Plan for long-term capacity challenges during outbreaks

Given the potential threat of SARS, bioterrorism, pandemic flu, and other large-scale outbreaks, hospitals should create surge-capacity plans to handle both casualties and concerned onlookers.

Many hospitals prepare for acute, short-term events that last 12 to 24 hours, says Zachary Goldfarb, EMT-P, CHSP, CEM, principal of Incident Management Solutions in New York. These are conventional, trauma-related incidents such as fires or chemical spills. Exceptions include people trapped in the rubble after earthquakes or biological incidents. "In the short term, surge means stretching rather than expanding" resources, Goldfarb says. "In the long term, it's expanding."

Long-term events include disease outbreaks and epidemics, says Alfred DeMaria, Jr., MD, assistant commissioner of the Massachusetts Department of Public Health, also serving as director of the state's Bureau of Communicable Disease Control. "They tend not to be localized," he adds.

Long-term events have the following characteristics, DeMaria says:

 The potential for spread

 An incubation period

 Prolonged illness and infection spread

 The need for IC procedures such as isolation and the use of personal protective equipment (PPE)

 The need for disinfection

 The exposure of staff to infection, requiring a system to monitor staff health

 The need for both prophylaxis and vaccination programs

Hospitals can use two types of temporary facilities when faced with a surge capacity situation: a neighborhood emergency health center or an acute-care center. Hospitals should be able to set up at least one of each of these, says Goldfarb. Both facilities enhance a hospital's outpatient capability. The Health Resources and Services Administration (HRSA), which provides grants for emergency preparedness, requires communities to plan and prepare to accommodate certain numbers of patients based on the size of the community, he adds. Communities must have the ability to care for 500 patients per million in population.

A temporary neighborhood emergency health center is the point of triage for the initial rush of patients and the "worried well" (those who are not injured, but who go to a hospital out of concern for relatives or friends, or who believe they are injured), says Goldfarb. This facility is open to the public, a fact the hospital should announce.

An acute-care center provides support care, but not critical care, including triage and some treatment, says Goldfarb. "It's a satellite, set up at a hotel, arena, or state fairground."

Hospitals must determine how many staff they need for these facilities, as well as how they will credential volunteer caregivers and delineate privileges. Plan by having a communitywide or regional credential accepted in advance, Goldfarb suggests.

You can also find help from Medical Reserve Corps, who are community-based health care workers who volunteer their services as part of a team, or put together a list of members from local medical societies, hospital associations, or nursing associations. In addition, develop alternative staffing for basic tasks such as triage and checking vital signs by training dentists, chiropractors, podiatrists, and veterinarians, says Goldfarb.

In the case of bioterrorism or a disease outbreak, the hospital may need to isolate patients. "It's very important to think of isolation as more than a negative-pressure room," DeMaria says. "You have to have certain numbers of isolation rooms, and you also need a wide variety of infection control protective measures." Take a full inventory of your facility to learn about the heating, ventilation, and air conditioning system, and the types of rooms available to use for surge capacity, says DeMaria. The facility can take droplet precautions in ordinary rooms if health care workers wear PPE, he adds. Make sure the facility has enough room and space to handle isolation.

If the hospital has plans for new construction, involve the IC professional in the planning process to build in isolation and negative-pressure rooms. "It's much easier to do at the time of construction than retrofitting," DeMaria notes.

In addition to determining what types of supplies and resources you need, convene a logistics and planning group to consider where these items are and how quickly you can move them during an emergency, Goldfarb says. Create plans for different seasons, types of weather, and darkness.

Put together a cache of equipment by contacting vendors and acquiring the equipment in advance, suggests Goldfarb. Put the equipment in a convenient location, and have more than one cache in a community if possible. When acquiring medical equipment, consider power needs and have adequate oxygen supplies on hand. Also, set up processes to acquire vehicles on an emergency basis, Goldfarb says.

Communications coordination is important, so make sure you have redundant systems, including phones, fax, backup two-way radios, data links, and Web-based links, Goldberg says. It's a good idea to have unlisted phone numbers to prevent all your phone lines from getting overloaded by the public. Also, a staff emergency hotline takes a lot of traffic off the main lines.

During mass-casualty incidents, you need a good triage system in place, DeMaria says. Divide patients into three groups: Those who are ill but can wait for care; those who need care to survive; and those who won't survive even if they receive care.

Hold discussions about these issues in advance, with the help of ethics consultants, DeMaria says. "The staff will have to deal with difficult situations in terms of making triaging decisions," he adds. "The health care facility itself will deal with an overwhelming amount of casualties."

As for liability concerns, most states have emergency powers and acts that cover these kinds of situations, says DeMaria.

Work closely with your local public health department to determine exactly what your state allows. In addition, federal regulations from groups such as OSHA "may have to go into abeyance in an emergency situation," he notes.

The traditional source for surge-capacity funding is the federal government, which provides grants through the Department of Homeland Security and HRSA, Goldfarb says. State and local health departments and emergency management agencies may also have funds available for this purpose.

Think creatively about other funding sources. If there's a nuclear plant in your area, your facility may be eligible for funding from the federal government and power companies related to emergency plans, says Goldfarb. It's also worth contacting your local and state legislators to see whether they can help.

In addition, there are some less obvious paths to take. Approach the foundations that may bankroll other programs in your hospital to see if you can get help in this area, says Barbara Bisset, RN, MPH, director of emergency response, safety management, and special police for New Hanover Health Network in Wilmington, NC.

Also consider other local agencies or departments that could spare resources. For example, New Hanover needed a command center and learned that the local school department sought to get rid of some buses, so the facility was able to acquire an old bus for $1 and convert it into a command center, Bisset notes.

Editor's note: Our sources' comments come from a recent audioconference sponsored by The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. HCPro publishes this newsletter. To order a tape of the program, called "Managing hospital surge capacity: How to plan for a mass casualty incident or disease outbreak," call HCPro customer service at 800/650-6787.  

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