1. Medical Surge Capacity
Bill Jermyn, DO, FACEP
11/24/2018

2. What Do We Have Today? I have no clear cut answers for you.
This is an awareness message.
Not what you wanted to hear.
As with everything else, we are better off than 4 years ago, but not yet prepared for a big event.
11/24/2018

3. What Do We Need for Surge Capacity?
Physical space
Equipment
Staff
11/24/2018

4. Physical Space
Many regions and hospitals have made plans for alternative sites to deliver care
Examples are auditoriums, gymnasiums, ambulatory care settings, etc
Actually getting possession may be problematic
Hospitals unlikely to be able to provide a significant number of beds
According to AHA: avg. open beds are only 4-6% of bed capacity
11/24/2018

5. Equipment
HRSA funded trailers are either dispersed or planned for dispersal across the state
Surge Trailers: cots and minimal supplies
Mass Casualty Trailers: cots, generators, and trauma supplies
Decontamination and PPE Trailers: Some supplies, wash down equipment, PPE, etc
Most hospitals have adopted “just in time” supply strategies
11/24/2018

6. Staff Probably the most critical component and the area least prepared
Complicated problem with no easy solutions—legal liability (civil and criminal), scope of practice, credentialing, payment, logistics
FYI: Post-SARS, Toronto doesn’t plan for outside facilities since there is no one to staff them
11/24/2018

7. Staff 20 years ago there was an RN surplus
Today, estimated shortfall is 126,000 RN’s
By 2020, 750,000 RN’s
Daily shortage of surgeons and on-call specialists for trauma call
Emergency Physicians are barely replacing themselves
11/24/2018

8. What Happened?
Since 1986, move to outpatient therapy and earlier discharges from the hospital (HMO’s, PPO’s, etc)
Result was fewer hospital beds
Community Hospitals:
1975: 424 beds/100,000 population
2003: 280 beds/100,000 population
11/24/2018

9. What Happened?
: Hospitals lost 103,000 inpatient medical/surgical beds and 7,800 ICU beds nationally.
: ED visits increased by 26% (90 to 114 million/year) while the number of ED’s dropped by 14%.
This has significantly increased the patient load of the remaining facilities.
11/24/2018

10. What Do We Have Now?
Day to day capacity is strained-crowding and ambulance diversion (every minute of every day)
Boarding, crowding, and diversion
National problem
Limited training for medical personnel to function in a disaster scenario
11/24/2018

11. What Do We Have Now?
Gina Lagarde, MD, MBA-LA Office of Public Health- Post-Katrina/Rita:“…care to patients in nontraditional settings was not understood.”
Hawaiian Medical Society polled thousands of healthcare workers post 9/11. Only 50% felt prepared enough to even come to work after potential chemical or biological exposures
11/24/2018

12. What Do We Have Now?
2003 ACEP survey: 80% respondents said their ED’s lacked surge capacity because of crowding, boarding, and a lack of on-call specialists
Shift to outpatient therapy has severely taxed our ability to respond when the system fails
11/24/2018

13. 2001 “…emergency departments are overwhelmed ….”
“The problem is that the supply of care has been choked back.”
“…another could be to recognize emergency medical care as an essential public service, one that should be provided to every community….”
11/24/2018

14. 2003
“Emergency Department crowding is not an issue that can be solved in the ED alone.Rather, it is a complex issue that reflects the broader health care market. It is clear that, as a key part of the health care safety net, ED’s in many of the nation’s largest cities are under strain.”
GAO
March 2003 HOSPITAL
EMERGENCY
DEPARTMENTS
Crowded Conditions
Vary among Hospitals
and Communities
GAO
11/24/2018

15. January 2006
“Local emergency departments are at the front line of this national crisis.”
“…they must wait in emergency department hallways for hours and sometimes days.”
“…emergency medicine systems in many states are under extreme stress.”
‘Policymakers, physicians, and the general public should take note and take steps to address the shortcomings….”
The National Report Card on the State of Emergency Medicine
American College of Emergency Physicians
11/24/2018

16. 14 June 2006
“…the nation’s emergency medical system is overburdened, underfunded, and highly fragmented….”
“This crisis is multifaceted and impacts every aspect of emergency care—from prehospital EMS to hospital-based and trauma care. The American public places its faith in the ability of the emergency care system to respond appropriately whenever and wherever a serious illness or injury occurs. But while the public is largely unaware of the crisis, it is real and growing.”
11/24/2018

17. Outpatient and “Special Needs”
Estimated 150,000 home health patients in MO
Dialysis patients
Dementia patients
Assisted living, rehabilitation facilities, skilled nursing facilities, and nursing homes
Elderly and chronically ill will increase as baby boomers mature
Home oxygen therapy, nebulizer patients, etc
Estimates run 45-55% of the population
11/24/2018

18. Why? Healthcare is not funded for surge capacity.
Encouraged to be 100% efficient.
We need to develop a way to assist healthcare with their ability to surge properly.
11/24/2018

19. 11/24/2018

20. Take Home Physical space and equipment are being addressed
Staffing remains a problem
Hospitals will be unable to provide much capacity without significant help
Medical system at capacity daily
Shelters only provide a place to lay down; need to plan for field hospital care
11/24/2018

21. Take Home
Liability and altered standards of care issues need to be addressed
Credentialing process is needed
Backfill needs to be supported
Pediatrics are forgotten too often
Need to plan for care for families of workers
The normal flow of emergencies will not cease during a disaster scenario
11/24/2018