State of research in high-consequence hospital surge capacity

Managing Surges in Demand: A Grounded Conceptual Framework of Surge Management Capability

Surge management is important to hospital operations, yet surge literature has mostly focused on the addition of resources (e.g., 25% more beds) during events like pandemics. Such views are limiting, as meeting surge demands requires hospitals to engage in practices tailored to a surge's unique contingencies. We argue that a dynamic view of surge management should include surge management capability, which refers to how resources are deployed to respond to surge contingencies. To understand this capability, we qualitatively studied five hospital systems experiencing multiple surges due to COVID-19 between April 2020 and March 2022. We develop a framework showing that managing surges involves preserving capacity, expanding capacity, smoothing capacity demand, and enabling surge management. We contribute to surge literature by identifying practices hospitals can adopt to address surges and offering a better understanding of surge conditions (e.g., degree of novelty) that make some surge management practices more appropriate than others.

A Case Study on Community Treatment Center for Response to COVID-19 in Korea: Focusing on Surge Capacity 4S Component Analysis and Social Well-Being Perspective

In March, 2020, during the COVID-19 pandemic in Korea, the first Community Treatment Center (CTC), which is a motel-type Alternate Care Site (ACS) for mild and asymptomatic patients, was opened. This is a case study of the first Community treatment center prepared to respond to COVID-19. One of the researchers worked as a medical doctor in one of the CTCs operated by the Korean government. The CTC's eight medical staff members were interviewed in-depth one-on-one. Then the data obtained from observation, collection, and interview were triangulated. In this study, it was identified based on the 4S factor that evaluates the surge capacity to meet the medical needs of CTC. And how the CTC was operated from a medical and social welfare perspective and what problems appeared to patients during the operation were analyzed. Three dormitories of a national training center were used as the CTC. Each patient used a room equipped with a toilet, a shower, and a washbasin. Medical staff and government officials with various backgrounds were dispatched. Telemedicine was also used to prevent the spread of infection. The CTC made a significant contribution to both medical and social welfare fields. It provided patients psychological stability in a comfortable environment. But some patients had psychological problems and difficulties involving work and family care. Various efforts in conjunction with participation from social workers are required to reduce these problems.

A Multisite Investigation of Areas for Improvement in COVID-19 Surge Capacity Management

The congressionally authorized National Disaster Medical System Pilot Program was created in December 2019 to strengthen the medical surge capability, capacity, and interoperability of affiliated healthcare facilities in 5 regions across the United States. The COVID-19 pandemic provided an unprecedented opportunity to learn how participating healthcare facilities handled medical surge events during an active public health emergency. We applied a modified version of the Barbisch and Koenig 4-S framework (staff, stuff, space, systems) to analyze COVID-19 surge management practices implemented by healthcare stakeholders at 5 pilot sites. In total, 32 notable practices were identified to increase surge capacity during the COVID-19 pandemic that have potential applications for other healthcare facilities. We found that systems was the most prevalent domain of surge capacity among the identified practices. Systems and staff were discussed across all 5 pilot sites and were the 2 domains co-occurring most often within each surge management practice. These results can inform strategies for scaling up and optimizing medical surge capability, capacity, and interoperability of healthcare facilities nationwide. This study also specifies areas of surge capacity worthy of strategic focus in the pilot's planning and implementation efforts while more broadly informing the US healthcare system's response to future large-scale, medical surge events.

Interdisciplinary Collaboration in International Crisis Medical Relief: A Look at the Nepal Earthquake and Ebola Relief Efforts

OBJECTIVE

This study explores interprofessional collaboration among medical and non-medical personnel planning and implementing international crisis health and medical relief efforts, and how disciplinary and professional background influences these activities.

METHODS

This study analyzes semi-structured interviews with individuals involved in organizations medical or health services to the Ebola epidemic in West Africa (2014-2016) or the 2015 Nepal earthquake.

RESULTS

Disciplinary background, sometimes coupled with organization role, shaped how relief workers engaged in the process of planning and implementing crisis medical relief. There were 3 thematic areas where these differences emerged: issue focus, problem -solving approaches, and decision-making approaches. Solutions from the field emerged as a fourth theme.

CONCLUSIONS

The study demonstrates medical relief required collaboration across medical and non-medical professions and highlights the importance of relief workers' disciplinary background in shaping the planning and implementation of crisis medical relief. Successful collaboration requires that people involved in crisis relief communicate the relevance of their own expertise, identify limits of their own and others' disciplinary perspective(s), seek out strengths in others' expertise, and can identify/ respond appropriately to others who do not see their own disciplinary limits, as well as learn these skills before engaging in relief.

A practice-based nursing emergency management system model for public health emergencies: A descriptive qualitative study

AIM

This study aims to explore nursing emergency management system under public health emergencies.

DESIGN

A descriptive qualitative study.

METHOD

Semi-structured interviews were conducted during March-November 2020 with 11 nursing emergency management administrators from 11 COVID-19 designated hospitals and infectious disease hospitals under four administrative divisions in China, who were recruited through convenience and purposive sampling. Interviews were audio-recorded and transcribed. Data were analysed with Braun and Clarke's inductive thematic analysis. The study adhered to the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

Three main themes emerged from data analysis: (1) Five core elements of nursing emergency management system: Structure, Staff, System, Setting, and Supply (5S); (2) Four phases of nursing emergency management system: Reduction, Readiness, Response and Recovery (4R); and (3) operational process of nursing emergency management system (5S*4R). The findings generated a conceptual model of a nursing emergency management system.

PUBLIC CONTRIBUTION

This study provides a theoretical basis for nursing emergency management system for public health emergencies in the future. Nurse administrators could refer to this model to either review or develop their system and develop viable interventions to prepare for future public health emergencies.

Incidence management system of the healthcare institutions for disaster management in Sri Lanka

BACKGROUND

Incident management systems and disaster planning processes facilitate maximal use of available resources. Evaluation of the Incident Command System (ICS) is one of the top five key areas of research priority in the field of surge. The study was aimed at assessing the disaster preparedness and ICS of the public healthcare institutions for the disaster management in a disaster-prone district of Sri Lanka.

METHODS

A descriptive cross-sectional study was conducted among all public sector healthcare institutions (n = 74), including curative-healthcare institutions (n = 46) which have inward-care facilities for patient care and preventive healthcare institutions (n = 28) in Kurunegala district, Sri Lanka from May-September 2019 using a validated interviewer administered questionnaire which was based on 'CO-S-TR Model' for ICS assessment including 'Clear need for increased capacity (≤25%), Basic level (26 - 50%), Moderate level (51 - 75%) and High level (>75%)'.

RESULTS

Focal points for disaster management were nominated by the majority of the curative sector (n = 33; 76.7%) and preventive sector (n = 19; 73.1%) healthcare institutions. A written disaster preparedness and response plans were available in 72% (n= 31) curative sector and 76% (n= 19) preventive sector institutions. The higher proportion of the curative sector institutions had moderate level capacity in the area of providing treatment, and basic level capacities were in the areas of 'staff mobilization, coordination of activities, supplying of special needs, triage of cases and transportation'. There is a clear need for improvement in the areas of communication commanding, management of controlling the incidence and tracking of the cases in the curative sector. The majority of the preventive sector institutions had moderate level capacity in commanding, control, coordination and tracking of cases. The basic level capacity in the areas of staff mobilization, stuff management and triage of cases. There is a clear need for improvement in the areas of communication in preventive sector. Of the public sector healthcare institutions, the higher proportion of the preventive sector (n = 20; 76.9%) and curative sector (n = 29; 67.4%) had basic level overall surge capacity of ICS for disaster management.

CONCLUSION

Coordination, communication, commanding, management of controlling the incidence and tracking of cases following outbreaks need to be improved and capacity development programmes could implement to develop the preparedness for future disasters.

An Overview of Hospital Capacity Planning and Optimisation

Health care is uncertain, dynamic, and fast growing. With digital technologies set to revolutionise the industry, hospital capacity optimisation and planning have never been more relevant. The purposes of this article are threefold. The first is to identify the current state of the art, to summarise/analyse the key achievements, and to identify gaps in the body of research. The second is to synthesise and evaluate that literature to create a holistic framework for understanding hospital capacity planning and optimisation, in terms of physical elements, process, and governance. Third, avenues for future research are sought to inform researchers and practitioners where they should best concentrate their efforts. In conclusion, we find that prior research has typically focussed on individual parts, but the hospital is one body that is made up of many interdependent parts. It is also evident that past attempts considering entire hospitals fail to incorporate all the detail that is necessary to provide solutions that can be implemented in the real world, across strategic, tactical and operational planning horizons. A holistic approach is needed that includes ancillary services, equipment medicines, utilities, instrument trays, supply chain and inventory considerations.

Registered nurses' experience as disaster preparedness coordinators during a major incident: A qualitative study

Aims

To explore registered nurses’ experiences as disaster preparedness coordinators of hospital incident command groups’ during a major incident.

Design

A qualitative descriptive design using semi‐structured interview.

Methods

This was a qualitative study based on one focus group discussion and six individual follow‐up interviews. Participants were registered nurses in their capacity as disaster preparedness coordinators with experience from Major Incident simulations and a real‐life Major Incident. The interviews were transcribed verbatim and analysed using content analysis. The COREQ checklist was used for reporting the findings.

Results

The analysis of data generated the main category: Expectations, previous experience and uncertainty affect hospital incident command group response during a Major Incident and three categories, (I) Gaining situational awareness (containing two subcategories), (II) Transitioning to management (containing three subcategories) and (III) Actions taken during uncertainty (containing two subcategories).

Emergency department registered nurses overestimate their disaster competency: A cross-sectional study

BACKGROUND

Major incidents continue to pose a threat to health care systems by overwhelming them with a sudden surge of patients. A major factor impacting a hospital's surge capacity is the skills, abilities, and knowledge of emergency department (ED) registered nurses (RN). The level of disaster nursing competency they possess affects patient safety and outcome. ED RNs' ability to accurately assess their competency and knowledge is imperative for mitigating the effect of major incidents. ED RN's perception of overall disaster preparedness has not been thoroughly addressed. The aim of this study was to assess emergency department registered nurses' self-perceived disaster preparedness.

METHOD

The study was a cross-sectional study per the STROBE checklist. A self-assessment questionnaire based on the results of a study identifying specific disaster nursing competencies for ED RNs was distributed to all ED RNs at six participating hospitals between January 10th to February 19th of 2019. A five-point Likert-type scale was used to assess competency.

RESULTS

ED RNs' disaster preparedness according to the Total Disaster Competency mean was low. Furthermore, the results indicate that ED RNs' significantly overestimate their disaster nursing competency when compared to the Total Disaster Competency mean. Additionally, this study identified factors such as experience and education were positively associated with disaster preparedness and self-assessment ability.

CONCLUSION

ED RNs' overestimate their disaster preparedness. However, ED RNs with experience and education may be better prepared. ED RNs with formal disaster education appeared to have better insight concerning their preparedness. Clinical experience, advanced levels of education, and training were positively associated with preparedness. Overestimating disaster competencies may negatively impact patient outcomes during a major incident.

Health workforce surge capacity during the COVID‐19 pandemic and other global respiratory disease outbreaks: A systematic review of health system requirements and responses

Health system decision‐makers need comprehensive evidence to mitigate surges in the demand for human resources for health (HRH) during infectious disease outbreaks. This study aimed to assess the state of the evidence on policy and planning responses to HRH surge capacity during the coronavirus disease (COVID‐19) pandemic and other viral respiratory disease outbreaks of global significance in the 21st century. We systematically searched eight bibliographic databases to extract primary research articles published between January 2000 and June 2020 capturing temporal changes in health workforce requirements and responses surrounding respiratory virus pandemics. Following the Preferred Reporting Items for Systematic Reviews and Meta‐analyses standard, 16 studies met our inclusion criteria. Five focused on COVID‐19, three on H1N1, and eight modelled a hypothetical pandemic. Investigations of different training, mobilization, and redeployment options to address pandemic‐time health system capacity were reviewed; however, few scenarios drew on observational HRH data, and heterogeneity of study approaches and outcomes generally precluded comparability across contexts. Notable evidence gaps included occupational and psychosocial factors affecting healthcare workers' absenteeism and risk of burnout, gendered considerations of HRH capacity, evaluations in low‐ and lower‐middle income countries, and policy‐actionable assessments to inform post‐pandemic recovery and sustainability of services for noncommunicable disease management.

Rapidly building surge capacity within a pandemic response using simulation-based clinical systems testing

INTRODUCTION

As the SARS-CoV-2 virus spread across the globe, hospitals around the USA began preparing for its arrival. Building on previous experience with alternative care sites (ACS) during surge events, Texas Children's Hospital (TCH) opted to redeploy their mobile paediatric emergency response teams. Simulation-based clinical systems testing (SbCST) uses simulation to test preoccupancy spaces and new processes. We developed rapid SbCST with social distancing for our deployed ACS, with collaboration between emergency management, paediatric emergency medicine and the simulation team.

METHODS

A two-phased approach included an initial virtual tabletop activity followed by SbCST at each campus, conducted simultaneously in-person and virtually. These activities were completed while also respecting the need for social distancing amidst a pandemic response. Each activity's discussion was facilitated using Promoting Excellence and Reflective Learning in Simulation (PEARLS) for systems integration debriefing methodology and was followed by compilation of a failure mode and effects analysis (FMEA), which was then disseminated to campus leaders.

RESULTS

Within a 2-week period, participants from 20 different departments identified 109 latent safety threats (LSTs) across the four activities, with 71 identified as being very high or high priority items. Very high and high priority threats were prioritised in mitigation efforts by hospital leadership.

DISCUSSION

SbCST can be rapidly implemented to hone pandemic responses and identify LSTs. We used SbCST to allow for virtual participation and social distancing within a rapidly accelerated timeline. With prioritised FMEA reporting, leadership was able to mitigate concerns surrounding the four Ss of surge capacity: staff, stuff, structure and systems.

Planning for large epidemics and pandemics: challenges from a policy perspective

PURPOSE OF REVIEW

Less than two decades into the 21st century, the world has already witnessed numerous large epidemics or pandemics. These events have highlighted inadequacies in both national and international capacity for outbreak prevention, detection, and response. Here, we review some of the major challenges from a policy perspective.

RECENT FINDINGS

The most important challenges facing policymakers include financing outbreak preparedness and response in a complex political environment with limited resources, coordinating response efforts among a growing and diverse range of national and international actors, accurately assessing national outbreak preparedness, addressing the shortfall in the global biomedical workforce, building surge capacity of both human and material resources, balancing investments in public health and curative services, building capacity for outbreak-related research and development, and reinforcing measures for infection prevention and control.

SUMMARY

In recent years, numerous epidemics and pandemics have caused not only considerable loss of life but also billions of dollars of economic loss. Although the events have served as a wake-up call and led to the implementation of relevant policies and counter-measures, such as the Global Health Security Agenda, many questions remain and much work to be done. Wise policies and approaches for outbreak control exist, but will require the political will to implement them.

Barriers and facilitators to provide continuity of care to dischargeable patients in disasters: A qualitative study

OBJECTIVE

Early discharge of some in-patients is the effective measure to create hospital surge capacity in disasters. However, some of these patients may need to post-discharge continuity of care. The aim of the current study then is to explore the barriers of continuity of care, and to provide suitable solutions for potentially dischargeable patients during disasters.

METHODS

This qualitative study was conducted in Iran in 2017. The data was collected via unstructured interviews with 24 disaster professionals; and analyzed by content analysis method.

RESULTS

Identified barriers to the continuity of care were classified into seven categories, 'lack of disaster paradigm'; 'challenges of pre-hospital system'; 'insufficient coordination and cooperation'; 'inadequate hospital preparedness'; 'lack of using available resources and capacities'; 'poor patients' knowledge' and 'poor planning'. The suggested solutions for post-discharge continuity of care were: creation of registry and follow-up system; removing pre-hospital challenges; including disaster management courses in medical school curriculum; promoting hospital preparedness by All-Hazard Approach; and effective use of available resources.

CONCLUSION

Understanding the barriers to continuity of care for discharged patients for adopting policies based on experiences of health care providers can help planners to design and implement effective programs, which will enhance patients' access to necessary care.

Surge Capacity of Hospitals in Emergencies and Disasters With a Preparedness Approach: A Systematic Review

Objective

Surge capacity is one of the most important components of hospital preparedness for responding to emergencies and disasters. The ability to provide health and medical care during a sudden increase in the number of patients or victims of disasters is a main concern of hospitals. We aimed to perform a systematic review of hospital surge capacity in emergencies and disasters with a preparedness approach.

Methods

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words “surge,” “surge capacity,” “preparedness,” “hospital emergency department,” “hospital,” “surge capability,” “emergency,” “hazard,” “disaster,” “catastrophe,” “crisis,” and “tragedy” were used in combination with the Boolean operators OR and AND. The Google Scholar, ISI Web of Science, Science Direct, PubMed, Scopus, Ovid, Pro Quest, and Wiley databases were searched.

Results

A total of 1008 articles were extracted and 17 articles were selected for final review of surge capacity based on the objective of the study. Seventeen studies (1 randomized controlled trial, 2 qualitative studies, and 14 cross-sectional studies) investigated the surge capacity of hospitals in emergencies and disasters to evaluate the best evidence to date. The results of selected articles indicated that there are various ways to increase the capacity of hospitals in 4 domains: staff, stuff, structure, and system.

Conclusion

Surge capacity is a basic element of disaster preparedness programs. Results of the current study could help health field managers in hospitals to prepare for capacity-building based on surge capacity components to improve and promote hospital preparedness programs. (Disaster Med Public Health Preparedness. 2017;11:612–620)

Adequacy of US Hospital Security Preparedness for Mass Casualty Incidents: Critical Lessons From the Israeli Experience

CONTEXT

Due to Israel's threat environment, Israeli hospitals have developed effective and innovative security preparations for responding to all-hazards incidents. Although Israeli hospital preparedness has been the subject of international praise and attention, there has been a dearth of research focused specifically on applying Israeli hospital security measures to the US hospital setting to augment emergency planning.

OBJECTIVE

This study examined practical and cost-effective lessons from the Israeli experience for improving US hospital security preparedness for a wide range of mass casualty incidents, both natural and man-made.

DESIGN

Sixty semi-structured interviews were conducted with officials throughout Israel's and America's health, defense, and emergency response communities. Hospital preparedness was examined and disaster drills were evaluated in both countries, with San Francisco hospitals analyzed as a case study. Qualitative analysis was conducted and recommendations were made on the basis of an all-hazards approach to emergency preparedness.

RESULTS

US hospitals examined in this study had not undertaken crucial preparations for managing the security consequences of a large-scale disaster. Recommendations from Israel included installing permanent emergency signage, improving security perimeter protocols and training, increasing defense against primary and secondary attacks, enhancing coordination with law enforcement, the National Guard, and other outside security agencies, and conducting more frequent and realistic lockdown exercises.

CONCLUSIONS

A number of US hospitals have overlooked the important role of security in emergency preparedness. This study analyzed practical and cost-effective security recommendations from Israel to remedy this dangerous deficiency in some US hospitals' disaster planning.

Assessing the State of Knowledge Regarding the Effectiveness of Interventions to Contain Pandemic Influenza Transmission: A Systematic Review and Narrative Synthesis

BACKGROUND

Influenza pandemics occur when a novel influenza strain, to which humans are immunologically naïve, emerges to cause infection and illness on a global scale. Differences in the viral properties of pandemic strains, relative to seasonal ones, can alter the effectiveness of interventions typically implemented to control seasonal influenza burden. As a result, annual control activities may not be sufficient to contain an influenza pandemic.

PURPOSE

This study seeks to inform pandemic policy and planning initiatives by reviewing the effectiveness of previous interventions to reduce pandemic influenza transmission and infection. Results will inform the planning and design of more focused in-depth systematic reviews for specific types of interventions, thus providing the most comprehensive and current understanding of the potential for alternative interventions to mitigate the burden of pandemic influenza.

METHODS

A systematic review and narrative synthesis of existing systematic reviews and meta-analyses examining intervention effectiveness in containing pandemic influenza transmission was conducted using information collected from five databases (PubMed, Medline, Cochrane, Embase, and Cinahl/EBSCO). Two independent reviewers conducted study screening and quality assessment, extracting data related to intervention impact and effectiveness.

RESULTS AND DISCUSSION

Most included reviews were of moderate to high quality. Although the degree of statistical heterogeneity precluded meta-analysis, the present systematic review examines the wide variety of interventions that can impact influenza transmission in different ways. While it appears that pandemic influenza vaccination provides significant protection against infection, there was insufficient evidence to conclude that antiviral prophylaxis, seasonal influenza cross-protection, or a range of non-pharmaceutical strategies would provide appreciable protection when implemented in isolation. It is likely that an optimal intervention strategy will employ a combination of interventions in a layered approach, though more research is needed to substantiate this proposition.

TRIAL REGISTRATION

PROSPERO 42016039803.

Refining Surge Capacity: Conventional, Contingency, and Crisis Capacity

Health care facility surge capacity has received significant planning attention recently, but there is no commonly accepted framework for detailed, phased surge capacity categorization and implementation. This article proposes a taxonomy within surge capacity of conventional capacity (implemented in major mass casualty incidents and representing care as usually provided at the institution), contingency capacity (using adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on delivered medical care), and crisis capacity (implemented in catastrophic situations with a significant impact on standard of care). Suggested measurements used to gauge a quantifiable component of surge capacity and adaptive strategies for staff and supply challenges are proposed. The use of refined definitions of surge capacity as it relates to space, staffing, and supply concerns during a mass casualty incident may aid phased implementation of surge capacity plans at health care facilities and enhance the consistency of terminology and data collection between facilities and regions. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S59–S67)

Health systems' "surge capacity": state of the art and priorities for future research

CONTEXT

Over the past decade, a number of high-impact natural hazard events, together with the increased recognition of pandemic risks, have intensified interest in health systems' ability to prepare for, and cope with, "surges" (sudden large-scale escalations) in treatment needs. In this article, we identify key concepts and components associated with this emerging research theme. We consider the requirements for a standardized conceptual framework for future research capable of informing policy to reduce the morbidity and mortality impacts of such incidents. Here our objective is to appraise the consistency and utility of existing conceptualizations of health systems' surge capacity and their components, with a view to standardizing concepts and measurements to enable future research to generate a cumulative knowledge base for policy and practice.

METHODS

A systematic review of the literature on concepts of health systems' surge capacity, with a narrative summary of key concepts relevant to public health.

FINDINGS

The academic literature on surge capacity demonstrates considerable variation in its conceptualization, terms, definitions, and applications. This, together with an absence of detailed and comparable data, has hampered efforts to develop standardized conceptual models, measurements, and metrics. Some degree of consensus is evident for the components of surge capacity, but more work is needed to integrate them. The overwhelming concentration in the United States complicates the generalizability of existing approaches and findings.

CONCLUSIONS

The concept of surge capacity is a useful addition to the study of health systems' disaster and/or pandemic planning, mitigation, and response, and it has far-reaching policy implications. Even though research in this area has grown quickly, it has yet to fulfill its potential to generate knowledge to inform policy. Work is needed to generate robust conceptual and analytical frameworks, along with innovations in data collection and methodological approaches that enhance health systems' readiness for, and response to, unpredictable high-consequence surges in demand.

Secondary surge capacity: a framework for understanding long-term access to primary care for medically vulnerable populations in disaster recovery

Disasters create a secondary surge in casualties because of the sudden increased need for long-term health care. Surging demands for medical care after a disaster place excess strain on an overtaxed health care system operating at maximum or reduced capacity. We have applied a health services use model to identify areas of vulnerability that perpetuate health disparities for at-risk populations seeking care after a disaster. We have proposed a framework to understand the role of the medical system in modifying the health impact of the secondary surge on vulnerable populations. Baseline assessment of existing needs and the anticipation of ballooning chronic health care needs following the acute response for at-risk populations are overlooked vulnerability gaps in national surge capacity plans.

Cancellation of Scheduled Procedures as a Mechanism to Generate Hospital Bed Surge Capacity—A Pilot Study

Background: The ability to generate hospital beds in response to a mass-casualty incident is an essential component of public health preparedness. Although many acute care hospitals' emergency response plans include some provision for delaying or canceling elective procedures in the event of an inpatient surge, no standardized method for implementing and quantifying the impact of this strategy exists in the literature. The aim of this study was to develop a methodology to prospectively emergency plan for implementing a strategy of delaying procedures and quantifying the potential impact of this strategy on creating hospital bed capacity.

Methods: This is a pilot study. A categorization methodology was devised and applied retrospectively to all scheduled procedures during four one-week periods chosen by convenience. The categorization scheme grouped procedures into four categories: (A) procedures with no impact on inpatient capacity; (B) procedures that could be delayed indefinitely; (C) procedures that could be delayed by one week; and (D) procedures that could not be delayed. The categorization scheme was applied by two research assistants and an emergency medicine resident. All three raters categorized the first 100 cases to allow for calculation of inter-rater reliability. Maximal hospital bed capacity was defined as the 95th percentile weekday occupancy, as this is more representative of functional bed capacity than is the number of licensed beds. The main outcome was the number of hospital beds that could be created by postponing procedures in categories B and C.

Results: Maximal hospital bed capacity was 816 beds. Mean occupancy during weekdays was 759 versus 694 on weekends. By postponing Group B and C procedures, a mean of 60 beds (51 general medical/surgical and nine intensive care unit (ICU)) could be created on weekdays, and four beds (three general medical/surgical and one ICU) on weekends. This represents 7.3% and 0.49% of maximal hospital bed capacity and ICU capacity, respectively. In the event that sustained surge is needed, delaying all category B and C procedures for one week would lead to the generation of 1,235 hospital-bed days. Inter-rater reliability was high (kappa = 0.74) indicating good agreement between all three raters.

Conclusions: For the institution studied, the strategy of delaying scheduled procedures could generate inpatient capacity with maximal impact during weekdays and little impact on weekends. Future research is needed to validate the categorization scheme and increase the ability to predict inpatient surge capacity across various hospital types and sizes.

[Distribution planning of injured persons in mass disasters or catastrophes. Structuring of hospital capacities exemplified by the catastrophe network of the German Society for Trauma Surgery (DGU)]

Relevant changes have occurred in disaster management in Germany due to legal alterations and the introduction of the diagnosis-related groups (DRG) system. This has resulted in a reduction in bed capacities and an increase in bed utilization. In addition to the preclinical deployment strategy the provisional aspects of disaster medicine with the problem of the emergency service/hospital interface will be described. A suggestion for a solution for optimization of patient allocation in mass disasters or catastrophes will be demonstrated with the catastrophe network of the German Society for Trauma Surgery (DGU).

Laboratory surge response to pandemic (H1N1) 2009 outbreak, New York City metropolitan area, USA

Emergency preparedness programs are critical.

The North Shore–Long Island Jewish Health System Laboratories serve 15 hospitals and affiliated regional physician practices in the New York City metropolitan area, with virus testing performed at a central reference laboratory. The influenza A pandemic (H1N1) 2009 outbreak began in this area on April 24, 2009, and within weeks respiratory virus testing increased 7.5 times. In response, laboratory and client service workforces were increased, physical plant build-out was completed, testing paradigms were converted from routine screening tests and viral culture to a high-capacity molecular assay for respiratory viruses, laboratory information system interfaces were built, and same-day epidemiologic reports were produced. Daily review by leadership of data from emergency rooms, hospital facilities, and the Health System Laboratories enabled real-time management of unfolding events. The ability of System laboratories to rapidly increase to high-volume comprehensive diagnostics, including influenza A subtyping, provided key epidemiologic information for local and state public health departments.

Role of the primary care safety net in pandemic influenza

An influenza pandemic would have a disproportionately adverse impact on minority populations, the poor, the uninsured, and those living in underserved communities. Primary care practices serving the underserved would face special challenges in an influenza pandemic. Although not a formalized system, components of the primary care safety net include federally qualified health centers, public hospital clinics, volunteer or free clinics, and some local public health units. In the event of an influenza pandemic, the primary care safety net is needed to treat vulnerable populations and to provide health care surge capacity to prevent the overwhelming of hospital emergency departments. We examined the strength, capacity, and preparedness of key components of the primary care safety net in responding to pandemic influenza.

The current crisis in emergency care and the impact on disaster preparedness

Background

The Homeland Security Act (HSA) of 2002 provided for the designation of a critical infrastructure protection program. This ultimately led to the designation of emergency services as a targeted critical infrastructure. In the context of an evolving crisis in hospital-based emergency care, the extent to which federal funding has addressed disaster preparedness will be examined.

Discussion

After 9/11, federal plans, procedures and benchmarks were mandated to assure a unified, comprehensive disaster response, ranging from local to federal activation of resources. Nevertheless, insufficient federal funding has contributed to a long-standing counter-trend which has eroded emergency medical care. The causes are complex and multifactorial, but they have converged to present a severely overburdened system that regularly exceeds emergency capacity and capabilities. This constant acute overcrowding, felt in communities all across the country, indicates a nation at risk. Federal funding has not sufficiently prioritized the improvements necessary for an emergency care infrastructure that is critical for an all hazards response to disaster and terrorist emergencies.

Summary

Currently, the nation is unable to meet presidential preparedness mandates for emergency and disaster care. Federal funding strategies must therefore be re-prioritized and targeted in a way that reasonably and consistently follows need.

Planning for pandemic influenza: effect of a pandemic on the supply and demand for blood products in the United States

BACKGROUND

Influenza causes episodic pandemics when viral antigens shift in ways that elude herd immunity. Avian influenza A H5N1, currently epizootic in bird populations in Asia and Europe, appears to have pandemic potential.

STUDY DESIGN AND METHODS

The virology of influenza, the history of the 1918 pandemic, and the structure of the health care and the blood transfusion systems are briefly reviewed. Morbidity and mortality experience from the 1918 pandemic are projected onto the current health care structure to predict points of failure that are likely in a modern pandemic.

RESULTS

Blood donor centers are likely to experience loss of donors, workers, and reliable transport of specimens to national testing laboratories and degradation of response times from national testing labs. Transfusion services are likely to experience critical losses of workers and of reagent red cells (RBCs) that will make their automated procedures unworkable. Loss of medical directors, supervisors, and lead technicians may make alternative procedures unworkable as well.

CONCLUSIONS

Lower blood collection capacity and transfusion service support capability will reduce the availability of RBCs and especially of platelets. Plans for rationing medical care need to take the vulnerability of the blood transfusion system into account.