CONFERENCE PRESENTATIONS
Understanding Surge Capacity: Essential Elements Donna F. Barbisch, RN, MPH, DHA, Kristi L. Koenig, MD
Abstract As economic forces have reduced immediately available resources, the need to surge to meet patient care needs that exceed expectations has become an increasing challenge to the health care community. The potential patient care needs projected by pandemic influenza and bioterrorism catapulted medical surge to a critical capability in the list of national priorities, making it front-page news. Proposals to improve surge capacity are abundant; however, surge capacity is poorly defined and there is little evidence-based comprehensive planning. There are no validated measures of effectiveness to assess the efficacy of interventions. Before implementing programs and processes to manage surge capacity, it is imperative to validate assumptions and define the underlying components of surge. The functional components of health care and what is needed to rapidly increase capacity must be identified by all involved. Appropriate resources must be put into place to support planning factors. Using well-grounded scientific principles, the health care community can develop comprehensive programs to prioritize activities and link the necessary resources. Building seamless surge capacity will minimize loss and optimize outcomes regardless of the degree to which patient care needs exceed capability. ACADEMIC EMERGENCY MEDICINE 2006; 13:1098–1102 ª 2006 by the Society for Academic Emergency Medicine Keywords: surge capacity, public health, emergency management, emergency medicine, disaster management, domestic preparedness, operational medicine
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commonly heard question is, ‘‘Are we prepared?’’ Surge capacity is a critical component of preparedness, but it is challenging to define. It is difficult to determine: Prepared for what? How much is enough? How fast do we need it? Where are we going to get it? Even if we can afford it, how do we maintain capability? Given our need for support from other functional areas, how do we link with their resources? A review of these questions will help frame the broad overarching policies and plans to develop surge capacity. Planning for surge capacity for overwhelming numbers of casualties accelerated when President Clinton
From the Institute for Global and Regional Readiness (DFB), Washington, DC; and Department of Emergency Medicine, University of California at Irvine (KLK), Irvine, CA. Received June 13, 2006; revision received June 29, 2006; accepted June 30, 2006. Presented at the Academic Emergency Medicine Consensus Conference, ‘‘Establishing the Science of Surge,’’ San Francisco, CA, May 17, 2006. Address for correspondence and reprints: Donna F. Barbisch, RN, MPH, DHA, Institute for Global and Regional Readiness, 101 E Street SE, Washington, DC 20003. Fax: 202-547-7073; e-mail:
[email protected].
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published the U.S. Policy on Counterterrorism in 1995.1 The Department of Health and Human Services, as the lead federal agency for health and medical support in national planning, established Metropolitan Medical Response Teams. This evolved into the Metropolitan Medical Response System, a program designed to integrate capability at the local level.2 The Department of Health and Human Services continued to expand the role of the National Disaster Medical System, a top-down federal program, to provide federal assistance to local communities in coordinating mass casualty management.3 In 1996, Congress allocated preparedness funding in the Defense Against Weapons of Mass Destruction Act, thus elevating surge capacity to a national priority.4 As a result, in 1997, the Department of Defense Domestic Preparedness Program initiated the Biological Warfare Improved Response Program to identify, evaluate, and demonstrate best practical approaches to improve biological warfare domestic preparedness.5 The initial Biological Warfare Improved Response Program nine-month study identified mass casualty management and surge capacity as priorities. The study developed a proposed template to achieve integrated and sustainable surge capacity within the community.6 The third federal partner in health care, the Department of Veterans Affairs, in its fourth mission of contingency support to national emergencies and disasters, increased its emphasis on emergency management and support to local communities.7
ª 2006 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2006.06.041
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In the ten years since the federal government introduced surge capacity as a priority, additional legislation with associated funding directed states and localities to improve capability. A 2003 General Accounting Office study identified that improvements have been made but problems remain.8 The study identified inadequacies such as workforce shortages, lack of equipment, limited isolation facilities, and gaps in disease surveillance. The General Accounting Office also reported that levels of preparedness varied across cities with a general lack of regional planning. As we move forward in identifying and validating the basic science of surge capacity, it is imperative that we have a systems approach to seamlessly integrate capability. It is not simply beds or ventilators, but appropriately trained personnel (staff), comprehensive supplies and equipment (stuff), facilities (structure), and, of imperative importance, integrated policies and procedures (systems) to develop optimized sustainable surge capacity. PLANNING ASSUMPTIONS Before initiating programs that operationalize surge capacity, it is crucial to have a standardized, widely accepted strategic definition of the concept. Webster’s dictionary defines surge as ‘‘to rise suddenly to an excessive or abnormal value.’’ One of the earliest definitions of medical surge capacity was published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2003. They said, ‘‘Surge capacity encompasses potential patient beds; available space in which patients may be triaged, managed, vaccinated, decontaminated, or simply located; available personnel of all types; necessary medications, supplies and equipment; and even the legal capacity to deliver health care under situations which exceed authorized capacity.’’9 While JCAHO’s concept is detailed, it focuses on health care facilities, excluding many elements that are necessary for a complete definition of surge capacity. In March 2005, the Department of Homeland Security published the Interim National Preparedness Goal.10 Surge capacity is one of the 37 associated target capabilities.11 The Target Capabilities List is intended to define the capabilities, outcomes, measures, and risk-based target levels of capability for the nation to achieve the preparedness goal. National surge targets include surge guidelines of 500 beds per one million population for patients with symptoms of acute infectious disease and 50 beds per one million population for noninfectious disease and injury.12 These planning factors assume that hospital beds are a large part of the solution and that 500 is the right number. Questions remain as to how to validate these planning factors. In developing integration models across the critical elements affecting surge, one can borrow methods from the systems integration community where the goal is integrating complex systems. Dynamic programming algorithms suggest that the optimal solution to a problem is a combination of optimal solutions to its subproblems.13 The subproblems in surge capacity are, in effect, the components of surge. The challenge, of course, is that we now must go about the process of identifying all of the components of surge, recognizing that many of
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the subcomponents may be obscure. Through a systematic process of exploring the components of surge, we can develop a realistic dynamic model to evaluate and determine best practice in building surge capacity. Military principles of operational planning dictate that validating planning factors before putting a plan in place is critical to the operational success of the plan.14 Building and maintaining operationally effective surge capacity is dependent on identification and validation of the underlying components of surge. THE COMPONENTS OF SURGE: WHERE HEALTH CARE HAPPENS There are various communities that each need to provide staff, stuff, and structure for surge capacity. Further, there must be linkages between these foci of health care activities to form a comprehensive surge system. While hospitals are a crucial element in health care surge, there are clearly other factors. A descriptive analysis includes five basic elements15: 1. Out-of-hospital care (emergency medical services) 2. Hospital care 3. Out-of-hospital health care (e.g., clinics, physician offices, nursing homes, home health, hospice) 4. Out-of-hospital health and medical assets (e.g., laboratory, pharmacy, radiology, occupational health, medical supply) 5. Nonhealth and medical assets that support health and medical operations (e.g., communications, power, water, security, transportation). Out-of-hospital care is broken out separately because it is a large part of the emergency management system. Hospitals may have some capability described in the outof-hospital health care sector if they are part of a larger health care delivery system. The classification of elements into out-of-hospital health care or out-of-hospital health and medical assets is somewhat subjective. The categorization is simply designed to identify all elements supporting health care. A full assessment of functional areas in health care can assist in identifying needs beyond health care organizations. These areas can be based on the National Incident Management System and include but are not limited to command and control, communications systems, stress management, preventive medicine and public health, laboratory, mortuary affairs and funeral services, personnel, logistics, transportation, and veterinary services. SUDDEN IMPACT VERSUS OBSCURE EVENTS The shift in resource requirements that occurs when moving from standard operations to one in which health care resources are exceeded and surge capacity is needed must be seamless. Internal operations in health care facilities manage ‘‘daily surge’’ on a routine basis, but what happens in the face of a catastrophic event? Figure 115 depicts an immediate impact event. The local response surges to meet the challenges, peaks, and within 8–48 hours exhausts capability. The just-in-time inventory (stuff) delivery may be interrupted. Personnel (staff) become exhausted. The physical facility (structure)
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Figure 1. Health and medical surge timeline for a sudden impact event. (Community Preparedness and Response to Terrorism, Part I: The Terrorist Threat and Community Response. Edited by Gerald R. Ledlow, James A. Johnson, and Walter J. Jones. Copyright ª 2005 by Gerald R. Ledlow, James A. Johnson, and Walter J. Jones. Reproduced with permission of Greenwood Publishing Group, Inc., Westport, CT.15)
is literally out of space. The planning timeline for mutual aid partners and federal support to arrive is 72 hours.16 While the time for arrival of selected assets may be shorter, it also could be much longer depending on several factors, such as time to obtain authorizations and weather-related delays affecting transport vehicles. In addition, even if significant supplies and personnel could be rapidly mobilized from the federal level, if the disaster were widespread and the transportation and communications infrastructure disrupted, it may be problematic to determine exactly where to place the resources at the local level. The period between the dropoff of routine local response and the arrival of federal support is considered the period when local jurisdictions must plan
ESSENTIAL ELEMENTS OF SURGE CAPACITY
Figure 2. Health and medical surge timeline for an obscure event.
and develop self-sufficient surge capacity. If the timeline were continued, a reduction in needed resources would shift the curve back toward baseline for a response phase that can last weeks or even years. During an infectious disease outbreak or event with an unclear starting point (obscure event) (Figure 2), the timeline and delivery of resources will change. The event will in all likelihood begin before there is any awareness. The local response may be similar to the immediate impact event but may last longer because the presentation of casualties may be slower. Because the obscure event may be happening in many areas simultaneously, federal support may be slow or nonexistent. The surge needs will extend for a longer period and will wax and wane rather than gradually decrease. If the timeline were continued beyond what is depicted in Figure 2, it would show that the response phase in this event might last for months to years.
Figure 3. Seamless Emergency Medical Logistics Expansion System (SEMLES) surge model.
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Many of the statistics that drive surge capacity planning focus on how many patients die or require critical care. The total human impact, however, projects that the ‘‘potentially exposed’’ can be up to 100 times the number of those that are actually exposed. Those potentially exposed, if not managed properly and triaged to appropriate areas, will create overwhelming logistical challenges to the already overburdened health care community. After defining the needs for surge capacity, a paradigm shift must occur as we move from thinking about normal health care operations and daily surge to disaster surge for a catastrophic event. In addition to needs, we must establish priorities, coordinate resources, and establish a process to align and allocate or ‘‘triage’’ critical assets.17
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requires optimizing surge and the subcomponents of surge. Surge capacity must be conceptualized across the full spectrum of health care before implementing policies and procedures if we are to be successful. To recognize the components of surge, we must explore the elements that make up a comprehensive health care delivery system. The United States is rich with resources. The challenge is to identify the stuff, the staff, and the structure that make health care happen and then develop the system to coordinate and operationalize the process by balancing activity across all domains, training and educating to standards, and seamlessly responding to escalating health care demands for surge capacity. It is true more today than ever that life is full of opportunities temporarily disguised as overwhelmingly insolvable problems.
FROM CONCEPT TO OPERATIONAL CAPABILITY The management challenges in medical surge can be overwhelming. By breaking down the domains of supplies and equipment (stuff), personnel (staff), and facilities (structure) and putting them into context with policies and procedures, and the federally mandated National Incident Management System, we can build a systems approach and begin to operationalize surge capacity. Operational efficiency is dependent on the dynamic linkage of all of the subcomponents of the interwoven domains. Critical points of failure exist when subcomponents are not synchronized. For example, the supplies and equipment must have the requisite and appropriately trained personnel to run the equipment. Without memoranda of understanding and plans to use alternate facilities, the stuff and the staff may find themselves with inadequate resources to provide patient care as volunteers arrive on the scene and there is no process to credential, (just-in-time) train, and optimize their skill set to support the event. Once the subissues within the domains are defined and validated during planning, we can move seamlessly into the operational phase through the use of an integrating hub. Many local jurisdictions are developing public health emergency operations centers that take on this responsibility. It is critical that daily coordination include assessment of all domains and management processes to integrate across jurisdictions, both public and private. The concept of operations must also include coordination of training. Figure 3 depicts the Seamless Emergency Medical Logistics Expansion System surge model designed to manage the day-to-day challenges of planning and rapidly mobilize with balanced capability across all domains.18 It meets the objective of providing immediate and sustainable surge capacity in a cost-effective manner. The synchronization hub or operations team provides National Incident Management System–compliant integrated capability with in-depth situational awareness of stuff, staff, and structure. With links to all regional centers, it can easily cross-walk the policies and procedures that differ across regions and assist in prioritizing resources for critical services. CONCLUSIONS The scientific community has the tools to develop the path to seamless surge capacity. Optimizing outcomes
References 1. Presidential Decision Directive 39. U.S. Policy on Counterterrorism. Jun 21, 1995. Available at: http:// www.ojp.usdoj.gov/odp/docs/pdd39.htm. Accessed June 27, 2006. 2. Department of Homeland Security. History of MMRS. Apr 20, 2005. Available at: https://www.mmrs.fema. gov/publicdocs/07-05-05_mmrs_history.zip. Accessed May 28, 2006. 3. U.S. Department of Homeland Security. National Defense Medical System (NDMS) overview. Available at: http://ndms.chepinc.org/data/files/3/193.pps. Accessed Jun 8, 2006. 4. 104th Congress. Public Law 104-201 National Defense Authorization Act for Fiscal Year 1997. Title XIV. Defense Against Weapons of Mass Destruction. 5. Biological Warfare Improved Response Program. Executive Summary: 1998 Summary Report on BW Response Template and Response Improvement. Mar 10, 1999. Available at: http://www.chem-bio. com/resource/1999/dp_bw_irp_executive_summary. pdf. Accessed Jun 27, 2006. 6. Bioterrorism: The New Millennium Strategies to Meet Global Challenges. Presented at the 104th Annual AFDO Educational Conference, Burlington, VT, Jun 19, 2000. 7. Interview with Dr. Kristi Koenig. The Role of Veterans Affairs in Homeland Security. Dec 6, 2001. Available at: http://www.homelandsecurity.org/new journal/interviews/koenig_interview.html. Accessed Jun 5, 2006. 8. Government Accounting Office. GAO-03-654T Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have Improved Public Health Response, but Gaps Remain. Apr 9, 2003. Available at: http://www. gao.gov/new.items/d03654t.pdf. Accessed Jun 28, 2006. 9. Joint Commission on Accreditation of Healthcare Organizations. Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Strategies. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2003. Available at: http:// www.jointcommission.org/NR/rdonlyres/9C8DE5725D7A-4F28-AB84-3741EC82AF98/0/emergency_pre paredness.pdf. Accessed Jun 29, 2006.
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10. U.S. Department of Homeland Security. The National Preparedness Goal. Mar 31, 2005. Available at: http:// www.ojp.usdoj.gov/odp/docs/InterimNationalPrepare dnessGoal_03-31-05_1.pdf. Accessed Jun 5, 2006. 11. U.S. Department of Homeland Security. Target Capabilities List: Version 1.0; January 31, 2005. U.S. Department of Homeland Security Office of State and Local Government Coordination and Preparedness (ATTN: Office for Policy, Initiatives, and Analysis) 810 7th Street, NW Washington, DC 20531. Version 1.0 of the Target Capabilities List is available on the ODP Secure Portal (https://odp.esportals.com) and the Lessons Learned and Information Sharing network (www.llis.gov). 12. Health Resource and Service Administration (HRSA). U.S. Department of Health and Human Services. National Bioterrorism Hospital Preparedness Program (NBHPP). Washington, DC. Available at: http://www. hrsa.gov/bioterrorism/. Accessed Jun 29, 2006. 13. Mohammad RB. Design and analysis of algorithms. Available at: http://www.personal.kent.edu/wrmu hamma/Algorithms/MyAlgorithms/Dynamic/dynamic Intro.htm. Accessed May 28, 2006.
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14. Woodmansee PD, Faulkner TL, Blanchett WC. The Need to Validate Planning Assumptions. Military Review. Jan 2005. Available at: http://usacac.leavenworth. army.mil/cac/milreview/download/english/JanFeb05/ Bwoo.pdf. Accessed Jun 8, 2006. 15. Barbisch D. Regional responses to terrorism and other medical disasters: developing sustainable surge capacity. In: Ledlow GR, Johnson JA, Jones WJ, eds. Community Preparedness and Response to Terrorism, Part I: The Terrorist Threat and Community Response. Westport, CT: Praeger, 2005, p 77–88. 16. Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality following an earthquake. N Engl J Med. 1996; 334:438–44. 17. Burkle FM. Measures of effectiveness in large-scale bioterrorism events. Prehospital Disaster Med. 2003; 18:258–62. 18. Barbisch D. Surge Capacity: Seamless Emergency Medical Logistics Expansion System, from Concept to Operational Capability. NDMS Conference, Dallas, TX, Apr 20, 2004. Available at: http://ndms.chepinc. org/data/files/3/142.pdf#search=%22semles%20 surge%22. Accessed Aug 28, 2006.
