Planning and Organization for Emergency Mass Critical Care

James Geiling

Robert M. Gougelet

Lawrence C. Mohr Jr

Hospital and Community Disaster Response

The Importance of Hospitals in Disaster Response

Hospitals and their critical care units play important roles in a community’s response to a disaster, whether the disaster is sudden in nature, such as an explosion, or a more prolonged event, such as pandemic influenza. First of all, hospitals are the major source of a community’s medical care and provide rapid access to health care. Most likely, the first response of an individual with a disaster-related medical problem will be to go to the closest hospital. Similarly, emergency medical system ambulances will routinely transport critically ill or injured patients to the nearest hospital. Second, hospitals are capable of managing critically ill or injured patients in a timely manner if adequate staff and resources are available. Third, it is especially difficult to provide critical care outside of the hospital setting during a disaster. For example, it may be possible to provide medical care in a building of opportunity, such as a school gymnasium, for low-acuity patients. However, providing critical care in such a setting would require significant amounts of medical equipment, supplies, and specially trained staff. It would be logistically difficult, costly, and time consuming to move critical care resources to a nonhospital facility during a disaster. Finally, hospitals which are accredited by the Joint Commission or other accrediting agencies must meet specific requirements for disaster preparedness. These requirements include continuity-of-operations plans, an internal operations center with an incident command structure, and the planning and conduct of disaster response exercises in coordination with the neighboring community.

In summary, the hospital is the major healthcare asset in disaster response and is likely to be the only facility where critical care is provided. In order to maintain its capability to respond to the most critical patients during a disaster, the hospital must be part of a community-based healthcare response system that can be efficiently mobilized during a catastrophic event.

The large numbers of patients requiring care immediately after a disaster, the continued flow of patients during a prolonged disaster, or the loss of hospital infrastructure as a result of a disaster, all have the potential to overwhelm available resources at any hospital. Thus, it is possible that there will be limits to the number of patients that can be cared for and the level of care that can be provided by a hospital during a catastrophic event.

Surge capacity generally refers to the ability to manage a sudden or prolonged increase in numbers of patients that would otherwise severely challenge or exceed the present capacity of the facility. Medical surge capacity may be defined, more technically, as “the quantifiable amount of community or regional resources and services available for providing medical care in emergencies that overwhelm the normal medical infrastructure” [1]. To provide adequate surge capacity and maintain medical system resiliency during disasters, hospitals and communities must have medical preparedness plans, as well as carefully planned command and control systems that will efficiently manage the medical response.

Local Community Medical Response

Incident Command Systems

In the United States, both hospitals and community governments are required to adhere to the requirements of the National Incident Management System, which is managed by the Federal Emergency Management Agency [2]. This includes the requirement that both hospitals and communities have an Incident Command System (ICS) [3]. The currently used ICS model for disaster response is a modular system that follows the basic principles of organizational leadership, with one person in charge of a command section that supervises the activities of 3 to 7 subsections. Most ICS structures have five principal components:

Leadership—This is the command section, chaired by the leader of the response effort (the incident commander). The incident commander is supported by special staff, such as public affairs, public safety, legal counsel, etc.
Operations—This section oversees and coordinates the immediate response and ongoing operational activities. This tends to be the most active section during a disaster.
Planning—This section assesses the potential for future events, develops contingency plans for future events, and plans timelines for the deployment of critical resources. These planning activities permit the operations branch to focus on managing the response to active events.
Logistics—This section focuses on the logistical support that every event requires, including equipment, personnel, supplies, and infrastructure support.
Finance—This section accounts for and manages all money that is spent during responding to a disaster. While immediate costs and purchases during a disaster tend to be supported by affected communities and hospitals, accurate purchasing records, inventory records, personnel costs, and transportation costs must be carefully managed in order to recoup costs after the event.

The Hospital Incident Command System (HICS) manages the response within the hospital and coordinates the hospital’s efforts with the overall community response. The HICS is led by an incident commander within the hospital. The hospital’s incident commander and the community incident commander
communicate with each other directly through telephone, radio, computer, or via liaison personnel. The organization and leadership of the HICS is usually different than organizational structure and leadership of day-to-day hospital operations [4]. What works for managing the daily business of a hospital oftentimes does not work well for managing the response to a crisis. Therefore, hospitals, and their intensive care units (ICUs), must assign personnel to specific HICS positions as part of their disaster preparedness planning. Each individual assigned to an HICS position has specific duties that must be performed prior to, during, and following the disaster response. It is imperative that all HICS personnel be fully trained for the duties they are required to perform.

Modular Emergency Medical Systems

The Modular Emergency Medical System, or MEMS, is a community emergency medical care system consisting of temporary facilities that can be quickly set up to supplement hospital care during a disaster. This system provides a conceptual framework for managing a surge in patients who require screening, triage, antibiotic treatment, immunizations, prophylaxis, or noncritical inpatient care. The MEMS helps hospitals to maximize their critical care capacity during a disaster by providing temporary, alternate facilities that can care for noncritical patients in their respective communities.

The major MEMS components are Neighborhood Emergency Help Centers (NEHC) and Acute Care Centers (ACC). Both types of centers can provide screening and triage. The NEHC provides routine, nonurgent outpatient care. The ACC can provide inpatient care to acutely ill noncritical patients. The ACC can receive patients directly from the incident, or be a facility to which hospitals can offload stable inpatients in order to free up hospital critical care bed space during overwhelming events. Local or regional authorities can open an NEHC or an ACC under two scenarios: (i) when a federal public health incident or a federal disaster is declared or (ii) when the state governor has issued a state of emergency. Both types of temporary facilities will operate under the command and control of the local community ICS with support from a Regional Multiagency Command [5].

How Does Critical Care Fit into the MEMS Plan?

The hospital is only place where critical care can be provided immediately after a disaster. Therefore, the community’s medical surge plan must address how to protect the hospital from being overwhelmed with patients during a disaster. A carefully executed MEMS plan allows hospitals to offload stable patients to an ACC. This will help to prevent the hospital from being overwhelmed during a disaster and allow the hospital to expand its critical care capabilities by utilizing non-ICU hospital beds for critical care, if necessary.

Refining Surge Capacity

Hick and colleagues suggest a classification for surge capacity that may aid hospitals and communities in their planning for a major disaster [6]. They categorize surge capacity into three levels:

Conventional capacity—This level would be implemented in major mass-casualty incidents that trigger activation of the hospital emergency operations plan. The resources used (spaces, staff, and supplies) would be consistent with the hospital’s usual care levels.
Contingency capacity—This level would be used temporarily during a major mass casualty incident, or on a longer-term basis during a disaster whose medical demands exceeded community resources. The resources would require adaptations to medical care spaces, staffing constraints, and supply shortages, but without significant impact on the medical care that is delivered.
Crisis capacity—This level would be implemented in catastrophic situations that result in a significant impact on standard of medical care that can be provided. Severe limitations of space, staff, and supplies would not allow hospitals to provide the usual standard of medical care. If surge capacity reaches the crisis level, resources would be allocated in a way that facilitates the best possible medical care with the limited resources that are available.

It is recommended that hospitals and their critical care units develop disaster preparedness plans that contain specific criteria for each level of surge capacity. It is important to note that the same disaster event might have very different effects on different hospitals, depending on the institution’s size. For example, an eight-victim automobile crash may require a conventional level of surge capacity for a large hospital that has a level 1 trauma center, but could require a contingency or crisis level of surge capacity for a small community hospital.

Critical Care in Disasters

Current Status

From 2002 to 2007, the Hospital Preparedness Program of the U.S. Department of Health and Human Services spent $2.2 billion to support medical preparedness goals, which included improvement of hospital surge capabilities [7]. However, in 2008 the U.S. General Accounting Office reported that many states are still not adequately prepared to respond effectively to a catastrophic event, such as pandemic influenza, in which medical resources could become overwhelmed and there would be a need to change the way medical care is provided by altering or adjusting the care pathways [8]. During a major disaster, nothing will challenge hospitals more than attempting to provide high-quality critical care with limited resources.

Traditionally, most hospitals have focused their disaster planning on trauma care capabilities. However, the advent of severe acute respiratory syndrome (SARS) and the risk of an H1N1 influenza pandemic have caused hospitals to consider their overall critical care capability, to include medical critical care, as an important component of disaster response plans. For example, it is estimated that without adequate critical care resources during the 2003 SARS outbreak in Toronto, the case fatality rate would have been approximately 20%, compared to the 6.5% case fatality rate that actually occurred [9]. These data highlight the importance of including the overall critical care capabilities of hospitals in disaster planning efforts, not just the capabilities for trauma care.

At present, it is estimated that the average daily occupancy rate of critical care beds in the United States is 65%. This suggests that some hospitals may have the capability to expand critical care services during a disaster, assuming that staff and supplies are available [10]. However, even with normal excess capacity, there does not appear to be a sufficient number of critical care beds to meet the demands of a pandemic that might affect the entire nation at the same time. It is estimated that critically ill patients who are not cared for in an ICU have a threefold mortality rate compared with those who are cared for in an ICU [11]. Thus, if critical care capabilities become overwhelmed by large numbers of critically ill or injured patients during a disaster, high mortality rates are likely to occur.

Surging Assets to Optimize Critical Care Capability

In planning for surge capacity during disasters, hospitals need to prepare for events that have a sudden impact and are of relatively short duration, such as transportation accidents,
explosions, bombings, as well as more prolonged events, such as earthquakes, hurricanes, and influenza pandemics [12,13].

Figure 216.1. Stepwise modifications in resource use to maintain positive-pressure ventilation. HME, heat and moisture exchanger. [From Rubinson L, Hick JL, Hanfling DG, et al: Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity. Chest 133:18S–31S, 2008.]

A common rubric for the planning of critical care surge capacity places critical care resources into three categories: “stuff”—the medical supplies and equipment necessary for providing critical care; “staff”—the availability of trained critical care providers and support personnel; and “space”—the physical space within the hospital that can be used to provide critical care to a large number of critically ill or injured patients [14]. In all disaster situations, the effective utilization of critical care surge capacity will ultimately depend on the training and effectiveness of the hospital and community incident command systems which must execute surge capacity plans [15].

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