In a mass casualty event of any significant magnitude, hospitals and other traditional venues for health care will most likely be overwhelmed with patients or rendered inoperative, making it necessary to establish ACFs, defined as alternate locations for the provision of care that would usually be provided in an inpatient facility, including acute, subacute, and chronic care. The concept of providing medical care at a non-hospital ACF was demonstrated during the Civil War, the San Francisco earthquake of 1906, the influenza pandemic of 1918-1919, and, more recently, Hurricanes Katrina and Rita1 . During the Cold War in the 1950s and 1960s, this concept was developed and formalized by the U.S. Civil Defense Agency in cooperation with the U.S. Department of Health, Education, and Welfare as "Packaged Disaster Hospitals" (PDH). These PDHs consisted of modularized, pre-deployed units for 50, 100, or 200 beds. In 1972, funding for the PDH concept and the 2,500 deployed units was discontinued by Congress, and these units were declared surplus and disposed of over the next decade. We are now rediscovering, resurrecting, and refining this concept.
The focus on catastrophic bioterrorism over the past decade has resulted in some key efforts in the development of the concept of ACFs. The most widely recognized effort was the development of the Acute Care Center (ACC) and the Neighborhood Emergency Health Center (NEHC) by the U.S. Army Soldier and Biological Chemical Command.2-3 This innovative body of work addressed key concepts related to the delivery of care outside of established hospitals and focused on the following important issues:
- Level and scope of care to be delivered.
- Physical plant required for the establishment of such facilities.
- Staffing requirements for delivery of such care.
- Incident management structure required to integrate such facilities with the overall delivery of health care in the setting of a mass casualty event.
The ACC was described as having been "designed and equipped to treat patients who need inpatient treatment but do not require mechanical ventilation and those who are likely to die from an illness resulting from an agent of bioterrorism." This foundational planning guidance further defined the level of care that could reasonably be delivered in such a setting. The ACC was designated to "provide biologic agent-specific therapy and supportive care while hospitals focused on the treatment of critically ill patients."
In the aftermath of the 9/11 attacks, a more concerted focus was placed on the definition and development of health and medical surge capacity. A distinction was drawn between "health care facility" surge capacity and "community" surge capacity, with the understanding that community surge capacity strategies were focused on creation of out-of-hospital solutions for the delivery of health care, closely mirroring the ACC concept.4
Further conceptual development on the subject of surge capacity was conducted by the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission) and focused on the establishment of "surge hospitals." A number of important concepts were explored including the use of "facilities of opportunity," which were defined as "non-medical buildings that, because of their size or proximity to a medical center, can be adapted into surge hospitals."5 The use of "mobile medical facilities," mobile surge hospitals placed on tractor-trailer platforms, with surgical and intensive care capabilities, was also described. Also described was the importance of "portable facilities," transportable medical facilities that can be set up quickly and that are fully equipped, self contained, turnkey systems usually stored in a container system and based on military medical contingency planning.5 Indeed, all three types of contingencies were deployed during the augmentation of the health care disaster response in the aftermath of Hurricanes Katrina and Rita.
In the setting of this limited but important body of work on this subject, "alternate care facility" has been defined as a location for the delivery of medical care that occurs outside the acute hospital setting for patients who would, under normal circumstances, be treated as inpatients. It also may be identified as a site to provide event-specific management of unique considerations that might arise in the context of catastrophic mass casualty events, including the delivery of chronic care, the distribution of vaccines or medical countermeasures, or the quarantine/cohorting/sequestration of potentially infected patients in the setting of an easily transmissible infectious disease. The broad interpretation of the concept of alternative care sites must also include home care. This would be most appropriate for individuals requiring quarantine, patients who are mildly ill, or those requiring palliative care.
The identification and use of an ACF for the management and treatment of patients resulting from a mass casualty event represents a response to a scarce medical resource: hospital beds. This can only be done in the context of pre-event planning that delineates those medical functions and treatment objectives to be accomplished by implementing such a facility. Community planners, comprised of participants from municipal agencies including public safety, public health, and emergency management as well as representatives from local health care organizations or institutions, must conceive of, develop and implement a plan in which ACFs serve in concert with existing health care facilities including hospitals, outpatient clinics, and multi-specialty group offices, as well as home care, in order to deliver a wide-ranging level of medical services to the population in need. This assumes that the requirement is met for an organized mechanism for triage of patients into high acuity, moderate acuity, low acuity and expectant/expired categories, focusing on matching patient needs with available medical resources. This division of patients must also identify those for whom no manner of medical intervention is likely to result in a positive outcome and who are therefore candidates for palliative care. Such planning also assumes that the most severely ill or injured high acuity patients can only receive medical care commensurate with what would be expected within the setting of a hospital facility or an ACF that is outfitted to serve as an acute care hospital, which is unlikely.
Most communities will not be able to procure the quantity and complexity of resources or the level of staffing that would provide for the outward extension of hospital facilities into designated ACFs, which will often be located in "buildings of convenience." Therefore, it is imperative for planners to establish clear operational definitions of what can and cannot be accomplished in the setting of an ACF. The principle of managing patients under relatively austere conditions, with only limited supplies, equipment, pharmaceuticals, and staffing, must be the starting point for such plans.
Such facilities may ultimately be developed to serve different purposes depending on the circumstances. For example, an ACF might serve as a primary triage point, helping to decide which patients require hospitalization, which patients can be managed at home, which patients might benefit from observational care and minimal interventions available at the ACF, or which patients might be appropriate for palliative care that might also be available at an ACF. Such a facility might also be reasonably expected to cohort a group of patients who have been exposed to certain infectious agents who may only need continued observation and minimal, if any, medical intervention. Such facilities also may be designated as community-focused ambulatory care clinics that serve as points of distribution for medications, vaccinations, or other medical interventions that must be delivered to a wide population. Finally, such facilities could be designed to serve as low-acuity patient care sites to permit the off-loading of stable patients from hospitals in order to enhance the hospitals' internal patient care surge capability or as primary sites for the care of stable low-acuity patients.
The development of ACFs will not be accomplished in a vacuum of planning. Such facilities will necessarily be inextricably linked to local health care and emergency management systems, all of which should be involved in the planning process, including the commitment of financial support. ACFs should be integrated into the concept of operations of any regional health care alliance that is drawn together to plan for response to disasters. As such, these facilities must fit within the broader spectrum of medical and health care incident management.6-7 Community planners must identify the logistical support necessary for establishing and operating such ACFs. Planners should also attempt to identify and create protocol-driven patient management objectives based on assumptions about the types of patients that would be managed in such facilities.
A note on terminology: As the concept of the ACF has been developed and refined, multiple terms have evolved to describe this basic concept. Some of these terms include: alternative care facilities (or sites), acute care centers, alternate treatment facilities, alternate medical treatment sites, alternate treatment centers, alternate care centers, and temporary alternative health care facilities. Unless otherwise noted, the concepts discussed here apply to all of these different terms. Basically, ACF encompasses all non-hospital-based locations where organized non-ambulatory or ambulatory care can be provided at a time of markedly increased need during a naturally occurring or man-made disaster.
1. Trabert E, Giovachino M, et al: After Action Review of Federal Medical Station (FMS) Operations During Hurricanes Katrina and Rita, Department of Health and Human Services, 2006.
2. Church J. A Mass Casualty Care Strategy for Biological Terror Incidents: Neighborhood Emergency Help Center. SBCCOM Dept. of Army. May 2001.
3. Church J. A Mass Casualty Care Strategy for Biological Terror Incidents: Acute Care Center. SBCCOM Dept. of Army. December 2001.
4. Hick JL, Hanfling D, Burstein JL, DeAtely C, Barbisch D, Bogdan G, Cantrill S. Healthcare Facility and Community Strategies for Patient Care Surge Capacity. Ann Emerg Med 44:253-61;2004
5. Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission on Accreditation of Healthcare Facilities, Chicago, IL. 2006
6. Barbera J. Macintyre A. Medical and Health Incident Management System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management. December, 2002. George Washington University Institute for Crisis, Disaster, and Risk Management. https://www2.gwu.edu/~icdrm/
7. Reopening "Shuttered" Hospitals to Expand Surge Capacity. March 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/shuttered/.
* Many of the concepts presented here are enhancements of work originally presented in:
Cantrill SV, Bonnett C, Hanfling D, Pons R. Alternative Care Sites in Mass Medical Care with Scarce Resources: A Community Planning Guide. AHRQ Publication No. 07-0001. Rockville, MD, Agency for Healthcare Research and Quality, February 2007. http://www.ahrq.gov/research/mce/ Accessed August 12, 2009, and in:
Cantrill SV, Eisert SL, Pons PT, et al. Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency. AHRQ Publication No. 04-0075. Rockville, MD: Agency for Healthcare Research and Quality, August 2004. Available at http://www.ahrq.gov/research/altsites/. Accessed August 12, 2009.