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Hospital Surge Model Version 1.3: Description

Public Health Emergency Preparedness

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

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Chapter 5. Mustard

This chapter describes the assumptions for the mustard scenario, including:

  • The severity categories.
  • The arrival pattern of casualties at the hospital(s).
  • The length of stay by hospital unit (i.e., ED, ICU, and the floor).
  • The path probability within the hospital(s) and the length of stay.
  • The overall outcome probabilities (i.e., probability of discharge and probability of death).
  • The assumed level of resource consumption per patient per day per hospital unit.

Footnotes in the text of a particular section refer to references at the end of the section. In the absence of specific references, parameter estimates were obtained from general references listed in the Hospital Module section.

5.1. Severity Categories

For the mustard scenario, patients arrive at the hospital(s) in one of two conditions:

  1. Irritated: Hoarseness or burning in throat and lungs, irritation in eyes.
  2. Severe: Temporary blindness, permanent eye damage, bronchopneumonia, and skin damage.

Users have the option of specifying either the number and type or simply the number of casualties who present at their hospital(s).

If the user specifies only the number of casualties, the model assumes the casualties arriving at the hospital(s) are randomly selected from among all casualties from the attack. The distribution of casualty types in this case is as follows:

Casualty Condition Percent
Irritated: Hoarseness or burning in throat and lungs, irritation in eyes 42.5%
Severe: Temporary blindness, permanent eye damage, bronchopneumonia, and skin damage 57.5%

This breakdown by casualty condition is based on work performed during development of the original Surge Model in 2005. In brief, plume modeling was used to determine different exposure levels dependent upon the radius from the attack. Then available dose-response data were used to group exposed individuals into those who died, experienced severe symptoms, or experienced irritation from the gas. The percents shown here represent the percentage in each category of those who survived the immediate effects of the attack.

5.2. Casualty Arrival Pattern

For the mustard scenario, all casualties are assumed to present at the hospital(s) on Day 1.

5.3. Length of Stay By Hospital Unit

The assumed average length of stay (in days) of patients the ED, in the ICU, and on the floor2,3,7,9,15 are:

Average Length of Stay by Hospital Unit Irritated Severe
ED 1 1
Floor, not via ICU 7 42
Floor, via ICU 4 21
ICU 3 21

5.4 Combined Path Probabilities and Lengths of Stay

The table below shows the assumed probabilities of different "paths" through the hospital(s).

Path Irritated Incapacitated
ED → Discharge 0% 0%
ED → Death 0% 0%
ED → Floor → Discharge 50% 0%
ED → Floor → Death 0% 0%
ED → Floor → ICU → Death 0% 0%
ED → Floor → ICU → Floor → Discharge 0% 0%
ED → Floor → ICU → Floor → Death 0% 0%
ED → ICU → Death 0% 0%
ED → ICU → Floor → Discharge 50% 100%
ED → ICU → Floor → Death 0% 0%

The breakdown of length of stay by patient type summed over all paths is:

Average Length of Stay by Patient Outcome Irritated Severe
Survivors 8.00 43.00
Fatalities 0.00 0.00
Average Combined 8.00 43.00

5.5. Overall Outcome Probabilities

Based on these inputs, the overall discharge and death probabilities are:

Outcome Irritated Incapacitated
Discharge 100% 100%
Death 0% 0%

5.6 Resources Consumed Per Patient Per Day

The assumed level of resource consumption per patient per day is shown in the table below:

Resource Units Category Subcategory Lambdaa Irritated Severe
ED ICU Floor ED ICU Floor
Med/Surg bed Unit of Use Capacity Floor 1 0.083 0 0 0.167 0 0
ICU bed Unit of Use Capacity ICU 1 0 1 0 0 0 0
Burn bed Unit of Use Capacity Burn 1 0 0 0 0 1 0
Intensivists (CCM) FTE Staff CCM 0.7 0.042 0.042 0 0.083 0.083 0
Critical care nurses (CCN) FTE Staff CCN 1 0.083 0.33 0 0.167 0.33 0
Surgeons FTE Staff Surgeon 0.3 0 0 0 0 0.083 0
Non-intensivists (MD) FTE Staff MD 0.9 0.083 0 0.021 0.083 0 0.021
Non-critical care nurses (RN/LPN) FTE Staff RN 1 0 0 0.33 0 0 0.333
Respiratory therapists (RT) FTE Staff RT 0.7 0.021 0.021 0.021 0.083 0.083 0.042
Radiology machines Machine Time Lab/Radiology Radiology 0.3 0.021 0.021 0 0.021 0.021 0
Radiologic technicians FTE Staff Rad Tech 0.3 0.021 0.021 0 0.021 0.021 0
Pharmacists (PharmD/RPh) FTE Staff Pharmacist 0.7 0.021 0.042 0.021 0.021 0.042 0.042
Mechanical ventilator Machine Time Capacity Ventilator 0.9 0 0 0 1 1 0
Ventilator equipment Unit of Use Equipment Vent Tubing 0.9 0 0 0 1 1 0
Oxygen (O2) Unit of Use Supplies Oxygen 0.9 1 1 1 2 2 0
Oxygenation monitoring equipment Machine Time Equipment O2 Monitoring 0.9 0.083 1 0 0.083 1 0.5
Surgical supplies Unit of Use Supplies Surgical 0.3 0 0 0 0 0.25 0
Radiology supplies Unit of Use Supplies Radiological 0.3 1 1 0 1 1 0
Antibiotics for secondary pneumonia Assorted Pharmacy Antibiotics 1 0 0 0 0 1 0
Surgical infection prophylaxis/treatment Assorted Pharmacy Antibiotics 1 0 0 0 0 0 0
Hemodynamic medications Unit of Use Pharmacy Hemodynamic 0.7 0 0 0 1 1 0
Intravenous fluids Unit of Use Pharmacy IVF 0.7 0 0 0 1 1 1
Intravenous infusions set Unit of Use Supplies IV Set 0.7 0 0 0 1 1 1
Laboratory machines Machine Time Lab/Radiology Laboratory 0.7 0.021 0.021 0.021 0.021 0.021 0.021
Laboratory supplies Unit of Use Supplies Laboratory 0.7 1 1 0.5 1 1 0.5
Temperature monitoring equipment Machine Time Equipment Temperature 1 0.083 1 1 0.083 1 1
Thromboembolism prophylaxis Unit of Use Pharmacy DVT Prophylaxis 1 0 1 0 0 1 1
Urine output monitoring equipment Unit of Use Equipment U/O 1 0 1 0 0 1 0
Universal precautions PPE Unit of Use PPE Universal 1 1 1 1 1 1 1
Chemical PPE Unit of Use PPE Chemical 0.3 1 0 0 1 0 0
Radiological PPE Unit of Use PPE Radiological 0.3 0 0 0 0 0 0
Waste disposal Unit of Use Waste Mgmt Decon Waste 0.3 1 0 0 1 0 0
Mortuary decontamination materials Unit of Use Mortuary Decon 0.3 0 0 0 0 0 0
Atropine sulfate 2mg Pharmacy Atropine 0.1 0 0 0 0 0 0
Pralidoxime 2g Pharmacy Pralidoxime 0.1 0 0 0 0 0 0
Diazepam 10mg Pharmacy Diazepam 0.1 0 0 0 0 0 0
Growth factors Unit of Use Pharmacy Growth factors 1 0 0 0 0 0 0
IV steroids Unit of Use Pharmacy Steroids 0.7 0 0 0 0 0 0
Enteral feedings (3/day/patient) Unit of Use Nutrition Enteral 1 0 0 0 0 0.5 0
Oral food (3 meals/ day/ patient) Unit of Use Nutrition Oral 1 0 0.5 1 0 0.5 1
Sheet change Unit of Use Housekeeping Laundry 1 1 1 1 1 1 1
Patient infection control FTE Epidemiology Infection Control 0.5 0.021 0.021 0.021 0.042 0.042 0.042
Engineering FTE Engineering Facility 0.7 0.042 0.083 0.042 0.042 0.083 0.042
Janitorial/Housekeeping FTE Housekeeping Janitorial 1 0.083 0.125 0.083 0.125 0.125 0.083
Nutrition FTE Nutrition Counseling 0.5 0 0.083 0.083 0 0.083 0.083
Psychological support FTE Ancillary Psychologist 0.5 0.021 0.042 0.042 0 0 0.042
Mortuary FTE Mortuary Morgue 0.1 0 0 0 0 0 0

a Lambda captures the resource requirement decay rate for a resource. Lambda = 1 implies no decay; the patient requires a constant amount of the resource while s/he is hospitalized. Lambda <1 implies that less of the resource is required each day the patient is hospitalized. Go to section 2.2 for details.

5.7 References

1. Anderson DR, Holmes WW, Lee RB, et al. Sulfur mustard-induced neutropenia: treatment with granulocyte colony-stimulating factor. Mil Med 2006;171(5):448-53.

2. Balali-Mood M, Hefazi M. The pharmacology, toxicology, and medical treatment of sulphur mustard poisoning. Fundam Clin Pharmacol 2005;19(3):297-315.

3. Balali-Mood M, Hefazi M, Mahmoudi M, et al. Long-term complications of sulphur mustard poisoning in severely intoxicated Iranian veterans. Fundam Clin Pharmacol 2005;19(6):713-21.

4. Borak J, Sidell FR. Agents of chemical warfare: sulfur mustard. Ann Emerg Med 1992;21(3):303-8.

5. Dachir S, Fishbeine E, Meshulam Y, et al. Amelioration of sulfur mustard skin injury following a topical treatment with a mixture of a steroid and a NSAID . J Appl Toxicol 2004;24(2):107-13.

6. Davis KG, Aspera G. Exposure to liquid sulfur mustard. Ann Emerg Med 2001;37(6):653-6.

7. Etezad-Razavi M, Mahmoudi M, Hefazi M, et al. Delayed ocular complications of mustard gas poisoning and the relationship with respiratory and cutaneous complications. Clin Experiment Ophthalmol 2006;34(4):342-6.

8. Hefazi M, Attaran D, Mahmoudi M, et al. Late respiratory complications of mustard gas poisoning in Iranian veterans. Inhal Toxicol 2005;17(11):587-92.

9. Kehe K, Szinicz L. Medical aspects of sulphur mustard poisoning. Toxicology 2005;214(3):198-209.

10. Le HQ, Knudsen SJ. Exposure to a First World War blistering agent. Emerg Med J 2006;23(4):296-9.

11. Mahmoudi M, Hefazi M, Rastin M, et al. Long-term hematological and immunological complications of sulfur mustard poisoning in Iranian veterans.Int Immunopharmacol 2005;5(9):1479-85.

12. McManus J, Huebner K. Vesicants. Crit Care Clin 2005;21(4):707-18, vi.

13. Mellor SG, Rice P, Cooper GJ. Vesicant burns. Br J Plast Surg 991;44(6):434-7.

14. Mi L, Gong W, Nelson P, et al. Hypothermia reduces sulphur mustard toxicity. Toxicol Appl Pharmacol 2003;193(1):73-83.

15. Munro NB, Watson AP, Ambrose KR, et al. Treating exposure to chemical warfare agents: implications for health care providers and community emergency planning. Environ Health Perspect 1990;89:205-15.

16. Rice P. Sulphur mustard injuries of the skin. Pathophysiology and management. Toxicol Rev 2003;22(2):111-8.

17. Ruhl CM, Park SJ, Danisa O, et al. A serious skin sulfur mustard burn from an artillery shell. J Emerg Med 1994;12(2):159-66.

18. Safarinejad MR, Moosavi SA, Montazeri B. Ocular injuries caused by mustard gas: diagnosis, treatment, and medical defense. Mil Med 2001;166(1):67-70.

19. Saladi RN, Smith E, Persaud AN. Mustard: a potential agent of chemical warfare and terrorism. Clin Exp Dermatol 2006;31(1):1-5.

20. Smith KJ. The prevention and treatment of cutaneous injury secondary to chemical warfare agents. Application of these finding to other dermatologic conditions and wound healing. Dermatol Clin 1999;17(1):41-60, viii.

21. Smith KJ, Skelton H. Chemical warfare agents: their past and continuing threat and evolving therapies. Part I of II. Skinmed 2003;2(4):215-21.

22. Smith KJ, Skelton H. Chemical warfare agents: their past and continuing threat and evolving therapies. Part II of II. Skinmed 2003;2(5):297-303.

23. Solberg Y, Alcalay M, Belkin M. Ocular injury by mustard gas. Surv Ophthalmol. 1997;41(6):461-6.

24. Treatment of chemical agent casualties and conventional military chemical injuries, Field Manual No. 8-285/NAVMED P-5041/Air Force Joint Manual No. 44-149/Fleet Marine Force Manual No. 11-11. Headquarters, Departments of the Army, the Navy, and the Air Force, and Commandant, Marine Corps. Washington, DC; 1995.

25. Vidan A, Luria S, Eisenkraft A, et al. Ocular injuries following sulfur mustard exposure: clinical characteristics and treatment. Isr Med Assoc J 2002;4(7):577-8.

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