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Disaster Alternate Care Facility Selection Tool

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Appendix A: References and Available Abstracts

Peer-Reviewed Literature Search Results

Adini, B., A. Goldberg, et al. (2006). "Assessing levels of hospital emergency preparedness." Prehosp Disaster Med 21(6): 451-7.
INTRODUCTION: Emergency preparedness can be defined by the preparedness pyramid, which identifies planning, infrastructure, knowledge and capabilities, and training as the major components of maintaining a high level of preparedness. The aim of this article is to review the characteristics of contingency plans for mass-casualty incidents (MCIs) and models for assessing the emergency preparedness of hospitals. CHARACTERISTICS OF CONTINGENCY PLANS: Emergency preparedness should focus on community preparedness, a personnel augmentation plan, and communications and public policies for funding the emergency preparedness. The capability to cope with a MCI serves as a basis for preparedness for non-conventional events. Coping with chemical casualties necessitates decontamination of casualties, treating victims with acute stress reactions, expanding surge capacities of hospitals, and integrating knowledge through drills. Risk communication also is important. ASSESSMENT OF EMERGENCY PREPAREDNESS: An annual assessment of the emergency plan is required in order to assure emergency preparedness. Preparedness assessments should include: (1) elements of disaster planning; (2) emergency coordination; (3) communication; (4) training; (5) expansion of hospital surge capacity; (6) personnel; (7) availability of equipment; (8) stockpiles of medical supplies; and (9) expansion of laboratory capacities. The assessment program must be based on valid criteria that are measurable, reliable, and enable conclusions to be drawn. There are several assessment tools that can be used, including surveys, parameters, capabilities evaluation, and self-assessment tools. SUMMARY: Health care systems are required to prepare an effective response model to cope with MCIs. Planning should be envisioned as a process rather than a production of a tangible product. Assuring emergency preparedness requires a structured methodology that will enable an objective assessment of the level of readiness.

Aylwin, C. J., T. C. Konig, et al. (2006). "Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005." Lancet 368(9554): 2219-25.
BACKGROUND: The terrorist bombings in London on July 7, 2005, produced the largest mass casualty event in the UK since World War 2. The aim of this study was to analyse the prehospital and in-hospital response to the incident and identify system processes that optimise resource use and reduce critical mortality. METHODS: This study was a retrospective analysis of the London-wide prehospital response and the in-hospital response of one academic trauma centre. Data for injuries, outcome, triage, patient flow, and resource use were obtained by the review of emergency services and hospital records. FINDINGS: There were 775 casualties and 56 deaths, 53 at scene. 55 patients were triaged to priority dispatch and 20 patients were critically injured. Critical mortality was low at 15% and not due to poor availability of resources. Over-triage rates were reduced where advanced prehospital teams did initial scene triage. The Royal London Hospital received 194 casualties, 27 arrived as seriously injured. Maximum surge rate was 18 seriously injured patients per hour and resuscitation room capacity was reached within 15 min. 17 patients needed surgery and 264 units of blood products were used in the first 15 h, close to the hospital's routine daily blood use. INTERPRETATION: Critical mortality was reduced by rapid advanced major incident management and seems unrelated to over-triage. Hospital surge capacity can be maintained by repeated effective triage and implementing a hospital-wide damage control philosophy, keeping investigations to a minimum, and transferring patients rapidly to definitive care.

Bennett, R. L. (2006). "Chemical or biological terrorist attacks: an analysis of the preparedness of hospitals for managing victims affected by chemical or biological weapons of mass destruction." Int J Environ Res Public Health 3(1): 67-75.
The possibility of a terrorist attack employing the use of chemical or biological weapons of mass destruction (WMD) on American soil is no longer an empty threat, it has become a reality. A WMD is defined as any weapon with the capacity to inflict death and destruction on such a massive scale that its very presence in the hands of hostile forces is a grievous threat. Events of the past few years including the bombing of the World Trade Center in 1993, the Murrah Federal Building in Oklahoma City in 1995 and the use of planes as guided missiles directed into the Pentagon and New York's Twin Towers in 2001 (9/11) and the tragic incidents involving twenty-three people who were infected and five who died as a result of contact with anthrax-laced mail in the Fall of 2001, have well established that the United States can be attacked by both domestic and international terrorists without warning or provocation. In light of these actions, hospitals have been working vigorously to ensure that they would be "ready" in the event of another terrorist attack to provide appropriate medical care to victims. However, according to a recent United States General Accounting Office (GAO) nationwide survey, our nation's hospitals still are not prepared to manage mass causalities resulting from chemical or biological WMD. Therefore, there is a clear need for information about current hospital preparedness in order to provide a foundation for systematic planning and broader discussions about relative cost, probable effectiveness, environmental impact and overall societal priorities. Hence, the aim of this research was to examine the current preparedness of hospitals in the State of Mississippi to manage victims of terrorist attacks involving chemical or biological WMD. All acute care hospitals in the State were selected for inclusion in this study. Both quantitative and qualitative methods were utilized for data collection and analysis. Six hypotheses were tested. Using a questionnaire survey, the availability of functional preparedness plans, specific preparedness education/training, decontamination facilities, surge capacity, pharmaceutical supplies, and laboratory diagnostic capabilities of hospitals were examined. The findings revealed that a majority (89.2%) of hospitals in the State of Mississippi have documented preparedness plans, provided specific preparedness education/training (89.2%), have dedicated facilities for decontamination (75.7%), and pharmaceutical plans and supplies (56.8%) for the treatment of victims in the event of a disaster involving chemical or biological WMD. However, over half (59.5%) of the hospitals could not increase surge capacity (supplies, equipment, staff, patient beds, etc.) and lack appropriate laboratory diagnostic services (91.9%) capable of analyzing and identifying WMD. In general, hospitals in the State of Mississippi, like a number of hospitals throughout the United States, are still not adequately prepared to manage victims of terrorist attacks involving chemical or biological WMD which consequently may result in the loss of hundreds or even thousands of lives. Therefore, hospitals continue to require substantial resources at the local, State, and national levels in order to be "truly" prepared.

Blackwell, T. and M. Bosse (2007). "Use of an innovative design mobile hospital in the medical response to Hurricane Katrina." Ann Emerg Med 49(5): 580-8.
On August 29, 2005, Hurricane Katrina caused widespread devastation to the Gulf Coast region of the United States. Although New Orleans had extensive damage from flooding, many communities in Mississippi had equal damage from storm surge and wind. Because the medical resources in many of these areas were incapacitated, resources from North Carolina were deployed to assist in the medical mission. This response included the initial use of Carolinas MED-1, a mobile hospital that incorporates an emergency department, surgical suite, critical care beds, and general treatment and admitting area. This asset, along with additional State resources, provided comprehensive diagnostic and definitive patient care until the local medical infrastructure was rebuilt and functional. The use of a mobile hospital may be advantageous for future deployments to large-scale disasters, especially when integrated with specialty teams.

Bolster, C. J. (2006). "Mobile hospital provides care when disaster strikes." Healthc Financ Manage 60(2): 114-6, 118.
When planning resources for disaster response, hospitals should: Understand the mission of the equipment to be used. Be able to provide training. Learn how to use the resources most efficiently.

Bonnett, C. J., B. N. Peery, et al. (2007). "Surge capacity: a proposed conceptual framework." Am J Emerg Med 25(3): 297-306.
There is a need for emergency planners to accurately plan for and accommodate a potentially significant increase in patient volume in response to a disaster. In addition, an equally large political demand exists for leaders in government and the health care sector to develop these capabilities in a financially feasible and evidence-based manner. However, it is important to begin with a clear understanding of this concept on a theoretical level to create this capacity. Intuitively, it is easy to understand that surge capacity describes the ability of a health care facility or system to expand beyond its regular operations and accommodate a greater number of patients in response to a multiple casualty-producing event. The way a response to this need is implemented will, of course, vary dramatically depending on numerous issues, including the type of event that has transpired, the planning that has occurred before its occurrence, and the resources that are available. Much has been written on strategies for developing and implementing surge capacity. However, despite the frequency with which the term is used in the medical literature and by the lay press, a clear description of surge capacity as a concept is lacking. The following article will provide this foundation. A conceptual framework of surge capacity will be described, and some new nomenclature will be proposed. This is done to provide the reader with a comprehensive yet simplified view of the various elements that make up the concept of surge capacity. This framework will cover the types of events that can cause a surge of patients, the general ways in which health care facilities respond to these events, and the categories of people who would make up the population of affected victims.

Brandenburg, M. A., M. B. Ogle, et al. (2006). "Operation Child-Safe": a strategy for preventing unintentional pediatric injuries at a Hurricane Katrina evacuee shelter." Prehosp Disaster Med 21(5): 359-65.
INTRODUCTION: Children represent a vulnerable population, and special considerations are necessary to care for them properly during disasters. Comprehensive disaster responses include addressing the unique needs of children during mass-casualty incidents, such as the prevention of unintentional injuries. Early in the morning of 04 September 2005, approximately 1,600 Hurricane Katrina and/or flood survivors from New Orleans, including approximately 300 children, arrived at Camp Gruber, an Oklahoma National Guard base in Eastern Oklahoma. PROBLEM: The primary function of Camp Gruber to train support personnel for the Oklahoma National Guard. This is not a child-safe environment. It was hypothesized that the camp contained numerous child injury hazards and that these hazards could be removed systematically using local child injury prevention experts, thereby preventing unintentional injuries to the displaced children. METHODS: On 08 September, "Operation Child-Safe" was launched by the Pediatric Injury Response Team to identify and remove pediatric injury hazards from Camp Gruber. Injury prevention experts from the Safe Kids Tulsa Area (SKTA) Chapter, the closest pediatric injury prevention group in the region, spearheaded the operation. Several visits were required to remove all of the injury hazards that were identified. RESULTS: Many hazards were identified and removed immediately, while others were addressed in a formal letter to the Camp Gruber Commander for required consent to implement changes. Hazards identified in the camp included, but were not limited to: (1) dangerous chemicals; (2) choking hazards; (3) open electrical outlets; and (4) missing smoke detectors. Bicycle helmets, car seats, strollers, portable cribs, and other safety-related items were passed out to families in need. A licensed daycare facility also was established in order to give the adult guardians a break from constant supervision. Over the course of one month, only one preventable injury (minor head injury) was reported during camp operations, and this particular injury occurred two days before "Operation Child-Safe" was initiated (Day 3 of camp operations). CONCLUSIONS: In the aftermath of an event that displaces large numbers of people, it is likely that children will be exposed to numerous injury hazards. Volunteers with expertise in child injury prevention are needed to make an evacuee shelter safer for children.

Bridgewater, F. H., E. T. Aspinall, et al. (2006). "Team Echo: observations and lessons learned in the recovery phase of the 2004 Asian tsunami." Prehosp Disaster Med 21(1): s20-5.
The 26 December 2004 Tsunami resulted in a death toll of >270,000 persons, making it the most lethal tsunami in recorded history. This article presents performance data observations and the lessons learned by a civilian team dispatched by the Australian government to "provide clinical and surgical functions and to make public health assessments". The team, prepared and equipped for deployment four days after the event, arrived at its destination 13 days after the Tsunami. Aspiration pneumonia, tetanus, and extensive soft tissue wounds of the lower extremities were the prominent injuries encountered. Surgical techniques had to be adapted to work in the austere environment. The lessons learned included: (1) the importance of team member selection; (2) strategies for self-sufficiency; (3) personnel readiness and health considerations; (4) face-to-face handover; (5) coordination and liaison; (6) the characteristics of injuries; (7) the importance of protocols for patient discharge and hospital staffing; and (8) requirements for interpreter services. Whereas disaster medical relief teams will be required in the future, the composition and equipment needs will differ according to the nature of the disaster. National teams should be on standby for international response.

Burkle, F. M., Jr., E. B. Hsu, et al. (2007). "Definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ICS." Disaster Med Public Health Prep 1(2): 135-41.
The incident command system provides an organizational structure at the agency, discipline, or jurisdiction level for effectively coordinating response and recovery efforts during most conventional disasters. This structure does not have the capacity or capability to manage the complexities of a large-scale health-related disaster, especially a pandemic, in which unprecedented decisions at every level (eg, surveillance, triage protocols, surge capacity, isolation, quarantine, health care staffing, deployment) are necessary to investigate, control, and prevent transmission of disease. Emerging concepts supporting a unified decision-making, coordination, and resource management system through a health-specific emergency operations center are addressed and the potential structure, function, roles, and responsibilities are described, including comparisons across countries with similar incident command systems.

Burkle, F. M., Jr. (2006). "Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster." Acad Emerg Med 13(11): 1118-29.
Both the naturally occurring and deliberate release of a biological agent in a population can bring catastrophic consequences. Although these bioevents have similarities with other disasters, there also are major differences, especially in the approach to triage management of surge capacity resources. Conventional mass-casualty events use uniform methods for triage on the basis of severity of presentation and do not consider exposure, duration, or infectiousness, thereby impeding control of transmission and delaying recognition of victims requiring immediate care. Bioevent triage management must be population based, with the goal of preventing secondary transmission, beginning at the point of contact, to control the epidemic outbreak. Whatever triage system is used, it must first recognize the requirements of those Susceptible but not exposed, those Exposed but not yet infectious, those Infectious, those Removed by death or recovery, and those protected by Vaccination or prophylactic medication (SEIRV methodology). Everyone in the population falls into one of these five categories. This article addresses a population approach to SEIRV-based triage in which decision making falls under a two-phase system with specific measures of effectiveness to increase likelihood of medical success, epidemic control, and conservation of scarce resources.

Burstein, J. L. (2007). "Walls of canvas, walls of steel." Ann Emerg Med 49(5): 589.

Burstein, J. L. (2007). "You shall not stand by." Ann Emerg Med 49(5): 610-1.

Buttross, S. (2006). "Responding creatively to family needs of hospital staff: caring for children of caretakers during a disaster." Pediatrics 117(5 Pt 3): S446-7.

DeLia, D. (2006). "Annual bed statistics give a misleading picture of hospital surge capacity." Ann Emerg Med 48(4): 384-8, 388 e1-2.
STUDY OBJECTIVE: I describe how annual hospital surge capacity is affected by within-year variation in patient volume and bed supply. METHODS: Surge capacity was measured as the percentage and total number of hospital beds that are not occupied by patients. Administrative data were used to calculate these bed statistics for 78 hospitals in New Jersey—statewide and by emergency planning regions—in 2003. Annual bed statistics were compared to more refined calculations for each day of the year. Calculated numbers of empty beds were compared to Federal disaster planning benchmarks. RESULTS: Annual bed statistics showed no major limitations on surge capacity. Statewide occupancy rates were well below 80% (ie, more than 20% of beds were empty), and the number of empty beds that were set up and staffed (ie, maintained) was well above Federal disaster planning benchmarks. In contrast, daily bed statistics reveal long periods in 2003 when regional and statewide surge capacity was severely strained. Strained capacity was most likely to occur on Tuesdays through Fridays and least likely to occur on weekends. On 212 days, statewide occupancy of maintained beds met or exceeded 85%. This occupancy rate met or exceeded 90% and 95% on 88 and 4 days, respectively. On 288 days, the statewide number of empty maintained beds fell below the Federal planning benchmark. CONCLUSION: Annual bed statistics give a misleading picture of hospital surge capacity. Analysis of surge capacity should account for daily variation in patient volume and within-year variation in bed supply.

Eastman, A. L., K. J. Rinnert, et al. (2007). "Alternate Site Surge Capacity in Times of Public Health Disaster Maintains Trauma Center and Emergency Department Integrity: Hurricane Katrina." J Trauma 63(2): 253-257.

Erich, J. (2007). "As good as advertised: mobile hospital shines in Katrina response." Emerg Med Serv 36(2): 38-9.

Farmer, J. C. and P. K. Carlton, Jr. (2005). "Hospital disaster medical response: aligning everyday requirements with emergency casualty care." World Hosp Health Serv 41(2): 21-4, 41, 43.
In this essay, we would like to pragmatically and realistically introduce three topics: (a) Within the hospital, critical care is acknowledged as an enormous cost driver that becomes even less manageable during a disaster response scenario. It is widely recognised that hospital critical care capabilities for large scale disaster response require significant increases, but an overarching plan to accomplish this goal is lacking. This plan necessarily includes equipment, personnel, training, and space expansion. Lesser degrees of illness and injury will likely be cared for in other venues. What is required to provide 'large scale' critical care? (b) During a true large scale disaster with a large casualty stream, the mandate is not to provide 'standard of care,' but rather 'sufficiency of care.' What is that, what does that mean to critical care and the hospital, and how is that determined? (c) Are there other mandated in-hospital requirements that can be appropriately and successfully leveraged for disaster medical response?

Fernald, J. P. and E. A. Clawson (2007). "The mobile army surgical hospital humanitarian assistance mission in Pakistan: the primary care experience." Mil Med 172(5): 471-7.
Military surgical field hospitals are frequently deployed for humanitarian missions. Current Department of Defense doctrine and World Health Organization policy question the appropriateness of their use, because the majority of patients require nonsurgical care. We describe our experiences during the deployment of a mobile army surgical hospital in response to the October 8, 2005, earthquake in Pakistan. More than 20,000 patients received care during a 4-month period. An initially high surgical workload quickly decreased while the volume of primary care patients increased, eventually accounting for 90% of patient visits. Our experience supports deploying primary care-oriented units for humanitarian missions.

Franco, C., E. Toner, et al. (2006). "Systemic collapse: Medical care in the aftermath of Hurricane Katrina." Biosecur Bioterror 4(2): 135-46.
This article describes and analyzes key aspects of the medical response to Hurricane Katrina in New Orleans. It is based on interviews with individuals involved in the response and on analysis of published reports and news articles. Findings include: (1) Federal, State, and local disaster plans did not include provisions for keeping hospitals functioning during a large-scale emergency; (2) the National Disaster Medical System (NDMS) was ill-prepared for providing medical care to patients who needed it; (3) there was no coordinated system for recruiting, deploying, and managing volunteers; and (4) many Gulf Coast residents were separated from their medical records. The article makes recommendations for improvement.

Gavagan, T. F., K. Smart, et al. (2006). "Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex." South Med J 99(9): 933-9.
On September 1, 2005, with only 12 hours notice, various collaborators established a medical facility—the Katrina Clinic—at the Astrodome/Reliant Center Complex in Houston. By the time the facility closed roughly two weeks later, the Katrina Clinic medical staff had seen over 11,000 of the estimated 27,000 Hurricane Katrina evacuees who sought shelter in the Complex. Herein, we describe the scope of this medical response, citing our major challenges, successes, and recommendations for conducting similar efforts in the future.

Grantham, H. (2006). "Tsunami ECHO Team response." Prehosp Disaster Med 21(5): 366-7.

Hanfling, D. (2006). "Equipment, supplies, and pharmaceuticals: how much might it cost to achieve basic surge capacity?" Acad Emerg Med 13(11): 1232-7.
The ability to deliver optimal medical care in the setting of a disaster event, regardless of its cause, will in large part be contingent on an immediately available supply of key medical equipment, supplies, and pharmaceuticals. Although the Department of Health and Human Services Strategic National Stockpile program makes these available through its 12-hour "push packs" and vendor-managed inventory, every local community should be funded to create a local cache for these items. This report explores the funding requirements for this suggested approach. Furthermore, the response to a surge in demand for care will be contingent on keeping available staff close to the hospitals for a sustained period. A proposal for accomplishing this, with associated costs, is discussed as well.

Hick, J. L., D. Hanfling, et al. (2004). "Health care facility and community strategies for patient care surge capacity." Ann Emerg Med 44(3): 253-61.
Recent terrorist and epidemic events have underscored the potential for disasters to generate large numbers of casualties. Few surplus resources to accommodate these casualties exist in our current health care system. Plans for "surge capacity" must thus be made to accommodate a large number of patients. Surge planning should allow activation of multiple levels of capacity from the health care facility level to the Federal level. Plans should be scalable and flexible to cope with the many types and varied timelines of disasters. Incident management systems and cooperative planning processes will facilitate maximal use of available resources. However, resource limitations may require implementation of triage strategies. Facility-based or "surge in place" solutions maximize health care facility capacity for patients during a disaster. When these resources are exceeded, community-based solutions, including the establishment of off-site hospital facilities, may be implemented. Selection criteria, logistics, and staffing of off-site care facilities is complex, and sample solutions from the United States, including use of local convention centers, prepackaged trailers, and State mental health and detention facilities, are reviewed. Proper pre-event planning and mechanisms for resource coordination are critical to the success of a response.

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