The Need for Surge Capacity: Patience Is Not the Solution!

The Joint Commission of Healthcare Accreditation Organizations (JCOHAO), the accrediting body that oversees hospitals, nursing homes, and other medical facilities, uses the following definition for surge: “The ability to expand capabilities in response to a sudden or more prolonged demand.”

From the point of view of the working professional, another way of saying it is that surge capacity is “the ability to shift from normal operational capacity levels to the substantially higher level needed to respond effectively to an increase in demand caused by a major disaster, natural or manmade.” That ability is particularly important, of course, if the disaster is sudden and/or unforeseeable – an earthquake, for example, or a 9/11 type of terrorist attack.

Surge means much more, though, than preparing in advance to cover the day-to-day ebb and flow of patients. Most hospitals experience spikes in their normal daily volume of patients, if only because of the natural randomness of life. In effect, therefore, surge capacity may be looked at as an equation. On one side is the capacity to take care of patients; on the other side is the number of patients physically present at the hospital at any given time. During normal conditions, this equation is (or should be) either perfectly balanced or tipping slightly to the capacity side. Surge conditions exist when the scale tips to the side showing the number of patients that must be cared for.

A Simple Concept – With Many Legal Entanglements

Most but not all of the nation’s fire and police departments, and many EMS (emergency medical services) agencies, plan to meet unforeseeable surges in demand by using mutual-aid agreements, which allow one department to quickly request and receive assistance – i.e., additional capacity – from their sister departments in the same geographic area. It seems like a simple concept: one agency or department backing up its neighbor. Legally, however, the development and implementation of such agreements requires enabling legislation at the state level, an approved plan of action at the municipal level, and/or, at the very least, a written memorandum of understanding (MOU).

Today, most traditional first-responder agencies typically have such legislation in place and have worked under such agreements for many years – decades, in some cases. The same is not true, though, of hospitals, public health agencies, and other critical components of the medical and public health communities. Moreover, many first-responder resources are by their nature mobile, or portable; an ambulance, for example, can be driven to the jurisdiction requesting additional resources, and it arrives completely staffed, equipped, and supplied. Day-to-day hospital capacity cannot be shifted so easily.

Because hospitals cannot readily transfer capacity from one facility to another when a major disaster occurs, the only effective solution available, in most if not quite all cases, is to control the patient-volume side of the equation. A well-run EMS system could shunt less seriously injured patients to other hospitals, at somewhat greater distances from the emergency scene, to ease the congestion in local hospitals. Ideally, as soon as EMS management and dispatch personnel recognize an incident’s potential for creating a substantial surge in patients, at least some of the ambulances available would immediately be directed to take their patients to other hospitals farther from the scene of the incident.

This solution depends, though, on the designation of an overall central authority who has been legally empowered to manage the local EMS resources as a collective whole – in this case, for example, by redirecting ambulances to other hospitals to restore the volume-vs.-capacity equation to an even keel. For such an order to be successful, however, there must be a continuing flow of timely and accurate information between the EMS authority and the hospitals.

The flow of communications must at a minimum give the EMS authority a true picture of the existing workload and other relevant conditions at each hospital under his or her jurisdiction. Without that information, the authority could not make the consequence-management decisions needed to minimize the loss of lives in the few precious hours after a major disaster. A central organizing authority cannot be created at the time of or immediately after a disaster. And the designation of an authority per se is not enough; to be effective in a true time of need the lines of communication with the hospitals covered in a mutual-aid agreement need to be used frequently.

Distance and Logistics Problems

In some areas of the country, the “next nearest hospital” may be over an hour away, and the number of ambulances available is often limited as well. This combination of circumstances makes the logistics task of simply removing the patients from the scene of the incident to any but the nearest hospital extremely challenging. Moreover, local EMS agencies may not be united under a regional control that can act as the central authority in a crisis.

Other solutions affect the capacity side of the equation. There are, fortunately, a number of private-sector vendors who will provide fully functional field hospitals that can be set up and put into operation on short or no notice to provide additional patient-care capacity. Alternately, makeshift but acceptable facilities such as schools, college dormitories, or convention rooms can be pressed into service as alternate care faculties.  

However, there are problems in relying on this solution. Primary among the several difficulties involved in the use of non-medical spaces is that all of the equipment and supplies needed to equip the alternate-care facility have to be transported and set up very quickly. Depending on how elaborately equipped the surge facility must be, this could be almost as expensive as using a commercially prepared field hospital.

Moreover, the owners and managers of the various alternate-care facilities that might be pressed into service are often, despite their own humanitarian instincts and willingness to help, not happy about having to accommodate a sudden and unexpected flow of sick or injured people. There usually are some liability concerns to consider, as well as problems caused by the disruption of the hotel’s or school’s, etc., own normal activities. In addition, at least in some situations, there could be a long-lasting stigma attached to the facility itself in the aftermath of a particularly horrendous incident.

The Superdome in New Orleans will likely be the classic textbook example of the latter problem for years and probably decades to come. A more common example, familiar to and accepted by many communities, is the school that is converted to an alternate medical facility and/or temporary shelter for victims of a flood or hurricane. Reoccupying the same school with elementary school children if it had been used to house and medicate persons afflicted with the avian flu or other infectious disease, however, would raise many a parental eyebrow, to say the least.

An important factor to consider in this context is that many hospitals, including those run by the Veterans Administration (VA), are now downsizing or – usually for budgetary reasons – being eliminated altogether. Some of these hospitals probably could be kept in operation on a multi-state or regional basis – with a relatively limited staff, if necessary – to meet the massive increase in surge capacity needed to cope with such catastrophic events as Hurricane Katrina.

Long-Term Thinking and Short-Term Events

Unfortunately, these partial solutions do not even begin to address the most important element of surge capacity: staffing. Hospitals are not merely buildings stocked with large quantities of advanced medical equipment. What makes a hospital function effectively is the people who work there – hundreds of them, in most large hospitals, representing a broad spectrum of essential medical specialties.

Many hospitals already have plans in place to meet surges that last a few shifts, or a day or two, by calling in additional staff, canceling elective admissions, and/or expediting discharges. These measures, combined with an effective plan to keep the temporarily overcrowded facility and complex medical equipment systems fully operational, usually will allow the hospital or other medical facility to manage the increase in surge capacity required by a short-term event such as a major fire, train wreck, or industrial accident.

States, and increasingly multi-hospital systems, must think on much larger terms, though. Several hospitals working in close cooperation in a well-coordinated fashion can distribute the increased volume of patients throughout their collective individual capacities. In addition, hospitals too distant to receive patients from the emergency scene could make members of their own staffs available to provide at least some of the surge capacity needed at the hospitals closer to the scene.

No Final Solution Possible

JCOHAO standards allow for the chief executive officer (CEO) and/or administrator of a hospital to grant temporary privileges to appropriate medical professionals. The judicious use of this authority allows licensed professionals to volunteer during an emergency without the hospital risking its own accreditation. An essential planning step in this situation is to codify the process by which the administrator would review the volunteer’s credentials and determine his or her suitability. Without such a plan, the hospital would certainly end up making decisions on a subjective basis.

Surge is a difficult issue to address in an era of continuous budget pressures to streamline operations at almost every hospital in the country. Today, in fact, it is inconceivable that any hospital would have the ability and/or financial resources needed to hire the additional doctors, nurses, lab technicians, and other personnel required to care for a massive influx of additional patients – and at the same time provide the extra bed spaces, medical equipment, and other physical resources that also would be needed. All hospitals have a certain amount of latitude to accommodate reasonably foreseeable spikes in intake, but this natural expansion of a hospital’s daily census is dwarfed by what might be expected in a major emergency.

Fortunately, even prior to Hurricane Katrina the U.S. Department of Health and Human Services had been funding state and local efforts on this issue through its Health Resources and Services Administration program – which, for the current grant period, has required states to meet specific minimum goals for hospital surge capacity. Meeting those goals – 500 regular beds per million of population, and 50 specialty beds per million of population – will reduce the size of the capacity problem, but will not solve it completely.

The difficulty in crafting a final and complete solution to the surge-capacity problem is that it is by nature an upward spiral. Initially a single hospital is overwhelmed, then all of the medical resources in the surrounding community, and then the surrounding communities and the state and finally the multi-state region. Clearly, there are some local surge issues that already are being worked on. There also are some broader national surge solutions, or partial solutions, possible – but these are not yet in place.

Additional Resources:

Joseph Cahill
Joseph Cahill

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.



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