Peer-Reviewed Literature Search Results
Adini, B., A. Goldberg, et al. (2006). "Assessing levels of hospital emergency preparedness." Prehosp Disaster Med 21(6): 451-7.
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: Health care 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.
Aylwin, C. J., T. C. Konig, et al. (2006). "Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005." Lancet 368(9554): 2219-25.
BACKGROUND: The terrorist bombings in London on July 7, 2005, produced the largest mass casualty event in the UK since World War 2. The aim of this study was to analyse the prehospital and in-hospital response to the incident and identify system processes that optimise resource use and reduce critical mortality. METHODS: This study was a retrospective analysis of the London-wide prehospital response and the in-hospital response of one academic trauma centre. Data for injuries, outcome, triage, patient flow, and resource use were obtained by the review of emergency services and hospital records. FINDINGS: There were 775 casualties and 56 deaths, 53 at scene. 55 patients were triaged to priority dispatch and 20 patients were critically injured. Critical mortality was low at 15% and not due to poor availability of resources. Over-triage rates were reduced where advanced prehospital teams did initial scene triage. The Royal London Hospital received 194 casualties, 27 arrived as seriously injured. Maximum surge rate was 18 seriously injured patients per hour and resuscitation room capacity was reached within 15 min. 17 patients needed surgery and 264 units of blood products were used in the first 15 h, close to the hospital's routine daily blood use. INTERPRETATION: Critical mortality was reduced by rapid advanced major incident management and seems unrelated to over-triage. Hospital surge capacity can be maintained by repeated effective triage and implementing a hospital-wide damage control philosophy, keeping investigations to a minimum, and transferring patients rapidly to definitive care.
Bennett, R. L. (2006). "Chemical or biological terrorist attacks: an analysis of the preparedness of hospitals for managing victims affected by chemical or biological weapons of mass destruction." Int J Environ Res Public Health 3(1): 67-75.
The possibility of a terrorist attack employing the use of chemical or biological weapons of mass destruction (WMD) on American soil is no longer an empty threat, it has become a reality. A WMD is defined as any weapon with the capacity to inflict death and destruction on such a massive scale that its very presence in the hands of hostile forces is a grievous threat. Events of the past few years including the bombing of the World Trade Center in 1993, the Murrah Federal Building in Oklahoma City in 1995 and the use of planes as guided missiles directed into the Pentagon and New York's Twin Towers in 2001 (9/11) and the tragic incidents involving twenty-three people who were infected and five who died as a result of contact with anthrax-laced mail in the Fall of 2001, have well established that the United States can be attacked by both domestic and international terrorists without warning or provocation. In light of these actions, hospitals have been working vigorously to ensure that they would be "ready" in the event of another terrorist attack to provide appropriate medical care to victims. However, according to a recent United States General Accounting Office (GAO) nationwide survey, our nation's hospitals still are not prepared to manage mass causalities resulting from chemical or biological WMD. Therefore, there is a clear need for information about current hospital preparedness in order to provide a foundation for systematic planning and broader discussions about relative cost, probable effectiveness, environmental impact and overall societal priorities. Hence, the aim of this research was to examine the current preparedness of hospitals in the State of Mississippi to manage victims of terrorist attacks involving chemical or biological WMD. All acute care hospitals in the State were selected for inclusion in this study. Both quantitative and qualitative methods were utilized for data collection and analysis. Six hypotheses were tested. Using a questionnaire survey, the availability of functional preparedness plans, specific preparedness education/training, decontamination facilities, surge capacity, pharmaceutical supplies, and laboratory diagnostic capabilities of hospitals were examined. The findings revealed that a majority (89.2%) of hospitals in the State of Mississippi have documented preparedness plans, provided specific preparedness education/training (89.2%), have dedicated facilities for decontamination (75.7%), and pharmaceutical plans and supplies (56.8%) for the treatment of victims in the event of a disaster involving chemical or biological WMD. However, over half (59.5%) of the hospitals could not increase surge capacity (supplies, equipment, staff, patient beds, etc.) and lack appropriate laboratory diagnostic services (91.9%) capable of analyzing and identifying WMD. In general, hospitals in the State of Mississippi, like a number of hospitals throughout the United States, are still not adequately prepared to manage victims of terrorist attacks involving chemical or biological WMD which consequently may result in the loss of hundreds or even thousands of lives. Therefore, hospitals continue to require substantial resources at the local, State, and national levels in order to be "truly" prepared.
Blackwell, T. and M. Bosse (2007). "Use of an innovative design mobile hospital in the medical response to Hurricane Katrina." Ann Emerg Med 49(5): 580-8.
On August 29, 2005, Hurricane Katrina caused widespread devastation to the Gulf Coast region of the United States. Although New Orleans had extensive damage from flooding, many communities in Mississippi had equal damage from storm surge and wind. Because the medical resources in many of these areas were incapacitated, resources from North Carolina were deployed to assist in the medical mission. This response included the initial use of Carolinas MED-1, a mobile hospital that incorporates an emergency department, surgical suite, critical care beds, and general treatment and admitting area. This asset, along with additional State resources, provided comprehensive diagnostic and definitive patient care until the local medical infrastructure was rebuilt and functional. The use of a mobile hospital may be advantageous for future deployments to large-scale disasters, especially when integrated with specialty teams.
Bolster, C. J. (2006). "Mobile hospital provides care when disaster strikes." Healthc Financ Manage 60(2): 114-6, 118.
When planning resources for disaster response, hospitals should: Understand the mission of the equipment to be used. Be able to provide training. Learn how to use the resources most efficiently.
Bonnett, C. J., B. N. Peery, et al. (2007). "Surge capacity: a proposed conceptual framework." Am J Emerg Med 25(3): 297-306.
There is a need for emergency planners to accurately plan for and accommodate a potentially significant increase in patient volume in response to a disaster. In addition, an equally large political demand exists for leaders in government and the health care sector to develop these capabilities in a financially feasible and evidence-based manner. However, it is important to begin with a clear understanding of this concept on a theoretical level to create this capacity. Intuitively, it is easy to understand that surge capacity describes the ability of a health care facility or system to expand beyond its regular operations and accommodate a greater number of patients in response to a multiple casualty-producing event. The way a response to this need is implemented will, of course, vary dramatically depending on numerous issues, including the type of event that has transpired, the planning that has occurred before its occurrence, and the resources that are available. Much has been written on strategies for developing and implementing surge capacity. However, despite the frequency with which the term is used in the medical literature and by the lay press, a clear description of surge capacity as a concept is lacking. The following article will provide this foundation. A conceptual framework of surge capacity will be described, and some new nomenclature will be proposed. This is done to provide the reader with a comprehensive yet simplified view of the various elements that make up the concept of surge capacity. This framework will cover the types of events that can cause a surge of patients, the general ways in which health care facilities respond to these events, and the categories of people who would make up the population of affected victims.
Brandenburg, M. A., M. B. Ogle, et al. (2006). "Operation Child-Safe": a strategy for preventing unintentional pediatric injuries at a Hurricane Katrina evacuee shelter." Prehosp Disaster Med 21(5): 359-65.
INTRODUCTION: Children represent a vulnerable population, and special considerations are necessary to care for them properly during disasters. Comprehensive disaster responses include addressing the unique needs of children during mass-casualty incidents, such as the prevention of unintentional injuries. Early in the morning of 04 September 2005, approximately 1,600 Hurricane Katrina and/or flood survivors from New Orleans, including approximately 300 children, arrived at Camp Gruber, an Oklahoma National Guard base in Eastern Oklahoma. PROBLEM: The primary function of Camp Gruber to train support personnel for the Oklahoma National Guard. This is not a child-safe environment. It was hypothesized that the camp contained numerous child injury hazards and that these hazards could be removed systematically using local child injury prevention experts, thereby preventing unintentional injuries to the displaced children. METHODS: On 08 September, "Operation Child-Safe" was launched by the Pediatric Injury Response Team to identify and remove pediatric injury hazards from Camp Gruber. Injury prevention experts from the Safe Kids Tulsa Area (SKTA) Chapter, the closest pediatric injury prevention group in the region, spearheaded the operation. Several visits were required to remove all of the injury hazards that were identified. RESULTS: Many hazards were identified and removed immediately, while others were addressed in a formal letter to the Camp Gruber Commander for required consent to implement changes. Hazards identified in the camp included, but were not limited to: (1) dangerous chemicals; (2) choking hazards; (3) open electrical outlets; and (4) missing smoke detectors. Bicycle helmets, car seats, strollers, portable cribs, and other safety-related items were passed out to families in need. A licensed daycare facility also was established in order to give the adult guardians a break from constant supervision. Over the course of one month, only one preventable injury (minor head injury) was reported during camp operations, and this particular injury occurred two days before "Operation Child-Safe" was initiated (Day 3 of camp operations). CONCLUSIONS: In the aftermath of an event that displaces large numbers of people, it is likely that children will be exposed to numerous injury hazards. Volunteers with expertise in child injury prevention are needed to make an evacuee shelter safer for children.
Bridgewater, F. H., E. T. Aspinall, et al. (2006). "Team Echo: observations and lessons learned in the recovery phase of the 2004 Asian tsunami." Prehosp Disaster Med 21(1): s20-5.
The 26 December 2004 Tsunami resulted in a death toll of >270,000 persons, making it the most lethal tsunami in recorded history. This article presents performance data observations and the lessons learned by a civilian team dispatched by the Australian government to "provide clinical and surgical functions and to make public health assessments". The team, prepared and equipped for deployment four days after the event, arrived at its destination 13 days after the Tsunami. Aspiration pneumonia, tetanus, and extensive soft tissue wounds of the lower extremities were the prominent injuries encountered. Surgical techniques had to be adapted to work in the austere environment. The lessons learned included: (1) the importance of team member selection; (2) strategies for self-sufficiency; (3) personnel readiness and health considerations; (4) face-to-face handover; (5) coordination and liaison; (6) the characteristics of injuries; (7) the importance of protocols for patient discharge and hospital staffing; and (8) requirements for interpreter services. Whereas disaster medical relief teams will be required in the future, the composition and equipment needs will differ according to the nature of the disaster. National teams should be on standby for international response.
Burkle, F. M., Jr., E. B. Hsu, et al. (2007). "Definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ICS." Disaster Med Public Health Prep 1(2): 135-41.
The incident command system provides an organizational structure at the agency, discipline, or jurisdiction level for effectively coordinating response and recovery efforts during most conventional disasters. This structure does not have the capacity or capability to manage the complexities of a large-scale health-related disaster, especially a pandemic, in which unprecedented decisions at every level (eg, surveillance, triage protocols, surge capacity, isolation, quarantine, health care staffing, deployment) are necessary to investigate, control, and prevent transmission of disease. Emerging concepts supporting a unified decision-making, coordination, and resource management system through a health-specific emergency operations center are addressed and the potential structure, function, roles, and responsibilities are described, including comparisons across countries with similar incident command systems.
Burkle, F. M., Jr. (2006). "Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster." Acad Emerg Med 13(11): 1118-29.
Both the naturally occurring and deliberate release of a biological agent in a population can bring catastrophic consequences. Although these bioevents have similarities with other disasters, there also are major differences, especially in the approach to triage management of surge capacity resources. Conventional mass-casualty events use uniform methods for triage on the basis of severity of presentation and do not consider exposure, duration, or infectiousness, thereby impeding control of transmission and delaying recognition of victims requiring immediate care. Bioevent triage management must be population based, with the goal of preventing secondary transmission, beginning at the point of contact, to control the epidemic outbreak. Whatever triage system is used, it must first recognize the requirements of those Susceptible but not exposed, those Exposed but not yet infectious, those Infectious, those Removed by death or recovery, and those protected by Vaccination or prophylactic medication (SEIRV methodology). Everyone in the population falls into one of these five categories. This article addresses a population approach to SEIRV-based triage in which decision making falls under a two-phase system with specific measures of effectiveness to increase likelihood of medical success, epidemic control, and conservation of scarce resources.
Burstein, J. L. (2007). "Walls of canvas, walls of steel." Ann Emerg Med 49(5): 589.
Burstein, J. L. (2007). "You shall not stand by." Ann Emerg Med 49(5): 610-1.
Buttross, S. (2006). "Responding creatively to family needs of hospital staff: caring for children of caretakers during a disaster." Pediatrics 117(5 Pt 3): S446-7.
DeLia, D. (2006). "Annual bed statistics give a misleading picture of hospital surge capacity." Ann Emerg Med 48(4): 384-8, 388 e1-2.
STUDY OBJECTIVE: I describe how annual hospital surge capacity is affected by within-year variation in patient volume and bed supply. METHODS: Surge capacity was measured as the percentage and total number of hospital beds that are not occupied by patients. Administrative data were used to calculate these bed statistics for 78 hospitals in New Jersey—statewide and by emergency planning regions—in 2003. Annual bed statistics were compared to more refined calculations for each day of the year. Calculated numbers of empty beds were compared to Federal disaster planning benchmarks. RESULTS: Annual bed statistics showed no major limitations on surge capacity. Statewide occupancy rates were well below 80% (ie, more than 20% of beds were empty), and the number of empty beds that were set up and staffed (ie, maintained) was well above Federal disaster planning benchmarks. In contrast, daily bed statistics reveal long periods in 2003 when regional and statewide surge capacity was severely strained. Strained capacity was most likely to occur on Tuesdays through Fridays and least likely to occur on weekends. On 212 days, statewide occupancy of maintained beds met or exceeded 85%. This occupancy rate met or exceeded 90% and 95% on 88 and 4 days, respectively. On 288 days, the statewide number of empty maintained beds fell below the Federal planning benchmark. CONCLUSION: Annual bed statistics give a misleading picture of hospital surge capacity. Analysis of surge capacity should account for daily variation in patient volume and within-year variation in bed supply.
Eastman, A. L., K. J. Rinnert, et al. (2007). "Alternate Site Surge Capacity in Times of Public Health Disaster Maintains Trauma Center and Emergency Department Integrity: Hurricane Katrina." J Trauma 63(2): 253-257.
Erich, J. (2007). "As good as advertised: mobile hospital shines in Katrina response." Emerg Med Serv 36(2): 38-9.
Farmer, J. C. and P. K. Carlton, Jr. (2005). "Hospital disaster medical response: aligning everyday requirements with emergency casualty care." World Hosp Health Serv 41(2): 21-4, 41, 43.
In this essay, we would like to pragmatically and realistically introduce three topics: (a) Within the hospital, critical care is acknowledged as an enormous cost driver that becomes even less manageable during a disaster response scenario. It is widely recognised that hospital critical care capabilities for large scale disaster response require significant increases, but an overarching plan to accomplish this goal is lacking. This plan necessarily includes equipment, personnel, training, and space expansion. Lesser degrees of illness and injury will likely be cared for in other venues. What is required to provide 'large scale' critical care? (b) During a true large scale disaster with a large casualty stream, the mandate is not to provide 'standard of care,' but rather 'sufficiency of care.' What is that, what does that mean to critical care and the hospital, and how is that determined? (c) Are there other mandated in-hospital requirements that can be appropriately and successfully leveraged for disaster medical response?
Fernald, J. P. and E. A. Clawson (2007). "The mobile army surgical hospital humanitarian assistance mission in Pakistan: the primary care experience." Mil Med 172(5): 471-7.
Military surgical field hospitals are frequently deployed for humanitarian missions. Current Department of Defense doctrine and World Health Organization policy question the appropriateness of their use, because the majority of patients require nonsurgical care. We describe our experiences during the deployment of a mobile army surgical hospital in response to the October 8, 2005, earthquake in Pakistan. More than 20,000 patients received care during a 4-month period. An initially high surgical workload quickly decreased while the volume of primary care patients increased, eventually accounting for 90% of patient visits. Our experience supports deploying primary care-oriented units for humanitarian missions.
Franco, C., E. Toner, et al. (2006). "Systemic collapse: Medical care in the aftermath of Hurricane Katrina." Biosecur Bioterror 4(2): 135-46.
This article describes and analyzes key aspects of the medical response to Hurricane Katrina in New Orleans. It is based on interviews with individuals involved in the response and on analysis of published reports and news articles. Findings include: (1) Federal, State, and local disaster plans did not include provisions for keeping hospitals functioning during a large-scale emergency; (2) the National Disaster Medical System (NDMS) was ill-prepared for providing medical care to patients who needed it; (3) there was no coordinated system for recruiting, deploying, and managing volunteers; and (4) many Gulf Coast residents were separated from their medical records. The article makes recommendations for improvement.
Gavagan, T. F., K. Smart, et al. (2006). "Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex." South Med J 99(9): 933-9.
On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility—the Katrina Clinic—at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.
Grantham, H. (2006). "Tsunami ECHO Team response." Prehosp Disaster Med 21(5): 366-7.
Hanfling, D. (2006). "Equipment, supplies, and pharmaceuticals: how much might it cost to achieve basic surge capacity?" Acad Emerg Med 13(11): 1232-7.
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.
Hick, J. L., D. Hanfling, et al. (2004). "Health care facility and community strategies for patient care surge capacity." Ann Emerg Med 44(3): 253-61.
Recent terrorist and epidemic events have underscored the potential for disasters to generate large numbers of casualties. Few surplus resources to accommodate these casualties exist in our current health care system. Plans for "surge capacity" must thus be made to accommodate a large number of patients. Surge planning should allow activation of multiple levels of capacity from the health care facility level to the Federal level. Plans should be scalable and flexible to cope with the many types and varied timelines of disasters. Incident management systems and cooperative planning processes will facilitate maximal use of available resources. However, resource limitations may require implementation of triage strategies. Facility-based or "surge in place" solutions maximize health care facility capacity for patients during a disaster. When these resources are exceeded, community-based solutions, including the establishment of off-site hospital facilities, may be implemented. Selection criteria, logistics, and staffing of off-site care facilities is complex, and sample solutions from the United States, including use of local convention centers, prepackaged trailers, and State mental health and detention facilities, are reviewed. Proper pre-event planning and mechanisms for resource coordination are critical to the success of a response.
Kaji, A., K. L. Koenig, et al. (2006). "Surge capacity for healthcare systems: a conceptual framework." Acad Emerg Med 13(11): 1157-9.
This report reflects the proceedings of a breakout session, "Surge Capacity: Defining Concepts," at the 2006 Academic Emergency Medicine Consensus Conference, "Science of Surge Capacity." Although there are several general descriptions of surge capacity in the literature, there is no universally accepted standard definition specifying the various components. Thus, the objectives of this breakout session were to better delineate the components of surge capacity and to outline the key considerations when planning for surge capacity. Participants were from diverse backgrounds and included academic and community emergency physicians, economists, hospital administrators, and experts in mathematical modeling. Three essential components of surge capacity were identified: staff, stuff, and structure. The focus on enhancing surge capacity during a catastrophic event will be to increase patient-care capacity, rather than on increasing things, such as beds and medical supplies. Although there are similarities between daily surge and disaster surge, during a disaster, the goal shifts from the day-to-day operational focus on optimizing outcomes for the individual patient to optimizing those for a population. Other key considerations in defining surge capacity include psychosocial behavioral issues, convergent volunteerism, the need for special expertise and supplies, development of a standard of care appropriate for a specific situation, and standardization of a universal metric for surge capacity.
Kanter, R. K. and J. R. Moran (2006). "Hospital Emergency Surge Capacity: An Empiric New York Statewide Study." Ann Emerg Med.
STUDY OBJECTIVE: National policy for emergency preparedness calls for hospitals to accommodate surges of 500 new patients per million population in a disaster, but published studies have not evaluated the ability of existing resources to meet these goals. We describe typical statewide and regional hospital occupancy and patterns of variation in occupancy and estimate the ability of hospitals to accommodate new inpatients. METHODS: Daily hospital occupancy for each hospital was calculated according to admission date and length of stay for each patient during the study period. Occupancy was expressed as the count of occupied beds. Peak hospital capacity was defined as the 95th percentile highest occupancy at each facility. Data obtained from the New York Statewide Planning and Research Cooperative System were analyzed for 1996 to 2002. Patients were classified as children (0 to 14 years, excluding newborns) or adults. Vacant hospital beds per million age-specific population were determined as the difference between peak capacity and average occupancy. RESULTS: In New York State, 242 hospitals cared for a peak capacity of 2,707 children and 46,613 adults. Occupancy averaged 60% of the peak for children and 82% for adults, allowing an average statewide capacity for a surge of 268 new pediatric and 555 adult patients for each million age-specific population. After the September 11, 2001, attacks, in the New York City region, a discretionary modification of admissions and discharges resulted in an 11% reduction from the expected occupancy for children and adults. CONCLUSION: Typically, there are not enough vacant hospital beds available to serve 500 children per million population. Modified standards of hospital care to expand capacity may be necessary to serve children in a mass-casualty event.
Kanter, R. K. and J. R. Moran (2007). "Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care." Pediatrics 119(1): 94-100.
BACKGROUND: Federal planners have suggested that one strategy to accommodate disaster surges of 500 inpatients per million population would involve altering standards of care. No data are available indicating the extent of alterations necessary to meet disaster surge targets. OBJECTIVE: Our goal was to, in a Monte Carlo simulation study, determine the probability that specified numbers of children could be accommodated for PICU and non-ICU hospital care in a disaster by a set of strategies involving altered standards of care. METHODS: Simulated daily vacancies at each hospital in New York City were generated as the difference between peak capacity and daily occupancy (generated randomly from a normal distribution on the basis of empirical data for each hospital). Simulations were repeated 1000 times. Capacity for new patients was explored for normal standards of care, for expansion of capacity by a discretionary 20% increase in vacancies by altering admission and discharge criteria, and for more strictly reduced standards of care to double or quadruple admissions for each vacancy. Resources were considered to reliably serve specified numbers of patients if that number could be accommodated with a probability of 90%. RESULTS: Providing normal standards of care, hospitals in New York City would reliably accommodate 250 children per million age-specific population. Hypothetical strict reductions in standards of care would reliably permit hospital care of 500 children per million, even if the disaster reduced hospital resources by 40%. On the basis of historical experience that as many as 30% of disaster casualties may be critically ill or injured, existing pediatric intensive care beds will typically be insufficient, even with modified standards of care. CONCLUSIONS: Extending resources by hypothetical alterations of standards of care would usually satisfy targets for hospital surge capacity, but ICU capacity would remain inadequate for large disasters.
Kelen, G. D., C. K. Kraus, et al. (2006). "Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study." Lancet 368(9551): 1984-90.
BACKGROUND: The ability to provide medical care during sudden increases in patient volume during a disaster or other high-consequence event is a serious concern for health-care systems. Identification of inpatients for safe early discharge (ie, reverse triage) could create additional hospital surge capacity. We sought to develop a disposition classification system that categorises inpatients according to suitability for immediate discharge on the basis of risk tolerance for a subsequent consequential medical event. METHODS: We did a warfare analysis laboratory exercise using evidence-based techniques, combined with a consensus process of 39 expert panelists. These panelists were asked to define the categories of a disposition classification system, assign risk tolerance of a consequential medical event to each category, identify critical interventions, and rank each (using a scale of 1-10) according to the likelihood of a resultant consequential medical event if a critical intervention is withdrawn or withheld because of discharge. FINDINGS: The panelists unanimously agreed on a five-category disposition classification system. The upper limit of risk tolerance for a consequential medical event in the lowest risk group if discharged early was less than 4%. The next categories had upper limits of risk tolerance of about 12% (IQR 8-15%), 33% (25-50%), 60% (45-80%) and 100% (95-100%), respectively. The expert panelists identified 28 critical interventions with a likelihood of association with a consequential medical event if withdrawn, ranging from 3 to 10 on the 10-point scale. INTERPRETATION: The disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.
Klein, K. R. and N. E. Nagel (2007). "Mass medical evacuation: Hurricane Katrina and nursing experiences at the New Orleans airport." Disaster Manag Response 5(2): 56-61.
Hurricane Katrina, a category 4 storm, struck the U.S. Gulf States in late August, 2005, resulting in the most costly and second most deadly natural disaster in recent United States history. The storm and subsequent flooding due to levee failure necessitated the evacuation of 80% of the city of New Orleans' 484,674 residents. Most of the city's hospitals and other health care resources were destroyed or inoperable. The hurricane devastated many communities, stranding people in hospitals, shelters, homes, and nursing homes. Nurses and other health care providers deployed to New Orleans to provide medical assistance experienced substantial challenges in making triage and treatment decisions for patients whose numbers far exceeded supplies and personnel. This article describes the experiences and solutions of nurses and other personnel from 3 Disaster Medical Assistance Teams assigned to the New Orleans airport responsible for perhaps the most massive patient assessment, stabilization, and evacuation operation in U.S. history. As the frequency of disasters continues to rise, it is imperative that the nursing profession realize its value in the disaster arena and continually take leadership roles.
Kost, G. J., N. K. Tran, et al. (2006). "Katrina, the tsunami, and point-of-care testing: optimizing rapid response diagnosis in disasters." Am J Clin Pathol 126(4): 513-20.
We assessed how point-of-care testing (POCT), diagnostic testing at or near the site of patient care, can optimize diagnosis, triage, and patient monitoring during disasters. We surveyed 4 primary care units (PCUs) and 10 hospitals in provinces hit hardest by the tsunami in Thailand and 22 hospitals in Katrina-affected areas. We assessed POCT, critical care testing, critical values notification, demographics, and disaster responses. Limited availability and poor organization severely limited POCT use. The tsunami impacted 48 PCUs plus island and province hospitals, which lacked adequate diagnostic instruments. Sudden overload of critical victims and transportation failures caused excessive mortality. In New Orleans, LA, flooding hindered rescue teams that could have been POCT-equipped. US sea, land, and airborne rescue brought POCT instruments closer to flooded areas. Katrina demonstrated POCT value in disaster responses. We recommend handheld POCT, airborne critical care testing, and disaster-specific mobile medical units in small-world networks worldwide.
Krol, D. M., M. Redlener, et al. (2007). "A mobile medical care approach targeting underserved populations in post-Hurricane Katrina Mississippi." J Health Care Poor Underserved 18(2): 331-40.
On August 29, 2005, Hurricane Katrina devastated the Gulf Coast Mississippi region, damaging health care infrastructure and adversely affecting the health of populations left behind. Operation Assist, a project of the Children's Health Fund and the Columbia University Mailman School of Public Health, operated mobile medical units to provide health services to underserved populations in the affected areas. Data collected from all patient encounters from September 5-20, 2005 demonstrate that in addition to common respiratory illnesses, skin conditions, and minor injuries, a high proportion of visits were for vaccine administration and chronic medical problems including hypertension, diabetes, and asthma. Mobile medical units staffed by primary care clinicians experienced in dealing with the clinical and social needs of the underserved and comfortable working in a resource-poor environment can make a positive contribution to post-disaster care.
Lafuente, C. R., V. Eichaker, et al. (2007). "Post-Katrina provision of health care to veterans in a mobile clinic: Providers' perspectives." J Am Acad Nurse Pract 19(8): 383-91.
Purpose: To describe the challenges faced by health care providers in the aftermath of one of the worst natural disasters in the United States. Data sources: Eight health care providers describe their perceptions of the care they provided to veterans at a mobile clinic in the aftermath of Hurricane Katrina. This informal report used Giorgi's phenomenological approach to gathering and analyzing information provided in written response to eight specific questions. Conclusions: Four broad categories of challenges and concerns are discussed in this article: (a) What was important in the provision of care for the veterans, (b) the hindrances encountered, (c) factors that facilitated the care given, and (d) the perceived effects of the care they provided. Three key themes characterized the lived experience of the eight participants: uncertainty, deprivation, and stabilization. Although this was not a formal research study, the authors and participants were able to use their research backgrounds and understandings to organize and make sense of their experiences during this chaotic period. Implications for practice: As hurricane season in the United States and the anniversary of Hurricane Katrina (August 2005) approach, it is hoped that this report on the experiences and recommendations of health care providers will benefit other providers in similar situations.
Leder, H. A. and P. Rivera (2006). "Six days in Charity Hospital: two doctors' ordeal in Hurricane Katrina." Ann Ophthalmol (Skokie) 38(1): 13-9.
Hurricane Katrina devastated the city of New Orleans as well as a large section of the Gulf Coastal region of the United States. Herein, we present a first-hand view of physicians who were actually running the hospital of a major medical center during this natural disaster. This event demonstrates the vulnerability of basic human services, including health care even in industrialized, wealthy countries.
Manley, W. G., P. M. Furbee, et al. (2006). "Realities of disaster preparedness in rural hospitals." Disaster Manag Response 4(3): 80-7.
Disaster preparedness has always been an area of major concern for the medical community, but recent world events have prompted an increased interest. The health care system must respond to disasters of all types, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common areas of preparedness must be explored. This study examines the experiences of rural hospital emergency departments with threat preparedness. Data were gathered through a nationwide survey to describe emergency department experience with specific incidents, as well as the frequency of occurrence of these events. Expanding surge capacity of hospitals and developing a community-wide response to natural or human-made incidents is crucial in mitigating long-term effects on the health care system. Analysis of preparedness activities will help identify common themes to better prioritize preparedness activities and maximize a hospital's response capabilities.
Millin, M. G., J. L. Jenkins, et al. (2006). "A comparative analysis of two external health care disaster responses following Hurricane Katrina." Prehosp Emerg Care 10(4): 451-6.
OBJECTIVE: Hurricane Katrina severely disrupted the health services in the U.S. Gulf Coast, necessitating an external health care response. The types and needs of patients following such an extensive event have not been well described. The objective of this study was to analyze the types of patients treated in two temporary clinics and to identify differences between them. METHODS: Two temporary sites were established: a disaster medical assistance team-based site in Mississippi and a volunteer-based site near New Orleans. Data were abstracted from patient charts for the two days of simultaneous operation: September 11 and 12, 2005. Each patient's age group, disposition, and primary discharge diagnosis was categorized and analyzed with descriptive and comparative statistics. RESULTS: There were a total of 501 patient encounters. The most common presentation overall was for chronic health conditions such as medication refills (20.6%), immunizations (11.0%), obtaining community resources (6.0%). and management of acute exacerbation of chronic hypertension (4.6%). There were important differences; the Mississippi site treated more acute conditions than the Louisiana site, including lacerations (13.7% vs. 0%; p < 0.001), musculoskeletal injuries (9.4% vs. 2.6%; p < 0.001), and other nonspecified injuries (3.0% vs. 0.4%; p = 0.020). CONCLUSIONS: With extensive damage to a health care system, these temporary clinics staffed by out-of-State volunteers provided needed health care. The most common health problems were related to chronic disease, primary health care, and routine emergency care, not to the direct impact of the hurricane. In addition to treating minor injuries, disaster planners should prepare to provide primary health care, administer vaccinations, and provide missing long-term medications.
Nieburg, P., R. J. Waldman, et al. (2005). "Hurricane Katrina. Evacuated populations—lessons from foreign refugee crises." N Engl J Med 353(15): 1547-9.
Phillips, S. (2006). "Current status of surge research." Acad Emerg Med 13(11): 1103-8.
The dramatic escalation of bioterrorism and public health emergencies in the United States in recent years unfortunately has coincided with an equally dramatic decline in the institutions and services we rely on for emergency preparedness. Hospitals in nearly every metropolitan area in the country have closed; those that remain open have reduced the number of available beds. "Just in time" supplies and health professional shortages have further compromised the nation's overall surge capacity. Emergency departments routinely operate at capacity. These circumstances make evidence-based research on emergency preparedness and surge capacity both more urgently needed and more complex. The Agency for Healthcare Research and Quality and other government and private agencies have been rapidly widening the field of knowledge in this area in recent months and years. This report focuses primarily on the work of the Agency for Healthcare Research and Quality.
Plotinsky, R. N. (2006). "Handwashing in a Texas evacuation center after Hurricane Katrina, 2005." Am J Infect Control 34(5): 327.
Policy, C. f. H. (2007). Adapting Standards of Care Under Altered Conditions (DRAFT), Columbia University School of Nursing.
Rivara, F. P., A. B. Nathens, et al. (2006). "Do trauma centers have the capacity to respond to disasters?" J Trauma 61(4): 949-53.
BACKGROUND: Concern has been raised about the capacity of trauma centers to absorb large numbers of additional patients from mass casualty events. Our objective was to examine the capacity of current centers to handle an increased load from a mass casualty disaster. METHODS: This was a cross-sectional study of Level I and II trauma centers. They were contacted by mail and asked to respond to questions about their surge capacity as of July 4, 2005. RESULTS: Data were obtained from 133 centers. On July 4, 2005 there were a median of 77 beds available in Level I and 84 in Level II trauma centers. Fifteen percent of the Level I and 12.2% of the Level II centers had a census at 95% capacity or greater. In the first 6 hours, each Level I center would be able to operate on 38 patients, while each Level II center would be able to operate on 22 patients. Based on available data, there are 10 trauma centers available to an average American within 60 minutes. Given the available bed capacity, a total of 812 beds would be available within a 60-minute transport distance in a mass casualty event. CONCLUSIONS: There is capacity to care for the number of serious non-fatally injured patients resulting from the types of mass casualties recently experienced. If there is a further continued shift of uninsured patients to and fiscally driven closure of trauma centers, the surge capacity could be severely compromised.
Romano, M. (2007). "Emergency preparedness. Texas system scores first with inflatable surge hospital." Mod Healthc 37(1): 16.
Sanford, C., J. Jui, et al. (2007). "Medical treatment at Louis Armstrong New Orleans International Airport after hurricane Katrina: The experience of disaster medical assistance teams WA-1 and OR-2." Travel Med Infect Dis 5(4): 230-5.
In the week following Hurricane Katrina, over 3000 patients were evacuated by air from a triage and medical treatment station at the Louis Armstrong New Orleans International Airport. This represents the largest air evacuation in history. Over 24,000 additional evacuees were transported from the airport to shelters. Disaster Medical Assistance Teams (DMATs) from several US States were deployed to the Louis Armstrong New Orleans International Airport to provide medical care to those evacuated from New Orleans. Despite warning from the US National Weather Service of catastrophic damage to New Orleans, adequate medical staffing was not attained at the airport triage station until 6 days after the hurricane struck. Organizational lapses, including inadequate medical and operational planning, understaffing of medical personnel, and failure to utilize Incident Command System, diminished the effectiveness of the Hurricane Katrina New Orleans Medical Operation.
Sariego, J. (2006). "CCATT: a military model for civilian disaster management." Disaster Manag Response 4(4): 114-7.
When major disasters incapacitate hospitals and definitive care facilities-as Hurricane Katrina did in 2005-a crisis point is rapidly reached. Critical care services are often the first to be overwhelmed. Personal experiences and regional disaster plans were examined in the wake of Hurricane Katrina to uncover shortfalls in delivery of care and resources. A search was undertaken for a viable model for delivering critical care services in the immediate post-disaster period. Such a model already exists in the US Air Force's (USAF) Critical Care Air Transport Teams (CCATT). These teams have functioned well during recent military conflicts by providing both ground critical care and transport of high-risk, severely injured patients. The need for augmented critical care and transport resources in the face of overwhelming casualties in the civilian environment does not require a de novo construct. The USAF's CCATT model should be easily adaptable to the civilian disaster scenario.
Saunders, J. M. (2007). "Vulnerable populations in an American Red Cross shelter after Hurricane Katrina." Perspect Psychiatr Care 43(1): 30-7.
TOPIC: During Katrina, people suddenly encountered multiple losses, including homes, finances, medications, and death of loved ones. The Model of Vulnerable Populations illustrates how reduced resources placed individuals at greater risk for harm. PURPOSE: Using vignettes and the Model of Vulnerable Populations, a psychiatric nurse discusses her experiences as an American Red Cross psychiatric/mental health nurse volunteer after the Katrina disaster at a Mississippi shelter. CONCLUSIONS: The role of the mental health nurse volunteer was demonstrated by assessment and interventions of advocacy, referral, crisis intervention, and general support and education. PRACTICE IMPLICATIONS: Using the Model of Vulnerable Populations, psychiatric nurses can improve mental health assessment and services by counseling, advocacy, triage, and teaching disease prevention strategies such as hand washing.
Schultz, C. H. and K. L. Koenig (2006). "State of research in high-consequence hospital surge capacity." Acad Emerg Med 13(11): 1153-6.
High-consequence surge research involves a systems approach that includes elements such as health care 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.
Schultz, C. H., J. L. Mothershead, et al. (2002). "Bioterrorism preparedness. I: The emergency department and hospital." Emerg Med Clin North Am 20(2): 437-55.
Fundamental precepts in hospital-based planning for bioterrorist events include having a comprehensive well-rehearsed disaster plan that is based on a threat and vulnerability analysis. JCAHO Environment of Care Standards and an "all-hazards" approach to disaster planning and management form the basis for a solid bioterrorism response plan. During preparation, education and training are imperative. Clinicians must maintain a high index of suspicion for use of bioterrorism agents, be able to make a rapid diagnosis, and promptly initiate empiric treatment. Other personnel from administration, security, public relations, laboratory, pharmacy, and facilities management should be familiar with the plan, know when and how to activate it, and understand their roles in the response. A recognized incident command system should be used. Hospital leadership must be aware of the facility's capabilities and capacities, and should have plans for expansion of services to meet the surge in demand. The command center should coordinate emergency personnel teams, decontamination, security, acquisition of supplies, and notification of public health and other authorities and the media. If the plan is ever implemented, stress management with psychologic support will play an important role in recovery.
Schultz, C. H. and S. J. Stratton (2007). "Improving hospital surge capacity: a new concept for emergency credentialing of volunteers." Ann Emerg Med 49(5): 602-9.
In the event of a large-scale terrorist attack, natural disaster, or other public health emergency, hospitals could not absorb the thousands of victims generated by the catastrophe. Even if hospitals can increase bed capacity by 20% to 30%, as some suggest, the problem of staffing these beds remains unresolved. One possibility is to rapidly increase hospital staff by providing emergency credentialing to volunteer health care professionals. Several organizations and systems currently exist that can deliver medical providers to a stricken area. Unfortunately, all of these have serious limitations that would make it difficult for hospitals to use the health care workers provided by such entities. We propose a unique concept that will allow hospitals to rapidly expand their staff with practitioners that meet their credentialing requirements. The concept is a database created by each hospital in a community that includes credentialed physicians, nurses, behavioral health professionals, and ancillary staff. The database will be limited to physicians with full privileges and all licensed hospital employees in good standing not currently facing disciplinary issues or practice restrictions. The individual databases would then be combined and stored on a single computer system housed at the county health care agency or other mutually acceptable organization, with copies sent back to participating hospitals and the State. After a large disaster, health care workers from unaffected areas, including other States, can approach affected hospitals and volunteer their services. Practitioners listed on the database could be given privileges in their specialties for 72 hours. This process is accurate, inexpensive, efficient, sustainable, and Joint Commission on Accreditation of Healthcare Organizations compliant and permits the immediate credentialing of large numbers of medical volunteers.
Sirbaugh, P. E., K. D. Gurwitch, et al. (2006). "Caring for evacuated children housed in the Astrodome: creation and implementation of a mobile pediatric emergency response team: regionalized caring for displaced children after a disaster." Pediatrics 117(5 Pt 3): S428-38.
Sobieraj, J. A., J. Reyes, et al. (2007). "Modeling hospital response to mild and severe influenza pandemic scenarios under normal and expanded capacities." Mil Med 172(5): 486-90.
William Beaumont Army Medical Center conducted quantitative modeling with FluSurge 2.0 (Centers for Disease Control and Prevention) to determine hospital capabilities in responding to patient arrival surges of the Fort Bliss population in mild 1968-type and severe 1918-type influenza pandemics. Model predictions showed that William Beaumont Army Medical Center could adequately care for all intensive care unit (ICU) and non-ICU patients during a mild pandemic, particularly if hospital capacity was expanded using the emergency management plan, excess surge plan, or activation of a contagious disease outbreak facility. For a severe influenza pandemic, model predictions showed that hospital beds, ventilators, and other resources would be exceeded within 2 or 3 weeks. Even at maximal hospital expansion, for a 12-week severe pandemic with a 35% attack rate there would be peak demand for 214% of available non-ICU beds, 785% of ICU beds, and 392% of ventilators. Health care planners and decision-makers should prepare for resource challenges when developing plans for the next influenza pandemic.
Velazquez, L., S. Dallas, et al. (2006). "A PHS pharmacist team's response to Hurricane Katrina." Am J Health Syst Pharm 63(14): 1332-5.
PURPOSE: The challenges and victories that a team of Public Health Service (PHS) pharmacists experienced in establishing pharmacy operations at a Federal medical station and conducting outreach missions are described. SUMMARY: The Gulf coast of Mississippi and southeast Louisiana were struck on August 29, 2005, by Hurricane Katrina, which caused widespread infrastructure damage, flooding, and loss of life. A team of 70 officers, which included 8 pharmacists, arrived on September 3 and 4 to establish a 480-bed Federal medical station in an aircraft hangar at the naval air station (NAS) in Meridian, Mississippi. Numerous challenges were encountered, including identifying a secure space for a pharmacy, determining how to manage the immediate shortage of medications, devising a dispensing system specific to controlled medications, handling personal medications brought in by patients, and maintaining adequate pharmacy staffing to provide for hospital needs. Two outreach efforts were also undertaken. The first was to assist the NAS pharmacy department, which was overwhelmed with nearly 800 Navy and Coast Guard personnel who were displaced to the Meridian NAS. The second outreach effort was to augment the staff at a local free clinic in Meridian, which needed help to set up their clinic so they could handle the influx of hurricane victims who were arriving daily. CONCLUSION: A team of PHS pharmacists established a pharmacy, provided pharmaceutical care, and conducted outreach programs to aid victims of Hurricane Katrina.
Vest, J. R. and A. M. Valadez (2006). "Health conditions and risk factors of sheltered persons displaced by Hurricane Katrina." Prehosp Disaster Med 21(2 Suppl 2): 55-8.
INTRODUCTION: During disasters, public health departments assume the role of maintaining the health of displaced persons. Displaced persons arrive with acute and chronic conditions as well as other risk factors. Descriptions of these conditions may aid future shelter planning efforts. METHODS: Approximately 4000 individuals from New Orleans, displaced by Hurricane Katrina, were sheltered in Austin, Texas. A stratified random sample of the population was selected using individual beds as the primary sampling unit. Adults were interviewed about their acute symptoms, chronic diseases, and other risk factors. RESULTS: The results indicate a substantial proportion of adults arrived with some symptoms of acute illness (49.8%). A majority of the adults reported living with a chronic condition (59.0%), and the prevalence of some chronic conditions was higher than that of the general population. Also, several factors that could complicate service delivery were prevalent. DISCUSSION: Acute illnesses present transmission risks within the shelter. Furthermore, chronic diseases must be managed and may complicate care of acute illnesses. Risks like activity limitation or substance abuse may complicate shelter operations. Defining the potential scope of the illness burden may be used to help public health departments better plan the services they must deliver to displaced populations.
Voelker, R. (2006). "Mobile hospital raises questions about hospital surge capacity." JAMA 295(13): 1499-503.