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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 7. 1 KT and 10 KT Nuclear Device

This chapter describes the assumptions for the nuclear scenario (both 1 KT and 10 KT), 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.

7.1 Severity Categories

For the 1 KT and 10 KT scenarios, patients arrive at the hospital(s) in one of eleven conditions:

  1. Burns (1)/moderate: Second-degree burns on hands and face.
  2. Burns (2))/severe: Third-degree burns on hands and face (and first-degree over the rest of the body).
  3. Trauma (1)/people who receive multiple lacerations from flying glass.
  4. Trauma (2)/people who receive blunt trauma.
  5. Trauma (3)/people in collapsed houses and other light buildings.
  6. Trauma (4)/people in collapsed skyscrapers.
  7. Radiation (1)/ mild: Nausea, vomiting, anorexia, fever, infections.
  8. Radiation (2)/moderate: More severe mild symptoms, plus bleeding, fatigue, and weakness.
  9. Radiation (3)/severe: More severe moderate symptoms, plus headache, prostration, dizziness, and disorientation.
  10. Fallout (1)/mild: 1Gy equivalent dose for blood effects, no other equivalent dose (some bleeding and infection issues).
  11. Fallout (2)/severe: 4Gy for blood effects (problems with bleeding and infection) and about 0.75 Gy for lethality and GI effects (some small fraction of people will die and others get nausea, vomiting, etc.).

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 follow:

Casualty Condition Percent (1KT) Percent (10KT)
Burns (1) / moderate: Second-degree burns on hands and face 0.5% 0.1%
Burns (2) / severe: Third-degree burns on hands and face (and first degree over the rest of the body) 0.5% 0.0%
Trauma (1) / people who receive multiple lacerations from flying glass 8.1% 2.7%
Trauma (2) / people who receive blunt trauma 0.1% 0.0%
Trauma (3) / people in collapsed houses and other light buildings 13.5% 65.8%
Trauma (4) / people in collapsed skyscrapers 34.0% 27.3%
Radiation (1) / mild: Nausea, vomiting, anorexia, fever, infections 0.2% 0.0%
Radiation (2) / moderate: More severe mild symptoms, plus bleeding, fatigue, and weakness 0.5% 0.1%
Radiation (3) / severe: More severe moderate symptoms, plus headache, prostration, dizziness ,and disorientation 0.9% 0.0%
Fallout (1) / mild: 1Gy equivalent dose for blood effects, no other equivalent dose (some bleeding and infection issues) 17.7% 1.7%
Fallout (2) / severe: 4Gy for blood effects (problems with bleeding and infection) and about 0.75 Gy for lethality and GI effects (some small fraction of people will die and others get nausea, vomiting, etc.) 24.1% 2.3%

This breakdown by casualty condition is based on work performed during development of the original Surge Model in 2005. In brief, for the nuclear scenarios, we modeled the effects of the blast looking at thermal, radiation, and blast effects at different radii from the center of the attack as well as whether individuals were in direct line-of-sight to the blast or were protected by buildings, walls, or other materials. More specifically:

  • Thermal effects are burns received from the thermal heat wave radiating from the blast. Casualties that arrive at the hospital are those who received second- or third-degree burns and exclude those that were vaporized or immediately killed. All these patients also experience radiation effects.
  • Blast effects include trauma resulting from the pressure wave of the blast. The pressure will cause the collapse of both skyscrapers and lighter buildings, as well as breaking all the windows of buildings further out. It will also cause flying debris to hit pedestrians. These effects are calculated based on the pressure at each radius and the resultant effects.
  • Radiation effects looked at both direct radiation affecting individuals and fallout which can be inhaled for long-term effects. Based upon the exposure and decay rate for these materials, we calculated the likelihood of mild, moderate, and severe radiation and mild and severe fallout.

The distribution of these effects is based upon a fixed weapon size of 1KT or 10KT.

7.2 Casualty Arrival Pattern

Casualties are assumed to present at the hospital(s) when symptoms appear. For this scenario, all patients arrive on Day 1.

7.3 Length of Stay By Hospital Unit

The assumed average length of stay (in days) of patients the ED, ICU, and the floor ( 1-3, 7, 9,10, 15, 16, 20, 25, 26 [for trauma]; 33-38 [for burns] are:

Length of Stay by Unit Burn
2
Burn
3
Trauma
1
Trauma
2
Trauma
3
Trauma
4
Rad
1
Rad
2
Rad
3
Fallout
1
Fallout
2
ED 1 1 1 1 1 1 1 1 1 1 1
Floor, not via ICU 7 17 5 5 5 5 7 8 14 7 7
Floor, via ICU 7 7 8 8 6 8 4 8 28 4 28
ICU 9 31 10 10 6 6 3 24 30 3 30

7.4 Combined Path Probabilities and Lengths of Stay

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

Path Burn
2
Burn
3
Trauma
1
Trauma
2
Trauma
3
Trauma
4
Rad
1
Rad
2
Rad
3
Fallout
1
Fallout
2

ED → Discharge

0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0%
ED → Death* 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
ED → Floor → Discharge 6% 0% 54% 31% 9% 6% 80% 46% 2% 67% 6%
ED → Floor → Death 0% 0% 0% 0% 16% 11% 10% 4% 1% 8% 1%
ED → Floor → ICU → Death 0% 0% 6% 3% 1% 1% 0% 14% 6% 0% 2%
ED → Floor → ICU → Floor → Discharge 4% 0% 9% 5% 1% 0% 0% 9% 1% 0% 0%
ED → Floor → ICU → Floor → Death 0% 0% 1% 1% 3% 2% 0% 1% 1% 0% 0%
ED → ICU → Death 7% 53% 10% 21% 16% 19% 1% 14% 71% 2% 71%
ED → ICU → Floor → Discharge 82% 45% 16% 34% 13% 6% 9% 10% 9% 22% 9%
ED → ICU → Floor → Death 0% 3% 2% 5% 41% 56% 0% 1% 10% 1% 10%

* By definition no trauma patients admitted to the hospital(s) were dead on arrival (DOA)

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

Average Length of Stay
by Patient Outcome
Burn
2
Burn
3
Trauma
1
Trauma
2
Trauma
3
Trauma
4
Rad
1
Rad
2
Rad
3
Fallout
1
Fallout
2

Survivors

16.56 39.00 10.16 13.44 10.39 10.66 8.00 16.54 52.67 8.00 38.85
Fatalities 6.59 16.13 8.93 8.27 7.40 8.10 4.87 14.28 16.70 4.71 16.41
Average Combined 15.75 26.34 9.92 11.88 8.07 8.40 7.64 15.75 20.85 7.63 19.90

7.5 Overall Outcome Probabilities

Based on these inputs (1-3, 7, 9,10, 15, 16, 20, 25, 26 [for trauma]; 33-38 [for burns], the overall discharge and death probabilities are:

Outcome Burn
2
Burn
3
Trauma
1
Trauma
2
Trauma
3
Trauma
4
Rad
1
Rad
2
Rad
3
Fallout
1
Fallout
2

Discharge

92% 45% 81% 70% 22% 12% 89% 65% 12% 89% 16%
Death 8% 55% 19% 30% 78% 88% 11% 35% 88% 11% 84%

7.6 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 Burns-Moderate Burns-Severe Trauma-Lacerations Trauma-Blunt
ED ICU Floor ED ICU Floor ED ICU Floor ED ICU Floor
Med/Surg bed One Bed Capacity Floor 1 0.083 0 0 0.083 0 0 0.083 0 0 0.083 0 0
ICU bed One Bed Capacity ICU 1 0 1 0 0 1 0 0 1 1 0 1 1
Burn bed One Bed Capacity Burn 1 0 0 1 0 0 1 0 0 0 0 0 0
Operating room One OR Suite Capacity OR 1 0.083 0 0 0.25 0 0 0.042 0 0 0.167 0 0
Airborne isolation room One Bed Capacity Isolation 0.9 0 0 0 0 0 0 0 0 0 0 0 0
Intensivists (CCM) FTE Staff CCM 0.7 0.083 0.083 0 0.083 0.083 0 0.083 0.083 0 0.083 0.083 0
Critical care nurses (CCN) FTE Staff CCN 1 0.167 0.5 0 0.333 0.5 0 0.125 0.5 0 0.25 0.5 0
Surgeons FTE Staff Surgeon 0.3 0.33 0.25 0.083 0.33 0.25 0.083 0.167 0.167 0.042 0.167 0.167 0.042
Non-intensivists (MD) FTE Staff MD 0.9 0.167 0 0.042 0.167 0 0.042 0.167 0 0.042 0.167 0 0.042
Non-critical care nurses (RN/LPN) FTE Staff RN 1 0.042 0 0.146 0.042 0 0.146 0.042 0 0.146 0.042 0 0.146
Respiratory therapists (RT) FTE Staff RT 0.7 0.083 0.083 0.042 0.083 0.083 0.042 0.083 0.083 0.042 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 0.042 0.042 0 0.042 0.042 0
Radiologic technicians FTE Staff Rad Tech 0.3 0.021 0.021 0 0.021 0.021 0 0.042 0.042 0 0.042 0.042 0
Pharmacists (PharmD/RPh) FTE Staff Pharmacist 0.7 0.021 0.042 0.042 0.021 0.042 0.042 0.021 0.042 0.042 0.021 0.042 0.042
Mechanical ventilator Machine Time Capacity Ventilator 0.9 1 1 0 1 1 0 1 1 0 1 1 0
Ventilator equipment One Ventilator Equipment Vent Tubing 0.9 1 1 0 1 1 0 1 1 0 0 1 0
Oxygen (O2) 24h O2 for Vent Supplies Oxygen 0.9 1 2 0 1 2 0 1 2 1 1 2 1
Oxygenation monitoring equipment Machine Time Equipment O2 Monitoring 0.9 0.167 1 1 0.333 1 1 0.125 1 1 0.25 1 1
Surgical supplies Trauma Set Supplies Surgical 0.3 1 0.25 0.125 1 0.25 0.125 1 0.25 0.125 1 0.25 0.125
Radiology supplies Radiographic Film Supplies Radiological 0.3 1 1 0 1 1 0 1 1 0 1 1 0
Ciprofloxacin or doxycycline 400mg/100mg bid Pharmacy Antibiotics 1 0 0 0 0 0 0 0 0 0 0 0 0
Rifampin or other 2nd line agent 600mg po bid Pharmacy Antibiotics 1 0 0 0 0 0 0 0 0 0 0 0 0
Antibiotics for secondary pneumonia Assorted Pharmacy Antibiotics 1 0 1 0 0 1 0 0 1 0 0 1 0
Surgical Infection prophylaxis/treatment Assorted Pharmacy Antibiotics 1 1 1 1 1 1 1 1 1 1 1 1 1
Neutropenia prophylaxis/treatment Assorted Pharmacy Antibiotics 1 0 0 0 0 0 0 0 0 0 0 0 0
Antibiotics intravenous infusion set One IV Piggyback Supplies IV set 1 1 0.5 0.5 1 0.5 0.5 1 0.5 0.5 1 0.5 0.5
Hemodynamic medications Assorted Pharmacy Hemodynamic 0.7 0 0 0 1 1 0 0 0 0 1 1 0
Intravenous fluids 24h LR or equiv. Pharmacy IVF 0.7 1 1 1 1 1 1 1 1 1 1 1 1
Intravenous infusions set One IV Set Supplies IV Set 0.7 1 1 1 1 1 1 1 1 1 1 1 1
Laboratory machines Machine Time Lab/Radiology Laboratory 0.7 0.083 0.083 0.042 0.083 0.083 0.042 0.083 0.083 0.042 0.083 0.083 0.042
Laboratory supplies CBC/CMP Reag. Supplies Laboratory 0.7 2 2 2 2 2 2 2 2 2 2 2 2
Temperature monitoring equipment Machine Time Equipment Temperature 1 0.167 1 1 0.333 1 1 0.125 1 1 0.25 1 1
Thromboembolism prophylaxis Enoxaparin 40mg sc qd Pharmacy DVT Prophylaxis 1 0 1 0 0 1 0 0 1 1 0 1 1
Urine output monitoring equipment Catheter and Bag Equipment U/O 1 0 1 0 0 1 0 0 1 1 0 1 1

Universal precautions PPE

Glove/gown/mask PPE Universal 1 1 1 1 1 1 1 1 1 1 1 1 1
Chemical PPE Level D PPE Chemical 0.3 0 0 0 0 0 0 0 0 0 0 0 0
Radiological PPE Level D PPE Radiological 0.3 1 1 0 1 1 0 1 1 0 1 1 0
Waste disposal Level D PPE Decon Waste 0.3 1 1 1 1 1 1 1 1 1 1 1 1
Mortuary decontamination materials Level D PPE Mortuary 0.3 0 0 0 0 0 0 0 0 0 0 0 0
Atropine sulfate 2mg Pharmacy Atropine 0.1 0 0 0 0 0 0 0 0 0 0 0 0
Pralidoxime 2g Pharmacy Pralidoxime 0.1 0 0 0 0 0 0 0 0 0 0 0 0
Diazepam 10mg Pharmacy Diazepam 0.1 0 0 0 0 0 0 0 0 0 0 0 0
EEG Machine Time Equipment Chemical 0.1 0 0 0 0 0 0 0 0 0 0 0 0
IV steroids Hydrocortisone 50mg IV q6h Pharmacy Steroids 0.7 0 0 0 0 0 0 0 0 0 0 0 0
DPTA 1g IV Pharmacy DPTA 0.1 1 1 1 1 1 1 1 1 1 1 1 1
Prussian blue 3mg po tid Pharmacy Prussian Blue 1 1 1 1 1 1 1 1 1 1 1 1 1
Growth factors Pegfilgrastim 6mg sc qw Pharmacy Growth factors 1 1 1 1 1 1 1 0 0 0 0 0 0
Stem cell transfusion Unit of Use Heme/Onc Stem Cell Trans 1 0 1 0 0 1 0 0 0 0 0 0 0
Geiger counter Machine Time Equipment Radiation 0.1 0.42 0.21 0.21 0.42 0.21 0.21 0.42 0.21 0.21 0.42 0.21 0.21
Enteral feedings (3/day/patient) Unit of Use Nutrition Enteral 1 0 0.5 0 0 0.5 0 0 0.5 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 0 0.5 1 0 0.5 1
Sheet change 1 linen change Housekeeping Laundry 1 1 1 1 1 1 1 1 1 1 1 1 1
Patient infection control FTE Epidemiology Infection Control 0.5 0.042 0.042 0.021 0.042 0.042 0.021 0.042 0.042 0.021 0.042 0.042 0.021
Engineering FTE Engineering Facility 0.7 0.042 0.083 0.042 0.042 0.083 0.042 0.042 0.083 0.042 0.042 0.083 0.042
Janitorial/Housekeeping FTE Housekeeping Janitorial 1 0.125 0.125 0.083 0.125 0.125 0.083 0.125 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 0 0.083 0.083 0 0.083 0.083
Psychological support FTE Ancillary Psychologist 0.5 0 0 0.042 0 0 0.042 0 0 0.042 0 0 0.042
Mortuary FTE Mortuary Morgue 0.1 0 0.042 0.042 0 0.042 0.042 0 0.042 0.042 0 0.042 0.042

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.

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