION: Hospital surge capacity is a crucial part of community disaster preparedness planning, which focuses on the requirements for additional beds, equipment, personnel, and special capabilities. The scope and urgency of these requirements must be balanced with a practical approach addressing cost and space concerns. Renewed concerns for infectious disease threats, particularly from a potential avian flu pandemic perspective, have emphasized the need to be prepared for a prolonged surge that could last six to eight weeks. NULL HYPOTHESIS: The surge capacity that realistically would be generated by the cumulative Greater Dayton Area Hospital Association (GDAHA) plan is sufficient to meet the demands of an avian influenza pandemic as predicted by the [US] Centers for Disease Control and Prevention (CDC) models. METHODS: Using a standardized data form, surge response plans for each hospital in the GDAHA were assessed. The cumulative results were compared to the demand projected for an avian influenza pandemic using the CDC's FluAid and FluSurge models. RESULTS: The cumulative GDAHA capacity is sufficient to meet the projected demand for bed space, intensive care unit beds, ventilators, morgue space, and initial personal protective equipment (PPE) use. There is a shortage of negative pressure rooms, some basic equipment, and neuraminidase inhibitors. Many facilities lack a complete set of written surge policies, including screening plans to segregate contaminated patients and staff prior to entering the hospital. Few hospitals have agreements with nursing homes or home healthcare agencies to provide care for patients discharged in order to clear surge beds. If some of the assumptions in the CDC's models are changed to match the morbidity and mortality rates reported from the 1918 pandemic, the surge capacity of GDAHA facilities would not meet the projected demand. CONCLUSIONS: The GDAHA hospitals should test their regional distributors' ability to resupply PPE for multiple facilities simultaneously. Facilities should retrofit current air exchange systems to increase the number of potential negative pressure rooms and include such designs in all future construction. Neuraminidase inhibitor supplies should be increased to provide treatment for healthcare workers exposed in the course of their duties. Each hospital should have a complete set of policies to address the special considerations for a prolonged surge. Additional capacity is required to meet the predicted demands of a threat similar to the 1918 pandemic.     

Who will show up? Estimating ability and willingness of essential hospital personnel to report to work in response to a disaster

Disaster planning in the healthcare setting requires consideration of surge capacity, specifically the community's ability to provide care for a rapid increase in numbers of patients having varied conditions. Adequate staffing is a key component of surge capacity. If fewer than anticipated healthcare personnel report to work in response to a disaster, safety and sustainability of the care provided may be jeopardized. In this article we discuss the need for essential personnel following a disaster, review the literature related to adequate disaster staffing, and share our study examining both the ability and willingness of healthcare personnel to report to work during a disaster and identified barriers to this reporting. We conclude by noting that healthcare personnel experience multiple barriers affecting ability and willingness to report to work during a disaster, with responsibility for children producing the greatest number of significant differences. Strategies for addressing these barriers are provided.     

Very serious and non‐ignorable problem: Crisis in emergency medical response in catastrophic event

The crisis of medical response caused by catastrophic events might significantly affect emergency response, and might even initiate more serious social crisis. Therefore, early identification and timely blocking the formation of crisis in the early phase after a major disaster will improve the efficiency of medical response in a major disaster and avoid serious consequences. In the present paper, we described the emergency strategy to crisis management of medical response after a major disaster. Major catastrophic events often lead to various crises, including excess demand, the crisis of response in barrier and the structural crisis in response. The corresponding emergency response strategies include: (i) shunt of catastrophic medical surge; (ii) scalability of medical surge capacity; (iii) matching of the structural elements of response; (iv) maintaining the functions of support system for medical response and maximising the operation of the integrated response system; and (v) selection of appropriate care ‘standard’ in extreme situations of overload of disaster medical surge. In conclusion, under the impact of a major catastrophic event, medical response is often complex and the medical surge beyond the conventional response capacity and it is easy to be in crisis. In addition to the current consensus of disaster response, three additional aspects should be considered. First, all relevant society forces led by the government and military should be linkages. Second, a powerful medical response system must be based on a strong support system. Third, countermeasures of medical surge should be applied flexibly to the special and specific disaster environment, to promote the effective medical response force.     

Collection of platelets depleted of red and white cells with the "surge pump" adaptation of a blood cell separator

The surge pump is a device which modifies platelet collection of a blood cell separator so that red and white blood cell contamination is minimized. Plasma collected from the donor is directed back into the centrifuge bowl at 200 ml per min, where it causes platelets to be floated off the red cell-plasma interface and thus is collected as an almost pure platelet preparation. Fifty plateletapheresis procedures with the surge pump adaptation were compared to 50 procedures using the standard red cell method. Mean (+/- SD) white cell (greater than 95% lymphocytes) contamination was 5.4 +/- 3.1 X 10(8) cells per collection with the surge pump and 63.5 +/- 10 X 10(8) cells per collection with the standard red cell method (p less than 0.0001). Mean collection hematocrit was 8.1 +/- 2.6% with the standard method and less than 1% with the surge pump eliminating the need for crossmatch or centrifugation to remove red cells from ABO incompatible platelets. Surge pump collection produced a mean of 4.0 +/- 1.6 X 10(11) platelets compared to 5.0 +/- 2.0 X 10(11) platelets for the standard method (p less than 0.01). The mean time per run was 14.8 +/- 2.4 min with the surge pump compared with 18.1 +/- 3.3 min with the standard method (p less than 0.001). Therefore, the platelet yield per minute of procedure time was comparable with both methods (surge pump, 37.3 +/- 11.7 X 10(8) platelets per min; standard method, 39.2 +/- 14.3 X 10(8) platelets per min.). Surge pump operation was learned easily by technologists and caused no donor complications. The surge pump is a simple and effective way of minimizing white and red blood cell contamination in platelet collections from the blood cell separator studied without compromising platelets yields.     

The Science of Surge: Detection and Situational Awareness

As part of the broader "science of surge" consensus initiative sponsored by Academic Emergency Medicine , this report addresses the issues of detection and situational awareness as they relate to surge in the practice of emergency medicine. The purpose of this report, and the breakout group that contributed to its content, was to provide emergency physicians and other stakeholders in the emergency medicine community a sense of direction as they plan, prepare for, and respond to surge in their practice.     

Interventions to safeguard system effectiveness during periods of emergency department crowding

This article summarizes the proceedings of a breakout session, "Interventions to Safeguard System Effectiveness," at the 2011 Academic Emergency Medicine consensus conference, "Interventions to Assure Quality in the Crowded Emergency Department." Key definitions fundamental to understanding the effectiveness of emergency care during periods of emergency department (ED) crowding are outlined. Next, a proposed research agenda to evaluate interventions directed at improving emergency care effectiveness is outlined, and the paper concludes with a prioritization of those interventions based on breakout session participant discussion and evaluation.     

Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs

OBJECTIVE: To estimate the potential for disaster mortality reduction with two surge response strategies: 1) control distribution of disaster victims to avoid hospital overcrowding near the scene, and 2) expand capacity by altering standards of care to only "essential" interventions. DESIGN: Quantitative model of hospital mortality. SETTING: New York City pediatric intensive care unit and non-intensive care unit pediatric hospital capacity and population. MEASUREMENTS AND MAIN RESULTS: Mortality was calculated for a hypothetical sudden disaster, of unspecified mechanism, assuming 500 children per million population need hospitalization, including 30% severely ill/injured warranting pediatric intensive care unit care, with high (76%) predisaster hospital occupancy. Triage rules accommodated patients at lower levels of care if capacity was exhausted. Specified higher relative mortality risks were assumed with reduced levels of care. In a pessimistic baseline scenario, hospitals near the disaster scene, considered to have 20% of regional capacity, were overcrowded with 80% of the surge patients. Exhausted capacity at overcrowded hospitals near the scene would account for most of the 45 deaths. Unused capacity would remain at remote facilities. If regional surge distribution were controlled to avoid overcrowding near the scene, then mortality would be reduced by 11%. However, limited pediatric intensive care unit capacity would still require triage of many severe patients to non-intensive care unit care. Instead, if altered standards of care quadrupled pediatric intensive care unit and non-intensive care unit capacity, then mortality would fall 24% below baseline. Strategies 1 and 2 in combination would improve mortality 47% below baseline. If standards of care were altered prematurely, preventable deaths would occur. However, additional simulations varying surge size, patient severity, and predisaster occupancy numbers found that mortality tradeoffs would generally favor altering care for individuals to improve population outcomes within the range of federal planning targets (500 new patients/million population). CONCLUSION: Quantitative simulations suggest that response strategies controlling patient distribution and expanding capacity by altering standards of care may lower mortality rates in large disasters.     

Critical assessment of statewide hospital pharmaceutical surge capabilities for chemical, biological, radiological, nuclear, and explosive incidents

INTRODUCTION: In recent years, government and hospital disaster planners have recognized the increasing importance of pharmaceutical preparedness for chemical, biological, radiological, nuclear, and explosive (CBRNE) events, as well as other public health emergencies. The development of pharmaceutical surge capacity for immediate use before support from the (US) Strategic National Stockpile (SNS) becomes available is integral to strengthening the preparedness of local healthcare networks. METHODS: The Pharmaceutical Response Project served as an independent, multidisciplinary collaboration to assess statewide hospital pharmaceutical response capabilities. Surveys of hospital pharmacy directors were conducted to determine pharmaceutical response preparedness to CBRNE threats. RESULTS: All 45 acute care hospitals in Maryland were surveyed, and responses were collected from 80% (36/45). Ninety-two percent (33/36) of hospitals had assessed pharmaceutical inventory with respect to biological agents, 92% (33/36) for chemical agents, and 67% (24/36) for radiological agents. However, only 64% (23/36) of hospitals reported an additional dedicated reserve supply for biological events, 67% (24/36) for chemical events, and 50% (18/36) for radiological events. More than 60% of the hospitals expected to receive assistance from the SNS within < or = 48 hours. CONCLUSIONS: From a pharmaceutical perspective, hospitals generally remain under-prepared for CBRNE threats and many expect SNS support before it realistically would be available. Collectively, limited antibiotics and other supplies are available to offer prophylaxis or treatment, suggesting that hospitals may have insufficient pharmaceutical surge supplies for a large-scale event. Although most state hospitals are improving pharmaceutical surge capabilities, further efforts are needed.     

Assessing levels of hospital emergency preparedness

INTRODUCTION: Emergency preparedness can be defined by the preparedness pyramid, which identifies planning, infrastructure, knowledge and capabilities, and training as the major components of maintaining a high level of preparedness. The aim of this article is to review the characteristics of contingency plans for mass-casualty incidents (MCIs) and models for assessing the emergency preparedness of hospitals. CHARACTERISTICS OF CONTINGENCY PLANS: Emergency preparedness should focus on community preparedness, a personnel augmentation plan, and communications and public policies for funding the emergency preparedness. The capability to cope with a MCI serves as a basis for preparedness for non-conventional events. Coping with chemical casualties necessitates decontamination of casualties, treating victims with acute stress reactions, expanding surge capacities of hospitals, and integrating knowledge through drills. Risk communication also is important. ASSESSMENT OF EMERGENCY PREPAREDNESS: An annual assessment of the emergency plan is required in order to assure emergency preparedness. Preparedness assessments should include: (1) elements of disaster planning; (2) emergency coordination; (3) communication; (4) training; (5) expansion of hospital surge capacity; (6) personnel; (7) availability of equipment; (8) stockpiles of medical supplies; and (9) expansion of laboratory capacities. The assessment program must be based on valid criteria that are measurable, reliable, and enable conclusions to be drawn. There are several assessment tools that can be used, including surveys, parameters, capabilities evaluation, and self-assessment tools. SUMMARY: Healthcare systems are required to prepare an effective response model to cope with MCIs. Planning should be envisioned as a process rather than a production of a tangible product. Assuring emergency preparedness requires a structured methodology that will enable an objective assessment of the level of readiness.