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Pediatric Hospital Surge Capacity in Public Health Emergencies

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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Table 2.  Employee Response During Patient Surge

Area Response

Admitting

On notification of a surge of patients, the admitting department should follow Unidentified Patient protocols for all disaster patients; this frequently involves assigning predetermined medical record numbers that are retained throughout hospitalization. The admitting department should maintain a record of all elective admissions that have been cancelled.

Anesthesia

After notification of disaster, all anesthesiology staff not immediately involved in a case should report to the emergency department (ED) to assist in patient management as needed.  Operating rooms should be made ready, and plans should be made to cancel elective cases. Depending on the level of operating room activity and the volume of patients, additional anesthesiology personnel may need to be summoned.

Blood bank

The director of the blood bank will contact the Hospital Command Group (HCG) to determine if any hemorrhaging patients have arrived or are expected. The blood bank will check inventory of blood to ensure appropriate amounts are in stock.  If sufficient blood is not immediately available, the blood bank will contact outside suppliers for additional material. Because blood banks often have limited staffing on nights and weekends, the director of the blood bank will consult with the HCG to determine who shall transport blood to the ED. 

Clinical laboratories

The laboratory supervisor will notify chemistry and hematology sections of the lab, as well as the laboratory director. The lab should follow the Unidentified Patient Policy protocols using the preassigned medical record number. The disaster patient retains this number throughout hospitalization.

Department of Medicine

The Department of Medicine should provide sufficient personnel to assist in the triage, resuscitation, and management of disaster patients in the ED; manage admitted patients; and provide administrative and medical support for the discharge of inpatients. 

Chief medical residents should be notified by pager. These individuals, in turn, notify the remainder of the resident staff. The chief residents designate the staff who will assist the ED in triage/resuscitation/ED management. The chief residents will also identify those patients appropriate for immediate discharge. After details of the bioterror release are known, the chief medical residents will begin to discharge inpatients.  Following discharge, the chief medical residents will review bed availability with the HCG. 

Medical Intensive Care Unit (MICU)

The MICU fellow or senior resident is dispatched to the ED assess patient needs.  The remainder of the MICU medical staff determines which patients can be discharged from the MICU in anticipation of disaster admissions. The MICU attending reassigns residents as needed, determines staffing needs, and calls in additional personnel to assist in patient management. The MICU charge nurse will periodically report to the HCG with bed availability. 

Nursing

The nursing administrator on call will assume responsibility for coordinating nursing activities during the disaster. Once the hospital transitions to a disaster footing to handle surges of patients, the nursing administrator will meet with the HCG. The nursing supervisor will assist with inpatient census management, bed availability, and nursing availability. The nursing administrator should also prepare floor nurses for the potential for numbers of patients on medical floors that greatly exceed normal "maximum" census for that patient location. 

The nursing administrator should also be responsible for providing adequate nursing staff for the ED and disaster discharge areas. If disaster staffing needs exceed the number of staff available in the hospital, then the nursing administrator should call in staff to that patient needs can be met. 

When the number of disaster patients exceeds the number of available beds, the nursing staff should transport patients suitable for early discharge to the designated discharge holding area. The nursing staff should notify the admissions department of all early discharges. 

Operating rooms

The anesthesiologist in charge should report to the HCG available ORs and staff.  The anesthesiologist in charge should also cancel elective/non-emergent cases. If patient volume exceeds available staff, then the anesthesiologist in charge should call in additional personnel. 

Day surgical units should be the location for all disaster patients requiring minor operative care. In the event of a bioterror release, the number of patients who meet this category is likely to be small. 

Postanesthesia Care Unit (PACU)

The PACU director should report PACU availability to the HCG. If necessary, additional staff should be called in. The anesthesiologist staffing the PACU should be responsible for making decisions regarding PACU matters. If a bioterror attack produces large numbers of intubated patients that overwhelm MICU capacity, the PACU should receive MICU overflow. 

Pathology

Pathology should oversee transport from the ED to the morgue. The route of transport from the ED to the morgue should be predetermined. If additional morgue/refrigerator space is needed, the pathology staff should arrange and confirm with local hospitals and private suppliers additional refrigeration capacity.

Pathology staff should be responsible for paperwork related to expirations, including identification, date and time of receipt, and the person receiving the body. All casualties of the bioterror disaster—either immediate or delayed—should be referred to the medical examiner. Pathology staff should remember to use contact precautions consistent with the type of bioterror attack.

Radiology

The chief radiologist should be notified of the disaster. A radiology attending should report to the ED along with a technologist to assist in the prioritization of studies needed by patients. In the event of airborne pathogen release, all plain films should be obtained portably in the ED. Although this approach may lead to suboptimal films, it limits exposure of the hospital and its staff to the bioterror agent. For other bioterror releases, only those patients requiring immediate studies or who are unstable for transport should receive portable studies. 

All inpatient and elective studies should be postponed until after the surge is cleared.

Respiratory Care

This department will oversee the administration of respiratory treatments. The respiratory therapist in charge will report to the ED and determine the type and amount of supplies needed. In the event of an airborne pathogen release, respiratory therapists will need to have adequate supplies of personal protective equipment to guard against infection. Furthermore, the number of respiratory therapists providing care in the ED should be limited, and those individuals should not return to the main hospital until cleared to do so. 

Department of Surgery

All ongoing operations in the main operating rooms and day surgery units will be ended as expeditiously as possible. No other procedures should begin until cleared to do so. All surgical patients will be evaluated for discharge by the nurse in charge of surgical floors, in consultation with the surgical staff. The department of surgery should postpone all elective surgeries until the surge is cleared. Attending staff should remain in the operating rooms in anticipation of procedures, while chief residents report to the ED to assist in patient management. The senior surgeon present determines when to call additional staff from home. 

Support Department

This department is responsible for the distribution of material to individual departments in the hospital. On notification of a surge of patients, normal paperwork requirements should be suspended. The support department should make available sufficient personnel to distribute supplies as directed by the Incident Commander.

The support department should keep a 48-hour supply of all equipment sufficient for the average hospital census plus an additional 100 patients. 

Child Life Services/Social Work

Child life services should provide staff support for operations in the disaster discharge area. Child life activities should collaborate with nursing services in providing these services.

Labor Pool/Volunteer Services

A labor pool should be organized from the staff of departments and services not directly involved with the disaster. The labor pool should be located centrally in a mid-sized conference room such as the emergency department conference room. The labor pool should assist in transporting specimens to the laboratories, medical records pickup, transporting/escorting patients, delivering supplies, and delivering written messages to patient care areas.

Pharmacy

The senior pharmacist on duty should assume responsibility for transitioning to emergency operations. The senior pharmacist should notify the Director of Pharmacy, call in additional staff if needed, and contact the physician in charge to offer services. The pharmacy department should maintain contact with other hospitals and local pharmacies for obtaining additional supplies. All pharmacy staff should remain on duty until the surge is cleared.

The pharmacy should maintain a 48-hour supply of all pharmaceuticals for the average daily hospital census plus an additional 100 patients. 

Public Affairs

One person such as the director of public affairs should report to the ED; this person should relay patient information to public affairs staff members at the main reception area of the hospital. Two public affairs staff persons should staff the main reception area of the hospital. One should receive patient names and conditions from the ED while the second should take media calls and respond to them. One staff member should be available to speak with members of the media, prepare a news conference, and assist in interviews. Public affairs staff should escort all members of the media within the hospital. 

Psychiatry

Psychiatry services should be available during the disaster. Anticipated services include providing treatment to patients, families, and staff; advocating for the needs of patients, families, and staff; providing education to patients, families, staff, and the media regarding psychosocial effects of terror attacks; and providing consultation to schools to assist in coping with trauma. 

Environmental services

 

Reception

Personnel assigned to the main reception are should assist parents of victims in locating children; act as a liaison between Social Service, Public Affairs, and the ED; screen arriving visitors; and assist Security in managing traffic flow. 

Security

A major responsibility of the security department should be to secure the emergency department against intrusion by unauthorized persons. Individual health care facilities must determine the level of personal protective equipment issued to security officers, as well as the level of force permissible to prevent unauthorized entry into the hospital. Securing the ED is vitally important to prevent contamination of the ED and to prevent the disruption of patient services. 

Security officers should be assigned to the triage area and the ED entrance.  These officers are responsible for ensuring that only casualties, emergencies, and specifically authorized personnel enter the ED. Personnel assigned to this area should have a unique identifier such as self-adhesive "disaster dot" affixed to their hospital identification card. 

One security officer should be assigned outside the main ED entrance; this person will exert initial control of persons entering the ED, and will distribute disaster dots to authorized personnel. The following personnel should be authorized to enter the ED during a disaster surge: medical staff, physicians, critical care nurses, hospital administration members, members of the ECG, materials transporters bringing supplies, and specimen transporters.

One security officer should be assigned to visitor and service elevators to restrict access to the hospital. An additional security officer should be assigned to ambulance bays to control access. All other available security officers should manage the traffic—both private and ambulance—arriving at the hospital. 

All other entrances to the hospital should be secured so that unauthorized entry—and contamination of the hospital—is impossible. Members of the media should not enter the hospital unless accompanied by a Public Affairs representative. 

Safety

Members of the safety department should make appropriate measurements and observations to ensure the magnitude of risk of exposure to patients, employees, visitors, local community, and environment. In the event of an airborne hazard release, members of the safety department may be needed to assess air sampling and, if necessary, provide recommendations for temporary airflow barriers to ensure that the entire facility does not become contaminated.

Telecommunications

Once a disaster is declared, the telecommunications department should page all persons on the disaster notification list. After all necessary pages have been accomplished, the page operator notifies the supervisor on call who in turn notifies the telecommunications manager. The telecommunications department should direct all inquiries pertaining to the disaster to Public Affairs. Telecommunications staff should also be prepared to release information hospital staff who inquire about the level of personal protective equipment that is needed. No information should be given to the public by the telecommunications staff. 

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