Most U.S. hospitals are designed to service a specific load of patients, with the number varying more or less in accordance with the population in the area and the prevalence of various diseases within that population. During a crisis situation, these resources can be stretched, but only within a certain limit. One of the most important healthcare goals in recent years, therefore, has been to plan for the expansion of hospital care beyond the physical walls of a specific hospital.
To meet that goal, many hospitals and communities have developed plans to use tent-based hospitals on the hospital campus. There is an innate efficiency in this plan, because the resources needed by tent-based hospitals can be distributed through and buttressed by the supply system of the hospital – and other resources can easily be shared between the two as well. However, resources that cannot be expanded – e.g., parking areas and road access – may become strained.
Other hospitals have favored the use of off-site facilities, including existing non-hospital structures. These Alternate Care Sites (ACSs) usually possess some unique advantages of their own – for example, they do not bring additional traffic to the main hospital. However, an ACS is not intended to be a full-service hospital but, rather, a separate medical facility equipped to care for less critically ill patients. For example, in cases of respiratory diseases such as influenza, an ACS can be used for patients who are too sick to stay home but, on the other hand, do not really have to be assigned to an intensive care unit.eally, a relatively large surge of patients with similar low-intensity needs can be monitored by a small cadre of staff at such an off-site facility.
Planning, Stockpiling, and Other Distinctions Although they share some common elements, an ACS should not be confused with a “points of distribution/vaccination” (POD/V) site – which is intended solely for the one-time distribution of medications to and/or vaccination of the general population. An ACS is specifically designed, and intended, to handle a surge of patients who would be admitted to the facility even during a non-surge situation and remain there until they are well enough to be discharged.
Planning for the design and use of an ACS requires more than: (a) stockpiling medical equipment, medicines, and other healthcare materials; and (b) locating a suitable facility. Planners should use the legal assets of the hospital during the planning process – if only because, for the ACS to function as a hospital, it may have to be licensed under the state and local laws governing healthcare facilities. Meeting this requirement probably will involve working in close cooperation with state healthcare quality regulators.
This may seem like a “minor detail” in the face of an imminent disaster (or one that has already occurred), but it obviously should be considered during the planning phase rather than during an actual crisis situation. Just as obviously, effective emergency planning will, or should, account for all such reasonably foreseeable issues so that, when disaster does strike, emergency personnel can devote their undivided attention to whatever unforeseen issues arise.
Although possessing a reasonable degree of surge capacity has been important enough for state and federal program committees to devote considerable time and energy to the planning efforts per se, putting those plans into effect will almost always be a costly process. Here, an important point to keep in mind is that a stay at an unlicensed ACS would probably not be “billable” under most health care plans. Following any disaster, there will come a time, though, sooner or later, when costs will have to be paid and previously unanswered questions can no longer be kept in the “hold” basket.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.