Skills Station: Surge

Objectives Utilize the four primary support elements that contribute to surge efficiency and effectiveness Implement the various strategies that provide for contingency and crisis surge capacity for health care facilities By the end of this skills station, you should be able to Distinguish surge capacity from surge capability Apply principles of surge response in a simulated exercise Describe pitfalls in development of effective surge response

D I S A S T E R D I S A T E R etection ncident management afety and security A ssess hazards upport [surge] T riage and treatment E vacuation R ecovery The DISASTER Paradigm™ provides a rapid framework for both planning and response in mass casualty events. Surge falls under Support in the context of health care facilities.

Surge Capacity Capability ability to expand space for casualty flow, routine patient flow, staff, and supplies Capacity ability to provide necessary casualty care phased over time Capability Surge capacity is the ability of a facility to expand space for casualty flow to accommodate more than routine patient flow Surge capability is the ability to provide necessary casualty care as phased treatments over time Capability is more qualitative; capacity is more quantitative

Space, staff, supplies, systems Surge Capacity Conventional Contingency Crisis Space, staff, supplies, systems A national goal remains 20% bed augmentation for surge capacity In many respects, surge can be framed as generating supply to meet demand Ways to manage supply: Free up existing space and capability (conventional) Reverse triage: discharge least sick patients to generate bed capacity Cancel elective surgeries & clinics Discharge ER patients & move ICU patients Generate new space & capability Use existing monitored settings as ICUs (contingency) Open alternate sites (flat space) within facility (crisis) What are ways to manage demand? Control influx of casualties Initial triage outside facility Security Rapidly defined/created spaces

Goals Minimize mortality in critically injured Maximize care delivered to casualty population Injured by disaster Regular emergencies

Situation Afternoon explosion 500 beds 2,000 casualties 100 ICU 200 dead 40 pediatric Closest hospital 20 OR, 20 PACU Near-full capacity So, we are going to move through a scenario: There has been an explosion this afternoon downtown Media reports indicate 2,000 casualties, with 200 dead at the scene Your hospital is the closest to the event and is near full capacity Your hospital has 500 beds 100 ICU 40 pediatric You have 20 operating rooms and 20 recovery room beds You have 10 minutes before the first casualties arrive What are your priorities? Here come the casualties—cards begin to flip on the model

You have 10 minutes before first casualties arrive You have 10 minutes before first casualties arrive. What are your priorities? What are your goals? [Move the scenario quickly] You have 10 minutes before the first casualties arrive. What are your priorities? What are your goals?

Special Considerations and Pitfalls

Surge Capability Special Considerations Special needs populations: Children Elderly Medical needs Disabled Access Psychiatric Special casualty needs Burn care Critical care with ventilators Surge capabilities address the needs of special populations at the extremes of age and those requiring dialysis Ventilator management requires ventilators and professionals to run them Sub-specialists include neurosurgeons, orthopaedists, and burn surgeons Limits of surge capability move decision making into rationing; secondary casualty distribution to other available facilities is also an option

Time-Limited Mass Casualty First wave: walking wounded and psychiatric arrive without EMS Instant bottleneck Security with redirected flow Second wave: critically injured arrive via EMS Screen casualties outside of ED In a time-limited mass casualty event, casualties present in waves to hospitals. The first wave is dominated by the walking wounded & psychiatric casualties. They present without EMS and can generate an instant bottleneck. Security is essential to redirect casualty flow and preserve the hospital for the critically injured/salvageable casualties. It is paramount that critical care resources are saved for casualties with critical injuries. The second wave includes more critically injured who arrive via EMS.

Minimize Hospital Contamination Secondary contamination risk Solutions: Receive and screen casualties outside of ED Decontaminate outside facility Do not assume away the risk of contamination. The Tokyo subway sarin gas attack and SARS are disconfirming examples for such an assumption. Secondary contamination of health care facilities remains a significant risk. Most casualties present on their own and away from scene decontamination efforts. Solutions include planning for decontamination outside the facility, with casualty screening outside the ED as well.

Outcome Total casualties = ??? Critically injured = ?? Musculoskeletal TM rupture Blast lung Head trauma Operations in 24 hours = ?? [After the exercise, share this slide that highlights the outcomes from this real-world event] There were 300 casualties, 30 (10%) of whom were critically injured There were a total of 30 operations over the first 24 hours, most of which were urgent orthopaedic procedures

Pitfalls Mass provider, media, or worried-well incidents Casualty flow bottlenecks Definitive, rather than phased care process No documentation (or over-documentation) Consistent pitfalls in surge for mass casualty events include Mass provider, media, & worried-well incidents: have a place for these groups to go Casualty flow bottlenecks: remember, surge enables phased treatments over time, not definitive evaluation and management Care process: routine care processes to definitive care do not enable greatest good for the greatest number of casualties; a phased care process is used whereby, initially, the least intervention is done to save and sustain as many lives as possible Communication: simplify communication of casualty care

Questions?

Summary Four elements to surge capacity include: Space Staff Supplies Systems Manage surge demand and supply Drills identify and avoid pitfalls In summary: Surge capacity increases usable casualty care space and mobilizes staff and resources; surge capability increases casualty care. Both supply & demand must be managed. The greatest pitfall is thinking of mass casualty management as business as usual. Surge increases care for the casualty population, not for the individual patient.