The concept of medical surge forms the cornerstone of preparedness planning efforts for major medical incidents. It is important, therefore, to define this term before analyzing solutions for the overall needs of mass casualty or mass effect incidents.
Medical surge describes the ability to provide adequate[2] medical evaluation and care during events that exceed the limits of the normal medical infrastructure of an affected community. It encompasses the ability of HCOs to survive a hazard impact and maintain or rapidly recover operations that were compromised (a concept known as medical system resiliency).
Beyond this rather simple explanation, medical surge is an extraordinarily complex topic that is difficult to comprehensively describe. The first step in doing so, however, is to distinguish surge capacity from surge capability.
1.1.1 Medical Surge Capacity
Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.
Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:
- Identify the medical need
- Identify the resources to address the need in a timely manner
- Move the resources expeditiously to locations of patient need (as applicable)
- Manage and support the resources to their absolute maximum capacity.
In other words, fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. Moreover, the integration of additional resources (whether standby, mutual aid, State or Federal aid) is difficult without adequate management systems. Thus, medical surge capacity is primarily about the systems and processes that influence specific asset quantity.
Basic example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds), minimizing purchase and maintenance of expensive equipment that generate no income except during rare emergency situations.
When addressing an overall medical surge strategy, it is recommended that guidance be delineated prospectively for maximizing the use of existing resources before resorting to the use of alternate care facilities and standards of care appropriate to the austere conditions of a disaster.[3]
1.1.2 Medical Surge Capability
Medical surge capability refers to the ability to manage patients requiring unusual or very specialized medical evaluation and care. Surge requirements span the range of specialized medical services (expertise, information, procedures, equipment, or personnel) that are not normally available at the location where they are needed (e.g., pediatric care provided at non-pediatric facilities). Surge capability also includes patient problems that require special intervention to protect medical providers, other patients, and the integrity of the HCO.
Basic example: Many hospitals encountered difficulties with the arrival of patients with symptoms of severe acute respiratory syndrome (SARS). The challenge was not presented by a high volume of patients, but rather by the specialty requirements of caring for a few patients with a highly contagious illness that demonstrated particular transmissibility in the healthcare setting. Protection of staff and other patients was a high priority, as was screening incoming patients and staff for illness, preventing undue concerns among staff, and avoiding publicity that could adversely affect the hospital's business. Coordination with public health, emergency management, and other response assets was critical.
1.1.3 Requirements of MSCC Strategies
Effective strategies for MSCC require a systematic approach to meet patient needs that challenge or exceed normal operational abilities, while preserving quality of care and the integrity of the healthcare system. The MSCC Management System demonstrates management processes that allow HCOs to coordinate existing resources and then obtain "outside" assistance in a timely and efficient manner. In this way, HCOs can transition from baseline operations to incident surge capacity and capability—to meet the response needs of catastrophic events—and then back to baseline.
Figure 1-1. Management System for Reaching MSCC Objectives
Any strategy to enhance MSCC must recognize that the required emergency interventions are time sensitive and must be based primarily at the local level. This urgency limits the ability of the Federal Government to independently establish, stockpile, or own/control resources necessary for immediate MSCC. In addition, because most medical assets in the United States are privately owned, MSCC strategies must bridge the public-private divide, as well as integrate multiple disciplines and levels of government.
A comprehensive effort to address response requirements must include a system description (i.e., how the different response components are organized and managed) and a concept of operations (i.e., how the system components function and interact through successive stages of an event). It must include "all-hazard" processes and procedures, mutual aid, and other validated emergency management concepts. The remainder of this chapter presents key considerations for the system design and the concept of operations to maximize integration between response components and, thus, enhance MSCC.
- Throughout this document, the term adequate implies a system, process, procedure, or quantity that will achieve a defined response objective.
- Readers are encouraged to visit the Agency for Health Research and Quality Web site (http://www.ahrq.gov/) for information on alternate care facilities and allocation of scarce resources.
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