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Mass Medical Care with Scarce Resources: The Essentials

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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6. Alternative Care Sites

Key Questions

What are the three most important issues to consider in establishing an alternative care site (ACS)?

How do planners go about defining the role of an alternative care site?

How do planners choose an alternative care site?

What are the staffing options for alternative care sites?

To respond effectively to an mass casualty event (MCE), community planners from municipal agencies, including public safety, public health, and emergency management must plan how ACSs will operate. The decision to open an ACS will be made in collaboration, as applicable, among:

  • Local, Tribal, and regional emergency planners.
  • Hospitals, outpatient clinics, multispecialty group offices and home care agencies.
  • Health care workers responsible for operating the facility.
  • County and State health officials; and
  • Any other institutions that will participate in staffing or logistical support of the ACS.

Planners need to identify the logistical support necessary for establishing an ACS. A mechanism must exist for triage of patients, so patient needs are matched with resources. Planners must delineate the specific medical functions and treatment objectives that the ACS facility would need to accomplish. The facility may serve as:

  • A primary triage point, providing primary victim care and helping decide which patients require hospitalization, which can be managed at home, which might need observational care and minimal interventions available at the ACS, which require palliative care, which also might be available at an ACS. Such a facility might be reasonably expected to cohort patients who have been exposed to certain infectious agents but do not need more than observation and minimal, if any, medical intervention.
  • A community-focused ambulatory care clinic that serves as a point of distribution for medications, vaccinations, or other medical interventions that must be delivered to a wide population.
  • A low-acuity patient care site to permit the offloading of stable patients from hospitals to increase their surge capacity or a primary site for the care of stable low-acuity patients.

Much of the information here also applies when a locale is supporting a Federal Medical Station (FMS). FMSs are deployed with logistical implementation teams by CDC's Division of the Strategic National Stockpile and provide medical surge capacity (equipment, material, pharmaceuticals) to communities overwhelmed by mass casualties.

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Ownership, Command, and Control

The most important issues in the successful establishment of an ACS are ownership, command, and control of the ACS. These issues should be decided at a local or regional (as opposed to institutional) level and must involve the identification of those individuals with the authority to decide whether, when, and where an ACS should be opened and with the authority to operate the site. The administrative structure for operation of an ACS should follow HICS concepts.

An ACS should operate from a "concept of operations" document that defines its role in advance. The ACS also should be integrated into the local CDC Health Alert Network (HAN), which is designed to ensure that each community has rapid access to health information and professional personnel.

Resource

More information on CDC's Health Alert Network is available at: http://www2a.cdc.gov/han/Index.asp.

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Selecting the Site

An ACS will likely be located in a building of convenience or shelter of opportunity. Each will have advantages and disadvantages. Possible ACSs include:

  • Adult detention facilities.
  • Aircraft hangers.
  • Churches or schools.
  • Community centers, recreation centers or meeting halls.
  • Convalescent care centers.
  • Fairgrounds.
  • Hotels or motels.
  • Government buildings, military facilities, or National Guard armories.
  • Same-day surgical centers or clinics.
  • Shuttered hospitals.
  • Sports facilities (including stadiums).
  • Trailers or tents (military or other).

Tentative sites are best identified in advance, and the mechanism of approval for use as an ACS should be investigated. As a rule, permission to use municipal buildings is easier to obtain, and it is easier to obtain MOUs to use existing staff members. Although site selection is usually a local function, State partners should be asked early in the planning process whether potential shelters or ACSs have been designated at a State or regional level. If the ACS must supply ambulatory patient care, it may help if it is located near a victim shelter to support victims with chronic medical needs.

A key decision point in care delivery at an ACS is whether the ACS will be able to provide oxygen and respiratory therapy, particularly mechanical ventilation. Sustaining oxygen delivery systems in an ACS setting is complex and can be expensive. The exception to this may be the use of nursing homes and long-term care facilities, given their existing medical gas supply.

AHRQ and ASPR are currently updating the ACS Selection Tool, which is designed to use in advance of a public health emergency to develop and maintain a list of potential ACSs. The new Disaster Alternate Care Facility Selection Tool was in press at the time of this report's publication. To check on availability, go to http://www.ahrq.gov/prep/.

Another useful tool from AHRQ is Reopening Shuttered Hospitals to Expand Surge Capacity. Although this tool focuses specifically on assessing shuttered hospitals, much of the information is valuable for assessment of any site.

Resource

Reopening Shuttered Hospitals to Expand Surge Capacity is available at http://www.ahrq.gov/research/shuttered/.

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Arranging for Supplies and Equipment

Routine supply chains will be stressed or not operational during an MCE of any magnitude or duration. Although the degree of need for certain supplies may be event specific (e.g., increased need for masks during a pandemic), the need for many basic supplies can be accurately forecasted. This is especially true for basic durable medical equipment (cots, IV poles, wheelchairs, etc.). Certain supplies have a limited shelf life and therefore will require product rotation or replacement. Supplies may be stored as portable caches, which can be transported to the ACS. Caches can vary from a bare minimum cache (Level I) for institutional augmentation to a very complete cache (Level III) as defined by the Soldier and Biological Chemical Command. Caches of supplies should be stored in modular units supporting 50-100 patients, allowing an ACS to be set up in stages.

As noted above, supplying supplemental oxygen to patients in an ACS poses a complex challenge. The three major mechanisms of supply are compressed cylinders, oxygen concentrators, and liquid oxygen. Each of the three mechanisms has advantages and disadvantages. At least two and possibly all three will be necessary.

Wheelchairs, walkers, and canes will also be needed in an ACS. Local or regional resources are not likely to be sufficient to deal with this requirement.

Expensive diagnostic and monitoring equipment (e.g., portable x-ray machines, ultrasounds, cardiac monitors) may be beyond the scope of an ACS. Advances in point-of-care clinical laboratory testing, however, may allow some basic laboratory tests to be performed at an ACS.

The Hospital Surge Model can help with determining resources needed for specific scenarios.

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Securing Pharmaceuticals

Pharmaceuticals require environmental storage, stock rotation, and legal control. In certain events, the Strategic National Stockpile may be of assistance in supplying pharmaceuticals, but this is not guaranteed and should not be depended on as a sole solution. Planners must address in advance the issues of obtaining, storing, controlling, and dispensing both controlled and noncontrolled medications.

Basic pharmaceuticals will be required for the management of a variety of medical conditions within the context of the ACS's limited scope of practice. These include medications related to:

  • Acute respiratory therapy.
  • Acute hemodynamic support.
  • Pain control and anxiolysis.
  • Antibiotic coverage.
  • Behavioral health.
  • Chronic disease management.

Patients requiring drugs used for Advanced Cardiac Life Support response, as well as those used in the management of worsening respiratory status, necessarily will be transferred from the ACS to a hospital inpatient setting, if at all possible.

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Addressing Staffing Issues

Many aspects of staffing may depend on the specific type of event. Even in situations in which staffing is adequate, the issues of verification, credentialing, supervision, and command and control will need to be considered. The ESAR-VHP or MRC may help address these issues.

Although some staffing levels for ACSs can be proposed in advance (go to box), unique staffing requirements tend to be event and population specific. The level of patient acuity certainly will have an Impact on staffing needs. In situations in which the ACS is Used to decompress hospitals, one option is to allow only those hospitals that contribute staffing to send patients to the ACS planners should consider other staffing options, such as:

Potential Staffing for a 50-Bed ACS per 12 Hours

PER 12-HOUR SHIFT: 32.5

  • Physician (1)
  • Physician Extender (PA/NP) (1)
  • RNs or RNs/LPNs (6)
  • Health Technicians (4)
  • Unit Secretaries (2)
  • Respiratory Therapist (1)
  • Case Manager (1)
  • Social Worker (1)
  • Housekeepers (2)
  • Lab (1)
  • Medical Assistant/Phlebotomy (1)
  • Food Service (2)
  • Chaplain/Pastoral (1)
  • Day Care/Pet Care
  • Volunteers (4)
  • Engineering/Maintenance (0.25)
  • Biomed (0.25)
  • Security (2)
  • Patient Transporters (2)
  • Regional hospital alliances, which can designate in advance a small number of key staff members, including pharmacists, laboratory workers (to be responsible for the point-of-care testing), respiratory therapists, and administrators to help support ACS operations.
  • A single hospital, which can adopt an ACS and in so doing may be able to provide staffing for an entire ACS.
  • The faith-based community and community health workers, which also can be viable sources of volunteers.
  • Academic medical centers, which can be sources of teams of health care workers who with centers outside of the local geographic area in advance of an event.
  • Administrative staff from large, geographically diverse health care systems, who also can help meet staffing needs.

Planners need to establish guidelines and protocols in advance for the care and management of patients treated in an ACS. These guidelines should help to minimize the difficulties inherent in bringing a new team of health care professionals together for the first time.

Other potential issues include:

  • Advance negotiation of overtime contracts in advance in cases where municipal-owned buildings are to be used as ACSs with municipal workers providing support staffing.
  • Identification of staff members, patients and their family members, which will require a name badge system that can be as simple as stick-on nametags or as complicated as a site-generated photo.
  • Housing provisions for the staff.

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Arranging Operational Support

Actual operation of an ACS will require a host of support services, including food services, sanitary services, infrastructure maintenance, and security. Although some of these needs will be driven by the nature of the event, much planning can and should be done in advance to assure that these support services will be delivered.

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Documentation of Care

Only modest patient care documentation can be expected at an ACS. Electronic medical records are not likely to be available or practicable. Rather, simple paper-based charting will be required. Forms for patient records (including nursing notes and flow sheets), patient tracking and discharge planning should be prepared in advance. Forms should be in adequate supply, along with clipboards and pens.

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Security Issues

As with hospital systems, ACS planners must develop robust security plans.

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Rules and Policies for Operation

Rules of behavior for patients, caregivers, and visitors are necessary for the smooth operation of the ACS. ACS planning should include establishment of such a set of rules, as well as operating procedures. Operating procedures should address incident command, staffing, criteria for admission, discharge and transfer, clinical roles and responsibilities, infection control, pharmacy and medication control, security, supplies, finances, documentation, staff housing, housekeeping, food services, and areas unique to the event.

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Development of an Exit Strategy

Criteria for disengaging the ACS should be established as part of the planning process. The actual decision to close the facility should be made in concert with local emergency managers and local or State health officials.

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Exercising the ACS

Plans for a regional ACS can be fully vetted only through exercises. Ideally, these exercises should include the ACS as a stand-alone facility and use the ACS support components in cooperation with other entities such as health care systems and Federal assets such as FMS and DMAT.

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