One of the most recent examples of medical surge in action was the response effort following a devastating EF5 tornado that ripped through the city of Joplin, Missouri, with virtually no warning on 22 May 2011. Among the most heavily damaged components of the city’s vital infrastructure was the area in and around the St. John’s Regional Medical Center – a 367-bed facility that was in the center of the tornado’s destructive path, which stretched along an axis 13.8 miles long and up to one mile wide.
Fortunately, Joplin had already started – prior to the 2011 emergency – to coordinate its plans with other healthcare coalition members to build a regional hospital partnership. Since 2010, participation in regional planning efforts from hospitals within the state has grown from 88 percent to almost 95 percent. In addition, participation in healthcare coalitions themselves has increased significantly across the nation – from only 43 percent in 2010 to almost 85 percent earlier this year. This fortunately timed focus on regional planning undoubtedly enhanced the medical surge capacity available during the 2011 tornado season.
Medical surge can be defined as the ability to provide adequate medical evaluation and care during significant weather events that exceed the limits of a community’s normal medical infrastructure. Individual hospitals, such as St. John’s, plan for and routinely handle surge requirements resulting from seasonal fluctuations in respiratory ailments, for example, and/or major disasters in the local community. The need for a greater surge capacity may also develop from a number of unexpected scenarios ranging from violent weather events (hurricanes and tornadoes) to highly toxic and widespread chemical releases to pandemic influenza and other acutely infectious disease outbreaks. The causes of any of these may be natural or manmade, accidental or deliberate, time-limited or open-ended, and either localized in one county or spread across a state, a multi-state region, or the entire country.
Considerations, Constraints & Collapses: Community-Based Planning
Each scenario presents its own set of considerations and constraints that will largely determine how surge capacity is handled. In the event of an emergency, most hospitals will activate their own internal disaster plans and redirect resources as needed to care for the most seriously ill or injured. However, in order to continue normal hospital operations – while also managing an overwhelming surge of additional, and unexpected, patients – an expansion of the local medical infrastructure is usually needed as well.
One significant success in Joplin was the regional hospitals’ focus (before the tornado struck) on community-based planning – which, as it turned out, provided the mechanisms needed to cope successfully with the numerous problems that developed in the minutes, hours, and days following the tornado. The Joplin experience demonstrated, among many other things, that when a community has to rely on its own responders and citizen volunteers to effectively manage such disasters, community-based planning is an effective way to build surge capacity. In Joplin, that planning included the establishment of two alternate care sites (ACSs) at local high schools.
Although the cause and size of almost any surge event imaginable cannot be precisely estimated, surge management planning provides an effective approach to develop a varying number of “what if” scenarios. Under normal circumstances, the existing hospital infrastructure is typically used to meet most surge capacity needs. However, in the case of St. John’s, the hospital suffered a direct hit from the tornado that caused enormous damage – e.g., broken windows, collapsed walls, and a torn-off roof. The tornado also destroyed the hospital’s generators, damaged sprinklers and sewer pipes, and disrupted service to all of the major utilities (water, gas, and electricity). The St. John’s officials had no choice, therefore, but to order the evacuation of all of its 183 patients.
Numerous Problems, Several Guidelines & Four Important Actions
The St. John’s experience was not unusual in that respect. Almost all of the nation’s hospitals have a limited ability to quickly expand their everyday healthcare capacity. One way to increase that capacity, therefore, is to expand surge planning geographically to include not only the local public health community but also the capacities and capabilities of several surrounding communities, counties, regions, and entire states. During large-scale health emergencies such as natural disasters that strain all local capacities, though, there are several guidelines that are worth considering. This type of planning is part of an all-hazard planning and preparedness culture that the healthcare and community practitioners need to instill in their operations and practices.
Following are four of the more important actions that should be taken before making any final decisions:
- Determine the current state of medical readiness – specifically including local first-responder capabilities, local bed capacity, and surge capacity currently available.
- Review current preparedness plans and the activities, exercises, and drills already being used to strengthen and coordinate medical readiness.
- Discover any current overlaps and/or inconsistencies in medical readiness plans and activities.
- Coordinate the drills, exercises, and training sessions required for everyone, and every facility, involved in the plan, so that a real disaster is not the first time a plan is actually (and fully) implemented.
In many cases, the communities that are most effective in coping with disasters are, not surprisingly, the ones that drill – and keep drilling. In the case of Joplin, there was very little time between the tornado warning and the actual impact, so no evacuations were possible prior to the physical destruction of the hospital. However, the hospital staff had been well trained and for that reason was able, fortunately, to move St. John’s patients to the hallway, give them pillows and blankets for additional protection, and close the blinds, window coverings, and doors.
To effectively manage an unexpected surge of patients, a community-based triage and medical care system is also required to reduce the huge burden imposed on individual hospitals and other healthcare facilities by efficiently redirecting, to other healthcare facilities, various segments of the population directly affected. During and after the Joplin tornado, St. John’s patients suffering from obvious physical injuries were transferred to Freeman West in Joplin and Freeman Neosha, which is 18 miles from Joplin – the remaining 124 patients, who did not require the same level of surgery, cardiac, and trauma capabilities, were transferred to other area hospitals.
Additional Complications – Dealing (Compassionately) with the Worried Well
The lesson learned: For maximum operational effectiveness, an effective surge plan involves: (a) the establishment of temporary facilities for critical and noncritical inpatient and outpatient care; (b) the combined use of field triage, population-based triage, and secondary triage; and (c) an effective community outreach plan, combined with public education, to help in transporting the directly affected population to treatment at another appropriate system location. Healthcare coalitions, such as the one in Joplin, offer community-level planning and sharing of resources and personnel for disaster and/or emergency events.
But this is not all that should be done and/or considered in the preplanning stages. Communities must also prepare for another group of “victims” who often present themselves, during times of sudden crisis, at various hospitals, emergency medical centers, and ACSs – the so-called “worried well” and/or “potentially exposed.” During and after large-scale emergency events, many citizens become understandably concerned about the current or impending crisis, thus triggering panic and surge at healthcare facilities – even though many local residents may be at low risk of injury. The worried-well population could in fact be even larger than the population that undoubtedly does require treatment. If nothing else, the worried-well problem reinforces the importance of establishing adequate field triage, population-based triage, and secondary triage capabilities.
After being triaged, many people requiring medical care may – depending on the surge capacity available – be sent to a hospital, returned to their homes, or transferred to temporary care facilities designated (again, beforehand) to provide a given level of medical care. In Joplin, where an estimated 8,000 homes, office buildings, and other structures were destroyed or severely damaged, the option of releasing patients to their homes was problematic. ACSs – i.e., any facility, including spaces within a hospital but outside the Emergency Department (ED), where medical care may be provided during a mass-casualty surge incident – offered information about shelters and alternate housing so that people could go “home.” The use of ACSs further expands the medical surge capacity available during major incidents while at the same time decreasing the burden on the hospital system(s) most directly affected.
Effective Pre-Planning Stressed – The Growing Importance of Trained Volunteers
The type of ACS that should be activated depends on the magnitude, severity, and nature of the specific public health emergency or pandemic, as well as the resulting medical needs of the local community directly affected. The ACS concept augments the existing healthcare system’s capacity for care in a specific service area, but is dependent upon the transportation system locally available for the movement of patients, decedents, and material resources. When the medical system is overwhelmed, hospitals must use ACSs to effectively manage: (a) the spread (of a pandemic, for example); and (b) the influx of a large number of potential patients likely to present themselves throughout the community.
Having a volunteer organization to assist first responders in properly handling a medical surge incident is yet another way a community can increase local capacity if, as, and when needed. To build that capability, an active volunteer program must be developed and maintained to deal with incidents that are faced by emergency responders on a daily basis. The program should be robust enough, of course, to identify pre-trained staff who are able to deal with the many (and sometimes unexpected) specific needs that develop during and/or because of a pandemic-type event.
One standardized approach that should be considered is having medically trained volunteers provide assistance during disasters and/or other emergency situations. When the time comes, these volunteers can be called upon to respond – e.g., the Oklahoma Medical Reserve Corps was activated to assist in Joplin. In the event of an emergency, hospitals activate their internal disaster plans and redirect resources to care for the most seriously ill. However, the ability to cope with an overwhelming surge of patients may require a significant expansion of the local medical infrastructure.
Effective surge management planning relies on: (a) community-based planning by the local hospital and public health communities; (b) the development and use of alternate care facilities; and (c) the strategic use of volunteers. Ultimately, an interdisciplinary team of emergency responders and community volunteers should work together to develop an effective and efficient response to a medical surge emergency. It is important to exercise planning efforts on a regular basis and update those plans based on the lessons learned and the best practices.
Probably the most difficult challenges to cope with during an actual disaster, such as the one that devastated Joplin, are: maintaining situational awareness; using triage and tracking to maximum advantage; providing an effective alternative to the frequently limited radio communications available; maintaining a knowledgeable and commanding presence in the emergency operations center; dealing with unreliable cell service; and finding ways to reduce the inability to inform people who are seriously injured that the hospital is already overwhelmed. The development and use of regional partnerships might well be the right answer to those problems.
Beth McAteer is the Public Health Program Director for Witt Associates, a public safety and crisis management consulting firm. She joined Witt Associates in 2010 with more than 15 years’ experience in the healthcare field in various positions – including a tour of duty at the Pennsylvania Department of Health, where she served as Emergency Medical Services Program Manager for the Commonwealth’s Clinical Education and Preparedness program. She also coordinated the response and deployment of Pennsylvania’s EMS Strike Teams in support of two federally declared disasters through the Emergency Management Assistance Compacts to Hurricanes Katrina and Gustav, and spearheaded the effort to design and implement an enterprise-wide information technology solution to support patient/evacuee tracking for emergency medical services and hospital personnel throughout the Commonwealth of Pennsylvania.