Chapter 34 Roy L. Alson While the primary environment in which EMS providers operate is an ambulance or the “street,” provision of medical care during an incident may necessitate the establishment of a temporary treatment facility, part of whose staffing and operation may fall under the EMS jurisdiction. The types and purposes of such facilities can vary based on the type of incident and available resources. While this is a common practice in EMS operations, most of what has been described in the literature has been focused on the response to disasters, which is also part of EMS’s role. Throughout history, armies have commandeered existing structures to establish places to care for wounded following a battle. Baron Dominque Larrey, Surgeon in Chief of Emperor Napoleon’s Grand Armee, is often credited as being the father of modern military medicine and EMS [1]. One of his major accomplishments was developing a system by which wounded soldiers were collected from the battlefield and brought to a treatment area or field hospital, often set up in a church or other building and staffed by surgeons who provided care to the wounded. These temporary facilities were the forerunners of the battalion aid station in the US military medical system or the casualty clearing station used by Commonwealth forces. Similar types of units remain in service with militaries around the world and function to stabilize wounded personnel prior to evacuation to higher echelons of care. These are essentially self-sufficient systems that bring with them the necessary supplies and personnel to accomplish their mission of caring for the wounded after combat. This chapter will not focus on those types of facilities used in or associated with mass humanitarian events such as famines or refugee evacuations. Certain basic principles for temporary facilities do apply to these large-scale events, but the issues related to international operations and coordination are beyond the scope of this chapter. For guidance in dealing with such events, the reader is directed to the World Health Organization (WHO) website where more detailed information is available [2]. Temporary facilities range from collection points all the way up to fully capable emergency departments (EDs) such as the “Rampart” facility set up each year at the Burning Man festival in Nevada [3] or the National Mobile Disaster Hospital, a 300+ bed transportable general hospital developed by the Federal Emergency Management Agency (FEMA) and currently housed in North Carolina (Figure 34.1). Figure 34.1 Partial set-up of national disaster mobile hospital showing operating room trailers with emergency room and ICU shelters. Source: NC Department of Health and Human Services. Reproduced with permission of NCDHHS. The type and design of a temporary facility are very much driven by the events that necessitate the creation or deployment of the facility. For planned events, temporary facilities are created to provide care on site, often with the objective of limiting demands on EMS transport and local medical facilities. By allowing persons to return to their activities after receiving care, a positive participant experience is also maintained. Another role for temporary medical facilities is the provision of responder health and rehabilitation. These can range from simple rest and rehydration areas on an incident scene with medical screening of providers prior to return to duty, to full-scale clinics set up to provide primary care and occupational medicine support at the base camps of prolonged events like large forest fires. The role of medical stations during planned events and their capabilities is covered in Volume 2, Chapter 27. Medical intelligence gathered from event planners and prior experience with the event helps guide the design and the capabilities of on-site facilities, including locations and level of care. Care given may be simple first aid all the way up to full Advanced Life Support staffed by physicians and nurses. They type of venue also affects the design of the facility. For example, an event with alcohol being consumed will have a different type of patient load from an event like a papal visit. Factors that must also be considered during planned event operations include ambient environmental conditions which can affect the participants, providers, and facility design. The facility must provide adequate protection from the environment. Minimal support requirements include power, water, lighting, and adequate space to provide the level of care that the leadership determines will be needed. Types of events will change the demographics of the expected crowds and can influence the numbers seeking care. Distances from and number and capabilities of facilities in the community also will influence design and operations and staffing of such units, as does whether there will be alcohol or other intoxicants served or used at the event. Finally, high-profile events such as political conventions or speeches by prominent individuals bring security-related concerns that must be addressed. Such large events are often multijurisdictional and this increases the need for coordination, and creates challenges with respect to staffing and accreditation. The key to success with planned events is beginning the planning process early and assuring that all parties involved in care are part of the process. Another area in which temporary medical facilities have a prominent role is in creating surge capacity for hospitals and EMS systems to deal with large-scale disasters or events. While this has been a long-standing component of US civilian disaster planning [4], the concept of non-hospital sites to address increased need for patient care came to the forefront with the 2009 influenza pandemic [5]. The number of hospital beds available was felt to be inadequate to meet the demands anticipated, as the illness would spread across the country. Many medical facilities and health care systems developed temporary treatment facility plans as a component of their system surge planning. Surge capacity is defined as the ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system [6]. While numerous strategies exist to deal with this issue, the use of temporary facilities, often designated to provide care to the less acutely ill or injured, has been a component in many suggested approaches to the surge issue. Among the more common terms to describe these facilities is “alternative care facility (ACF)” or “alternative care site.” Hick et al. [7] have presented a scheme to classify surge response and resources and classify such deployable assets under the heading of catastrophic surge. Keeping the less ill patients outside the primary hospital was felt to keep risk of spread down and allow the sickest patients to be cared for at the acute care hospitals. In events such as a pandemic influenza outbreak, it is anticipated that there will be a large increase in demand for medical services and that many of those needing services will not require hospital-level or ED care. By creating care sites at locations other than the ED, and directing patients with less acute symptoms and care needs away from the ED, these other care sites allow medical providers to focus scarce resources on those with the greatest need [5]. While the level of care offered at an ACF may vary by system, the key component of the process is that it frees the ED and other in-hospital areas to see those patients who require a more advanced level of care, and allows those with less acute problems to be seen in a timely and effective manner. It is during such events that the scarce resources must be allocated to where they will do the most good. There is no consensus as to whether the ACF should be on the hospital campus or not. Colocating allows for easier logistical management, including resupply and adjusting of staffing, but does increase the risk of overwhelming the ED and main facility. Moving off-campus does decrease this last issue but brings other issues up, including how to inform patients of the location and transport of patients to and from the center, especially at a time when there may be a shortage of personnel at many essential community services due to illness. One of the disadvantages of temporary facilities is that they do require time and personnel to establish them, once the decision is made to deploy them. They are therefore more useful in events that have some degree of advanced warning, such as an approaching hurricane or an infectious disease event like an influenza pandemic. Temporary medical facilities associated with planned events also give the planners and providers a degree of time to design and plan the medical operations for the event. No-notice events such as tornados, hazmat and transportation accidents, and terrorist events, by their nature, do not have a lead time in which resources can be mobilized and deployed. Thus facilities used in these events have to be rapidly established, often with limited staffing, and flexible in design and capability. Individual health facilities may not have sufficient resources or personnel to staff such centers by themselves even if they adjust staffing patterns elsewhere in the organization. These types of facilities are often best created and deployed at the community or coalition level. Since the set-up and operation, supply, and staffing of such units may cross jurisdiction or corporate boundaries, it is important to develop collaborative plans for such care systems. These plans must address triggers for activation of the resource, staffing and supply of the resource, and operational guidelines. While many mass casualty incidents (MCIs) are of short duration, temporary care facilities are often operational for prolonged periods and often continue operations after the acute period, as was seen with both National Disaster Medical System and state-level assets deployed to events such as Hurricane Katrina. These temporary facilities often become the de facto
Temporary treatment facilities
Introduction
Planned events
Surge capacity
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