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Keywords:

  • emergency medicine;
  • disaster management;
  • surge capacity

Abstract

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

For more than a decade, emergency medicine (EM) organizations have produced guidelines, training, and leadership for disaster management. However, to date there have been limited guidelines for emergency physicians (EPs) needing to provide a rapid response to a surge in demand. The aim of this project was to identify strategies that may guide surge management in the emergency department (ED).

A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations and identified underlying assumptions from disaster epidemiology and clinical practice. The group then characterized surge strategies from their corpus of experience; examined them through available relevant published literature; and collated these within domains of space, staff, supplies, and system operations. These recommendations detail 22 potential actions available to an EP working in the context of surge, along with detailed guidance on surge recognition, triage, patient flow through the ED, and clinical goals and practices. The article also identifies areas that merit future research, including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies, and measurement of strategy impacts on throughput, cost, and quality of care.

By the early 1990s, the World Health Organization, hospital associations, and other health bodies began to promulgate disaster management guidelines for hospitals.1–4 Since 1995, emergency medicine (EM) specialty societies have contributed to this effort, and EM concerns are now common in the literature.5–9 However, difficulties encountered in assessing the impact on EM have led to international calls for the development of standardized tools.10 Guidance on prehospital management of mass casualties has been incorporated into standardized training curricula for over a decade in the United Kingdom and more recently in the United States.11,12 In Australasia, a strategic plan for disaster medicine was published by emergency physicians (EPs) in 2003 with recommendations on developing standards for supply, equipment, and nomenclature relating to disasters.13

Critical to the management of mass casualties in emergency departments (EDs) is the ability to rapidly expand capacity to accommodate a sudden increase in demand.14 Surge capacity has been defined and considered for selected hazards15 with various models developed to predict the hazard-specific case load.16,17 Guidelines have been published on hospital capacity to manage critical care patients from selected hazards.18 A conceptual framework has emerged in the EM literature.19 Generic recommendations have been published in relation to department staffing and hospital beds.15 Altered standards of clinical care under disaster conditions have also been considered.20 By 2006, a “Science of Surge” consensus conference in the United States, sponsored by Academic Emergency Medicine and the National Center for the Study of Preparedness and Catastrophic Event Response, differentiated between daily and extraordinary surge requirements and made further calls for the setting of benchmarks to trigger surge actions.21,22 The American Medical Association and the American Public Health Association produced a consensus report from a leadership summit with eight generic recommendations on health system surge capacity. The report ultimately called for the establishment of common terminology and definitions and appealed to authoritative groups such as the Institute of Medicine to address health system surge capability.23

However, EM at present lacks agreed-upon strategies for tactical management of volume overload. A concise, authoritative, and practical set of management strategies is required. Such strategies become increasingly important in health systems that run at, or near, full capacity with access block, overcrowding, inpatient boarding, fully occupied beds, and ambulance diversion common.

The Australasian Surge Strategy Working Group (Working Group) was convened with the express purpose of producing a set of practical, scalable response strategies for EPs confronted with sudden excess demand arising either from a single mass casualty incident (MCI) or from the overwhelming demand of a “bad day.” This article offers recommendations for clinical management of these situations, as well as for future operations research.

Working group methods

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

The Working Group consists of Australasian EPs drawn from the Australasian College for Emergency Medicine (ACEM) Disaster Subcommittee. ACEM appointed 12 members to the disaster subcommittee based upon individual disaster expertise, experience, and interest. Six subcommittee members self-selected to form the writers’ group. Subcommittee members at large constituted the reviewers’ group. Members come from all states in Australia and New Zealand. The members have diverse clinical, management, and academic backgrounds, with professional practice experience in a variety of hospital settings including academic, nonacademic, urban, and rural hospitals. The subcommittee corpus of disaster field experience includes relief operations in 21 countries and territories working for governmental, nongovernmental, Red Cross, and United Nations organizations, as well as clinical management of focal MCIs with dozens of injured survivors.

The Working Group undertook a modified Delphi technique24,25 to examine response actions in surge situations. Core issues were explored in the biomedical literature using Medline from 1966 to 2007 implementing the key words “disaster,”“surge,” and “surge capacity.” Members of the group independently identified epidemiological and operational assumptions that underpinned EM surge situations. The assumptions were collated and then redistributed to the group. Once agreement was reached on the assumptions, the next round identified response actions—work practices under the control of the EP independent of prehospital and in-hospital constraints. These response actions were compiled within the domains of “space, staffing, supplies, and health system.”26 The overall strategy was collated into a draft written framework and collectively reviewed in February 2008. Unsettled issues led to further independent electronic review and framework revision until consensus emerged. All Working Group members supported the final recommendations.

Planning and operational assumptions

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

In developing its strategies, the Working Group identified and agreed on a number of assumptions, both epidemiologic and operational, that underlie the approach to the management of major incidents.

Epidemiologic Assumptions

  • • 
    Natural and transportation hazards are the most likely cause of disasters.27
  • • 
    Daily variations in demand, without a single event, are the most likely cause of surge in EDs.28
  • • 
    In the event of terrorist attacks, explosions using conventional weapons remain the most common cause,29 with one-third of patients deemed critical, and two-thirds of patients treated and released from an ED.30
  • • 
    Hazard-specific death rates will be low as even bomb blasts have been found to inflict a fatality rate of less than 5% on its victims.29 Hence, almost all disaster-affected persons must be considered as potential survivors.
  • • 
    Events may attract department visitors (media, VIPs, hospital staff, concerned families, etc.) far in excess of patients generated by the events.31
  • • 
    The majority of patients will be ambulatory.32 More specifically:
  • • 
    The vast majority of casualties in a disaster will leave the scene spontaneously.33 These patients are typically not triaged, treated, or transported by an emergency medical services (EMS) system, and they commonly arrive at the nearest hospital before the most injured patients.34
  • • 
    Major events may yield patients with psychiatric symptoms far in excess of patients with organic symptoms. For example, in the Tokyo Sarin nerve agent attack, the ratio of psychiatric to organically ill patients was 4:1.35

Operational Assumptions

  • • 
    EDs operate at full capacity at almost all times.32,36–38
  • • 
    There will be little or no advance warning.29,33
  • • 
    As most patients presenting as part of the surge following an incident will not have been transported by EMS, they may have had no triage, decontamination, or treatment provided before arrival.29
  • • 
    Approximately 50%–80% of the acute mass casualties in a disaster will arrive at the closest medical facilities, generally within 90 minutes following an event.16 Other hospitals outside the area may receive few, if any, casualties.34
  • • 
    There will be limited options in surge for patient diversion or transfer to another facility. Under standard operating procedures of local control, an ED may have the option to go on EMS diversion (bypass) during a typical busy day. However, an out-of-hospital MCI is considered likely to exclude that option. Moreover, under those circumstances, the EMS role in interfacility transfer of patients remains speculative, beyond control of the ED, and not considered an option.
  • • 
    Preventing the physical entry into the hospital of persons seeking emergency care is not considered an option during surge. While the concept is theoretically relevant to selected chemical, biologic, or radiation hazards,39 its rarity in clinical practice, its ethical challenges,40 and its bureaucratic dependence on the hospital executives put it beyond the scope of this article.
  • • 
    External deployable medical teams, portable hospitals, or portable decontamination units are not an immediately available response option for an affected hospital.32
  • • 
    All attempts will be made to maintain normal standards of care.

Findings

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

Findings of the Working Group are presented as an ED response framework in Tables 1 and 2. Table 1 identifies actions to be considered before the surge (preevent). Table 2 lists actions to be considered during the surge (event). The tables prioritize actions within categories of space, staffing, supplies, and systems. Key actions that differ markedly from routine work practices are considered in detail in the discussion. Actions with an asterisk apply particularly to the management of surge associated with a busy day unrelated to an MCI and are collectively considered at the end of the discussion.

Table 1.    Working Group Recommendations for Surge Management Preevent Priority Actions
  1. *Applies particularly to the management of surge associated with a busy day unrelated to a mass casualty incident.

SPACE
 Clear the ED of all admitted patients with cooperation of inpatient units as feasible and the hospital executive as needed.*
 Identify intra-ED expansible areas—corridors, transit lounge, short stay, fast track—for care of stretcher and sitting patients who can be cohorted.*
 Identify and set up an extra-ED diversion area for stable, ambulatory, nonemergency patients.
 Clear the waiting room of all patients fit for disposition to alternative providers.
 Send admitted patients to a predetermined holding area (e.g., outpatients, short stay unit) to allow immediate decant, and have inpatient units pick patients up rather than ED staff perform transfer.
STAFFING
 Allocate roles and distribute appropriate job action cards.
 Determine meeting points for new staff to arrive and staff updates to occur.
 Decide if or how the ED must modify its staffing model.*
SUPPLIES AND EQUIPMENT
 Distribute premade “disaster” IDs, chart packs, x-ray, and lab slips.
 Distribute tools for redundant communications—cell (mobile) phones, two-way radios, white boards, runners.
 Call for extra patient trolleys and chairs so every patient has a place to lie or sit.*
 Call for extra portable suction, ventilators, monitors.
 Create at least one portable disaster trolley appropriate for each cohort area. Stock with items such as fluids, dressings, IVs, analgesia, antibiotics.
SYSTEM OPERATIONS (FLOW)
 Notify EMS to arrange bypass of individual patients unrelated to the surge event.*
 Co-locate triage and security staff to create triage-security surge team(s).
 Preposition a surge team to the waiting room entrance.
 Call rounds or make rounds to force clinical decision-making on remaining ED patients.*
 Announce surge-induced goals of care and investigation and treatment processes.*
 Place security at all entry and exit points to ensure access exclusively to patients and properly badged staff.
 Announce intent to delegate extensively to free up the senior clinician(s) for decision-making purposes.*
 Bring in early use of disaster patient tracking system and have a dedicated staff member keep this updated.
 If recognized by the local system, invoke preestablished methods of utilizing alternative sites for patient disposition.
Table 2.    Working Group Recommendations for Surge Management Event Priority Actions
  1. *Applies particularly to the management of surge associated with a busy day unrelated to a mass casualty incident.

SPACE
 Maximize cohort care and minimize one-on-one care.*
STAFF
 Request surgical and critical care liaison points in ED
 Engage nonclinical staff (e.g., medical students) as  runners, scribes, and patient transporters.*
SUPPLIES AND EQUIPMENT
 Have a team member dedicated to restocking supplies in  main cohort areas, allowing staff in these areas to  maintain clinical roles.*
SYSTEM OPERATIONS (FLOW)
 Delegate extensively. Your job is to make decisions, not  gather data.*
 Make frequent rounds to geographic areas of cohort care.*
 Pursue an appropriate disposition even without a clear  diagnosis.*
 Consider the use of Focused Assessment with Sonogram  in Trauma (FAST) to assist early disposition.
 Limit contrast studies. ED staff read films, but insist on  real-time reporting of studies as driven by patient  instability or provider uncertainty.
 Minimize return of patients to the ED. A patient sent out of  the ED for a special study goes with a provisional  diagnosis and a disposition plan.

Discussion

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

The Working Group has identified several key principles that appear critical to the effective management of surge.

1. Recognizing Surge

Recognizing surge is the key to a prompt response. ED surge is a significant increase in the demands placed on an ED, given the normal capacity within which an ED can reasonably maintain standards of care. The surge may be reflected in rate of patient presentations, waiting times, patients queued, and ambulance diversions. A discrete, sudden mass casualty event makes activation relatively straightforward; however, a surge may occur without such declaration or in the absence of a discrete event. The Working Group focused its efforts on problems managing daily surge as well as single event surge from traumatic MCIs. The Working Group believes its recommendations provide a starting point for an EP managing a generic surge situation. In an “all-hazards” environment, the Working Group also acknowledges that prehospital hazards from chemical, biologic, and radiologic sources may require hazard-specific modification to the generic surge guidance provided here.

An understanding of the patterns of surge, including the previously listed epidemiologic assumptions, is critical to its identification and management. In these contexts, a hospital ED is more likely to be burdened by self-presenting patients and their families than by ambulance patients. Nevertheless, current literature emphasizes the numbers of available operating rooms (ORs) and critical care beds as major factors in determining a hospital’s capacity to care for critically injured casualties.30

Planning for surge has led to numerous types of quantitative triggers. These include absolute numbers of patients dead or affected, overflow beds required as a percent of hospital baseline,41 and numbers of patients per million of the host population.42 The Working Group believes the simple metrics of numbers of presenting patients will be most familiar to EPs. Further specifics are detailed in Section 5 below.

2. Initiating Action

The Working Group believes that initial strategies must be initiated from the ED. While a “whole of institution” disaster plan activation may ultimately be necessary, the Working Group believes that properly timed surge strategies can prevent a surge situation from overwhelming an ED and escalating into a facilitywide disaster. The Working Group recognizes that different EDs under the stress of surge may use a separate capacity enlargement plan or activate components of their disaster plan, depending on local policy. Unfortunately, the Working Group also recognizes reluctance of EPs to initiate volume-triggered surge strategies—particularly for daily surge. As a result, “business as usual” commonly prevails.

3. Maintaining Patient Flow

There is a need to ensure unidirectional flow through the system and to avoid bottlenecks where possible.43 The Working Group recommends that an EP consider a range of disposition options for patients in surge. An ED schematic with loci of application of different strategies is presented in Figure 1, which provides several functional insights into the scope of oversight of the attending physician. The convergence of staff and equipment in surge can impair free movement within the department and amplify problems of decontamination should breaches occur. Arrows in the figure convey how hospital spaces outside the ED may receive decanted or diverted patients as part of a surge strategy.

image

Figure 1.  Priorities in surge augmentation. Physical spaces/places are depicted with capitals; recommended priorities for the ED supervising consultant and senior colleagues are depicted in lower case. “CARE” = patient care area/treatment cubicles and resuscitation areas; “ROAD” = roadside; “SURGE” = surge areas (e.g., short stay unit, fast track area, corridor); “TRIAGE” = triage area; “Triage” = advance triage; “WAIT” = waiting room; “XRAY” = radiology department; inline image = redeployed senior ED staff member; inline image = Security personnel; inline image = extra trolleys/stretchers; inline image = medical supplies and equipment; [RIGHTWARDS ARROW] = usual patient flow; “Action” = action to reduce ED patient number/workload; reconfigure = reorganize staff and cohort patients.

Download figure to PowerPoint

  • • 
    Diverting inbound EMS patients is a well-recognized option, although it may require EMS resources beyond the control of the EP.
  • • 
    Decanting ED patients—sending the “walking wounded” to another supervised part of the acute care area—may decompress the treatment area without incurring EMTALA liabilities. Ambulatory surge patients who appear well at triage may be escorted away from a chaotic waiting room and observed by appropriate staff pending detailed examination by a treating physician. Particular care needs to be taken, however, with the detailed examination of ambulatory patients following terrorist bombings, to ensure occult shrapnel injuries are not missed.44
  • • 
    Discharge nonsurge, nonsick patients to community providers.

Overall, the working area of the ED enlarges with surge. Staff and crowd control must reach beyond the confines of the department’s treatment areas. Reallocating resources specifically permits the department to preposition key functions of security and triage, as discussed below.

4. Setting Clinical Goals

Notification of a surge in demand should prompt immediate review of staff work practices in anticipation of increased workloads. At issue is not that they work faster or harder than normal, but that they work to a different goal. In these circumstances the clinical goal shifts from individual patient satisfaction to doing “the most for the most.” This does not obligate a change in the standard of care, but does imply a change in the standard of service. Standards of service encompass amenities of care that become unsustainable in surge situations and frank disasters.19,45 These changes are listed in Table 3, for which a notional rank order is proposed. Senior staff members have the responsibility of articulating these practice changes to their junior staff and delegating appropriate tasks. Changes in the standard of care occurring through depletion of critical supplies or exhaustion of staff are beyond the scope of this paper.

Table 3.    Working Group Recommendations for Patient Priorities in Surge Settings
Patient Priority
1. Life threat
2. Limb threat
3. Other urgent bedside procedures (analgesia, splinting,  dressings, etc.)
4. Disposition decision
5. Diagnosis decision
6. Patient comfort (access to stretcher, blankets, pillows,  newspapers)
7. Visual and auditory privacy

5. Deploying a Surge Team for Advance Triage

Triage is fundamental to the efficient and effective management of multiple patients. Routine triage may be maladapted to ED needs in times of surge. Passive reception of patients at triage denies the ED the opportunity to control patient flow before it converges on the waiting room, invites contamination of the premises from patients with transported hazards, and delays initial clinical decision-making. Loss of crowd control in surge has been known to swamp a hospital within minutes.46

Triage and security are the lynchpins of the initial management of surge in the ED. Triage and security protect the ED from chaos and contamination and should also facilitate clinical care. In that context, triage and security must co-locate and work as a surge team. This may be as simple as one security officer and one triage nurse creating a surge team, or the team may enlarge with administrative and clinical staff.

The principal responsibilities of the surge team are to 1) ensure that the work environment stays safe from contamination, 2) divert nonclinical visitors to an appropriate non-ED destination, and 3) decant ambulatory patients (“walking wounded”) to a designated reception area. To these ends, the surge team must preposition itself ahead of the customary triage location. The numbers used in the graphic are illustrative and may differ between EDs dependent on staffing levels, bed capacity, and existing workload and occupancy. The key is to recognize the changes in practice associated with differing levels of demand and to maintain control of both patient entry to the ED and patient flow.

  • • 
    With the anticipated arrival of fewer than 10 additional patients, the surge team prepositions itself at the entrance to the waiting room.
  • • 
    If the waiting room is overloaded, or triage anticipates an imminent arrival of 10 or more additional patients, the surge team prepositions itself at the vehicle/ambulance entrance on the street.
  • • 
    If a patient load far in excess of 10 patients is anticipated, then the surge team should consider curbside triage and close the street to through traffic.

The data set for decision-making by surge teams is visual. There is no documentation. Patients are directed to the decontamination area as needed, decanted to the designated ambulatory reception areas, or passed through to the routine triage desk. The Working Group believes that the most senior clinicians (whether doctors or triage nurses) best perform this role, and most naturally project the gravitas needed for crowd control.

This model may be seen as controversial and appear resource-intensive, especially to small departments. However, the Working Group believes that advanced triage is critical to the effective management of surges in demand in the ED. This is particularly so when multiple civilian vehicles converge on the ED or when mass transport of minor casualties to the hospital has occurred. The need for these prepositioned staff is generally short-lived, and the consequences of mismanagement are chaos and/or contamination of the department. The value of this approach was exemplified in the London bombings, where critical mortality was reduced by repeated effective triage, implementation of a hospitalwide damage control philosophy, minimal clinical investigations, and rapid transfer to definitive care.47

Decanting stable, ambulatory patients to an appropriate treatment area is a key task that contributes to both efficient patient care and crowd control. This concept is well recognized in basic disaster training,12 but is uncommonly applied in ED settings. The Working Group believes that the near-simultaneous arrival of more than 10 ambulatory patients should prompt consideration of diversion to an in-ED “fast track” area or to an extra-ED ambulatory treatment area. To facilitate the movement of these “green” triage patients, we recommend a preestablished protocol with a dedicated hospital escort to assist with patient movement. One option is placing wide green adhesive tape (5 cm/2 inches wide) on the hospital floor to mark the path from the ED triage area to the decant area receiving ambulatory patients.

6. Providing Clinical Care

Emergency physicians typically focus on finding the pathology, but the demands of surge force the ED to find the “unmade” decision. Surge in demand should prompt clinical rounds of the ED to expose unmade decisions. In a small ED, this is easily organized, but in the large ED, taking all clinicians from their clinical duties to attend these rounds may be counterproductive, and different approaches may be necessary. Senior staff should regularly review patients under their care to ensure that timely decisions are made.

The Working Group recommends consideration of designated teams (one to two staff) for specific ED tasks—resuscitation, cohort care, bedside procedures, fluid and medication review, etc. A patient who is seriously ill or injured may require the attention of a resuscitation team. A patient not seriously ill or injured may be managed in a designated area of the ED by one of the dedicated teams. Allocation of individuals to specific tasks such as analgesia has been shown to be effective.48

One group of patients merits particular attention—the nondisaster/presurge patients. These patients may be easily marginalized by the demands of an incoming surge and its associated drama. Some of these patients may harbor serious pathology, but all of them call for clinical decision-making. For example, an ED with 50,000 visits/year may have 25 beds in geographically scattered domains—resuscitation, acute care, fast track, procedure room, etc. At any time, many of these beds may hold patients who have been triaged, assessed by a nurse, and are waiting for a doctor. The Working Group recommends that a senior clinician make quick bedside rounds on these patients to advance the decision process. Individual Working Group members have undertaken this action in concert with a charge nurse. They gather all the unseen patients’ charts, lab reports, etc., and then proceed to bedside round on the waiting patients. After a brief explanation of circumstances to the patient, they sort out the chief complaint, perform a focused inspection, and order necessary studies. The process takes approximately 1 minute per patient. In the 25-bed ED hypothesized above, even where recent turnover places new patients in half the beds, the clinical team will substantively sight all the department’s new patients in perhaps 12 minutes. Occasionally this process leads to immediate consultation and acceptance by an inpatient service—particularly for referred patients. After patients have been initially seen, nurses can play a major role in subsequent clinical decision-making by sharing clinical data with the treating physician as new data become available. The Working Group finds particular value in work practices that optimize information sharing in brief clinical encounters. Selected illustrative practices are listed in Table 4.

Table 4.    Working Group Recommendations for Clinical Work Practices in Surge Settings
Do not interrupt the expression of the chief complaint
Chart as you listen
Order laboratory investigations necessary to make a disposition, not necessarily to make a diagnosis
Limit imaging, particularly contrast imaging, as much as possible
Put selected patients with a clear diagnosis and limited care needs (IV fluid, analgesia, antibiotics) under the care of a junior doctor
Make a disposition plan with a key family member present to optimize understanding and minimize redundant conversations

Within the ED, disposition to inpatient locations should also be enhanced. Early investigations and early selection of patients suitable for transfer to the OR and intensive care unit aid faster patient transit and preservation of both ED space and staff capacity. This also allows critically ill patients to spend minimal time in the ED and to access definitive care earlier.

The Working Group recommends that a patient needing hospital admission be so admitted on determination of that need and after stabilization of the patient’s condition. By contrast, completion of a data set, particularly involving laboratory or radiologic studies, considered routine in nonsurge settings, becomes counterproductive in times of surge. Successful implementation of this approach will require preexisting agreements with affected inpatient services.

7. Using External and Ancillary Personnel

The Working Group notes that surge in the ED from an MCI is likely to last only several hours. With the exception of small EDs, the call-in of additional clinical staff is often too slow to affect the immediate situation. While call-in lists should be pre-prepared and updated regularly, the Working Group finds staff shortage is rarely an issue. Surge situations are characterized more by resource maldistribution than by absence. In those circumstances, planning should include a “corral point” for arriving staff, and a buddy system that partners non-ED staff (medical, nursing, clerical) to work with existing ED staff or supervisors. Medical and nursing students are a source of additional workforce and may assist with minor interventions (IVs, pathology specimen delivery) or serve as message bearers or scribes.44 Similarly, allied health staff are often neglected in surge planning, but may be able to fill a variety of valuable roles.49

8. Managing Surge Due to Variations in Daily Demand

The most common surge confronting EDs is the overwhelming demand of a very busy day aggravated by access block. The resultant crowding has been shown to be associated with adverse patient outcomes.50–52 Selected actions in Tables 1 and 2 are marked by asterisks for their applicability to these situations in the ED. In effect, surge management on a busy day amounts to a simplification of the options available in an MCI. The key is forthright recognition of the problem and willingness to activate an appropriate response.

Some actions, such as ambulance bypass, are commonly undertaken. Other actions, such as clearing the department of admitted patients, may be precluded by access block and effectively may yield little in terms of new ED bed space. The Working Group focused on those particular work practices under the control of the EP—independent of prehospital and in-hospital constraints.

Depending on local conditions, various options may be most applicable in given circumstances. Not all options suggested in this paper may be available to all departments at all times. It is also recognized that many of the recommendations are generic and will need to be adapted to suit both local practices and resource constraints. Nonetheless, the Working Group believes that an EP with a ready list of options is best equipped to serve his or her patients in a surge situation.

Future steps

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

The Working Group recognizes that these recommendations are simply the start of what needs to be a long-term effort to validate and optimize surge management strategies in EDs. Surge management is but one aspect of disaster management, and it will require the commitment of health and government leaders. The Working Group embraces the busy ED as a center for hospital clinical excellence and an opportunity for clinical education and operations research. To those ends, particular areas meriting future attention include:

  • • 
    A more complete understanding of factors limiting ED surge capacity is needed to enable development of appropriate response strategies.
  • • 
    How much surge capacity a hospital or health system should be expected to produce a priori remains unclear. Surge capacity benchmarks have been described in terms of percentage of usual bed capacity in Israel,41 population ratio in the United States,42 and absolute numbers of patient beds in other settings. Improved measures of population risk, agreement on performance indicators, and data transparency enabling assessment of preparedness are all future landmarks in the science of surge.
  • • 
    Operational research into the kinetics of patient flow merits future attention. Researchers will likely adopt tools commonly used in lean systems such as bar coding, provider ID card readers, and software enabling full department schematic display. Metrics of interest include patient volumes in areas of surge, elapsed times associated with the patient flow in Figure 1, and outcomes of care.
  • • 
    The effect of surge on quality of care also needs more study. Pioneering work in Australasia clearly shows excess mortality in patients presenting during periods of high ED occupancy.51 While competence in medicine is case-related, volume overload in EM remains linked to patient outcomes. Surge strategies appear destined to become integral to the achievement of standards of care in overburdened health facilities. Clearer understanding of consequences of surge management will guide future efforts to refine the strategies.

Summary

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References

The Working Group believes that the identification of “surge strategies” for EDs can lead to quantifiable measures of disaster preparedness. This will facilitate measurement of progress by individual departments and allow comparison between departments in pursuit of improved patient outcomes.

The Working Group thanks the staff of the ACEM for their support in coordinating the meetings of the group.

References

  1. Top of page
  2. Abstract
  3. Working group methods
  4. Planning and operational assumptions
  5. Findings
  6. Discussion
  7. Future steps
  8. Summary
  9. References
  • 1
    Pan American Health Organization. Disaster Mitigation Guidelines for Hospitals and other Health Care Facilities (Vol. 1-4). Washington, DC: Pan American Health Organization, 1992.
  • 2
    American Hospital Association. Disaster Readiness. Available at: http://www.hospitalconnect.com/aha/key_issues/disaster_readiness/index.html. Accessed Apr 2008.
  • 3
    Agency for Toxic Substances and Disease Registry. Hospital emergency departments: a planning guide for the management of contaminated patients. Vol. 2 revised. In: Managing Hazardous Materials Incidents. September 2001. CD-ROM available from ATSDR, Atlanta, GA. http://www.atsdr.cdc.gov.
  • 4
    Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness I: the emergency department and hospital. Emerg Med Clin North Am. 2002; 20:43755.
  • 5
    SAEM Disaster Medicine White Paper Subcommittee. Disaster medicine: current assessment and blueprint for the future. Acad Emerg Med. 1995; 2:106876.
  • 6
    Caldicott DG, Edwards NA. The global threat of terrorism and its impact on Australia. Emerg Med (Fremantle). 2002; 14:2145.
  • 7
    Tan GA, Fitzgerald MC. Chemical-biological-radiological (CBR) response: a template for hospital emergency departments. Med J Aust. 2002; 177: 1969.
  • 8
    Palmer DJ, Stephens D, Fisher DA, Spain B, Read DJ, Notaras L. The Bali bombing: the Royal Darwin Hospital response. Med J Aust. 2003; 179:35861.
  • 9
    Traub M, Bradt DA, Joseph T. Surge capacity for people in emergencies (SCOPE) study in Australasian hospitals. Med J Aust. 2007; 186:3948.
  • 10
    Task Force on Quality Control of Disaster Management. Health disaster management: guidelines for evaluation and research in the Utstein style: executive summary. Prehospital Disast Med. 1999; 14:4353.
  • 11
    Advanced Life Support Group. Major Incident Medical Management and Support—The Practical Approach. Plymouth, UK: BMJ Publishing Group, 1995.
  • 12
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