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Mass Medical Care with Scarce Resources

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 6 (continued)


Supply Caches

The following sources provide excellent guidance for planners in terms of establishing supply caches for different levels of alternative care sites (ACSs):

  • Agency for Healthcare Research and Quality. Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency. Available at: http://www.ahrq.gov/research/altsites.htm. Accessed July 21, 2006.
  • Hick JL, Hanfling D, Burstein JL, DeAtely C, Barbisch D, Bogdan G, Cantrill S. Healthcare facility and community strategies for patient care surge capacity. Annals of Emergency Medicine. 2004;44:253-261.
  • Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident. Soldier and Biological Chemical Command; May 2003. Available at http://www.nnemmrs.org/resources/index.html. Exit Disclaimer Accessed June 12, 2006.

Pharmaceuticals

Pharmaceuticals are an especially problematic issue, as they require a degree of 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. Pharmaceuticals fall into two major categories: those needed for the acute care of a patient and those needed for chronic diseases and ongoing maintenance of a patient's current condition. Basic pharmaceuticals will be required for the management of a wide variety of medical conditions within the context of the ACS's limited scope of practice.

The specific categories of medications that should be available include those 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.

Although it might be anticipated that stable patients, even those being observed after a possible exposure, would have few specific needs, most such patients have existing medical conditions that require ongoing pharmaceutical therapy. Medications for the care of chronic diseases and conditions all will be necessary. Planners must address in advance the issues of obtaining, storing, controlling, and dispensing both controlled and noncontrolled medications.

Staffing

Many aspects of staffing may depend on the specific type of event. Medical staff volunteers probably would be more abundant for a geographically limited noninfectious mass casualty event (MCE), for example, than for a geographically generalized (pandemic) infectious MCE. Even in situations where there will be adequate staffing, the issues of verification, credentialing, supervision, and command and control will exist. Development of the Emergency Systems for Advance Registration of Volunteer Health Professionals (ESAR-VHP) will help address these issues. The ESAR-VHP structure of verified health professional credential levels increases health system personnel capacity by providing a standardized way to identify significant numbers of credential-verified health professionals across a State. In addition to providing State-based advance registration, verification, and credentialing of medical volunteers, the system should enable interstate sharing of volunteers. Further development of the Medical Reserve Corps (MRC), with their local units of medical volunteers, including paramedics if available, also may help address some of these staffing issues. In 2005, more than 1,500 MRC members were willing to deploy outside their local jurisdiction on optional missions to hurricane-affected areas with their state agencies, the American Red Cross, and the Department of Health and Human Services (HHS).

Although some staffing levels for ACSs can be proposed in advance (go to Table 6.3), unique staffing requirements tend to be event and population specific. The level of patient acuity certainly will have an impact on staffing needs.

One option is that in situations in which the ACS is used to decompress hospitals, only those hospitals that contribute staffing would be allowed to send patients to the ACS. Planners should consider other staffing options, including the following:

Regional hospital alliances could 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. Given the aggregate number of allied health professionals employed per hospital, recruitment of such a relatively small number of staff members should not be overly burdensome.

A single hospital may 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  also may be viable sources of volunteers.

Moreover, in a geographically limited MCE, where there is a large possibility of volunteers from outside the impacted area, academic medical centers may be a source of teams of health care workers who could assist with staffing needs. This concept could be further refined through the establishment of partnerships with centers outside of the local geographic area in advance of an event. Tapping into the administrative structures of large, geographically diverse health care systems also could assist in meeting staffing needs.

Other Staffing-related Issues to Consider

  • The provision of housing for the staff may be an issue.
  • Identification of staff members (and patients and their family members) becomes an issue in the rapidly changing environment of an ACS and should be addressed by providing a name badge system that could be as simple as stick-on nametags or as complicated as a site-generated photo ID.
  • It may be appropriate to negotiate overtime contracts in advance in cases where municipal-owned buildings are to be used as ACSs with municipal workers providing support staffing.

Despite having staff members from distinct and separate health care organizations, there are many more similarities than differences evident in the delivery of medical care, particularly in any given region. 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 to work together for the first time.

Operational Support

Actual operation of an ACS will require a host of support services, including meals, 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 for many of these support issues.

Documentation of Care

Given the extraordinary conditions that will exist to require the use of ACSs for patient care delivery, only modest means for patient care documentation should be expected to be used. Electronic medical records are not likely to be available or practicable, particularly given the learning curve associated with their use and the dependence on technology that may not be operable. 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; there should be an adequate supply of such forms, as well as clipboards and pens.


Security Issues

In the chaos and confusion that accompany any large-scale MCE, security assumes an increased level of importance, especially since law enforcement resources will be severely taxed. To this end, planners must develop robust security plans. It is helpful if security personnel have previous experience in dealing with patients, especially those with behavior disorders. The best potential source of security staff would be off-duty hospital security personnel, but these individuals may not be available. Other potential sources would include on- or off-duty police officers, activated members of the National Guard, or volunteers.

Communications

Reliable communications will be required among the ACS and nearby health institutions, EMS providers, unified command, law enforcement, suppliers, staff members, and the public. Most MCEs, however, result in communication system failures, highlighting the need for redundant communication capability, including land lines, cellular phones, and local and regional radio communication (including HAM radios). Advance planning and selection of potential ACSs may facilitate the establishment of land line communication.

Relations with EMS

Any ACS will be dependent on local EMS for transport of patients to and from higher levels of care and to assist with patient dispositions. For this reason, local EMS providers should be part of the ACS planning process.

Rules and Policies for Operation

It became clear during the operation of the FMSs in the aftermath of Hurricanes Katrina and Rita that rules of behavior for patients, caregivers, and visitors were necessary for the smooth operation of the ACSs. ACS planning should include the establishment of such a set of rules as well as operating procedures.

Planners are referred to the following 2006 HHS document as an excellent reference for sample forms (emergency intake, patient assessment, etc.), sample rules, and operating procedures: After Action Review of Federal Medical Station (FMS) Operations During Hurricanes Katrina and Rita.

Operating procedures should address incident command, staffing, criteria for admission, discharge and transfer, clinical roles and responsibilities, infection control, pharmacy and medication control, safety, security, supplies, finances, documentation, staff housing, housekeeping, food services, and other areas unique to the event.

Development of an Exit Strategy

Part of the successful operation of an ACS is the decision of when to close the facility. 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 the local emergency managers and local or State health officials.

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 to assist with the establishment and operation of an FMS. Funding for these exercises can be supported with Health Resources and Services Administration 2006 bioterrorism grants and Urban Area Security Initiative funding.

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Lessons From Case Studies of ACSs

The 2005 hurricane season dealt the health care system of the Gulf Coast of the United States an unprecedented blow. The enormous number of patients and evacuees in the aftermath of Hurricanes Katrina and Rita overwhelmed local health care resources of the Gulf Coast of the United States. This afforded emergency managers and clinicians an excellent opportunity to witness firsthand the operation of alternative medical care facilities.

The near total destruction of the local health care system of the Gulf Coast region and especially the New Orleans metropolitan area made it necessary to evacuate thousands of healthy evacuees, acute medical patients, and persons with chronic medical conditions and special needs to unaffected areas. The concept of receiving casualties in areas which were otherwise unaffected by the original disaster has been described as evacuee surge capacity. This term differentiates it from the intrinsic surge capacity resources of the impacted location. It is a subtle distinction, but it takes into account that the receiving facilities at least have not suffered a blow to their infrastructures. Also, from an emergency planning standpoint, it encompasses the principle of distributing patients to several different receiving areas so as not to overwhelm any single facility.

The strategy of transferring patients away from the affected Gulf Coast area was used extensively in the late summer of 2005. Large ACSs were established in surrounding States, and smaller facilities were set up to accept evacuees throughout the United States. A number of clinicians and officials involved in EMS and emergency management at several of the locations where ACSs were established after Hurricanes Katrina and Rita were interviewed for this planning guide.

Lessons Learned: Key Areas to Consider in ACS Planning

Operations

  • Regional planning is important. Ensure that patients are distributed across the State(s) efficiently and appropriately.
  • Security makes patients and staff members feel safe and keeps out troublemakers. Having uniformed people on site, even Reserve Officer Training Corps (ROTC) cadets, makes a real difference.
  • There are distinct advantages to setting up an ACS near a college or university. For example, it provides extra manpower (e.g., football team) to carry patients, set up equipment, etc.

Medical

  • Plans must be made to segregate individuals with special medical needs from the general population.
  • Facilities should be laid out in an organized fashion. A grid system allows clinicians to make "rounds" and know exactly where to find a patient (e.g., bed A4).

Staffing

  • There should be extensive use and coordination of volunteers.
  • Acknowledge that volunteers may not want to do certain tasks (e.g., colostomy care, diaper changes). Establish who is going to do what.
  • Legal and jurisdictional issues will need to be addressed.
  • It is important to develop an Incident Command System that can help avoid "turf battles" between employees of different health systems who are staffing the same facility.

Logistics

  • Public health issues are critical (e.g., safe food and water, sanitation, latrine resources).

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Special Needs Shelter Case Study

Converting a Veterinary Hospital in College Station, TX

In anticipation of Hurricane Rita, emergency planners and officials from the Texas A&M Health Sciences Center converted the Large-Animal Hospital at the College of Veterinary Medicine and Biomedical Sciences into a medical facility to house special needs patients and their caregivers from Houston and Galveston. Officials at the University previously had worked out a hypothetical plan to convert the animal hospital into just such a surge hospital during times of scarce medical resources. The facility was quickly cleaned and brought online to receive patients and remained operational for 1 week.

A type III Federal Medical Station (later redesigned as a Level IV FMS) was dispatched through an HHS-CDC-coordinated effort; this addition supplied two 250-bed caches of equipment, which increased the capacity to 1,081 beds.

U.S. Public Health Service staff eventually assumed medical control of the facility. In total, the facility took care of more than 350 patients (many of whom were ventilator or dialysis dependent) and housed more than 650 people (including patients' caregivers). This facility was instrumental in allowing the pressure to be taken off the local acute care facility, St. Joseph Hospital.

Lessons learned from this experience include the following:

  • Veterinary hospitals can offer significant advantages in planning for surge capacity due to preexisting facilities (e.g., water, lighting, medical gas pipelines).
  • If such vet hospitals are associated with a university medical system, they are easier to integrate into the overall medical system.
  • It is important to have a plan for conversion to human use, including plans for care of animals.

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Mobile Medical Facilities Case Study

Mobile Field Hospital in Waveland, MS

During Hurricane Katrina, the Hancock County Medical Center was completely incapacitated, with mud covering the entire first floor. The State of Mississippi worked with HHS and the State of North Carolina through the Emergency Management Assistance Compact (EMAC) to deploy a mobile medical field hospital. The hospital was comprised of the North Carolina State Medical Assistance Team (SMAT) together with a tractor trailer from the Carolinas Medical Center in Charlotte.

In addition to the North Carolina SMAT, two Disaster Medical Assistance Teams from NDMS and a U.S. Air Force Expeditionary Medical Support system (EMED + 25) were among the many field medicine service providers rendering medical care to local residents of Hancock County. The North Carolina SMAT conducted medical operations for more than 7 weeks and treated more than 7,500 patients, including some surgeries. More than 500 health care professionals from North Carolina were deployed from all over the State to staff this field unit during the 2-month deployment.

Lessons learned from this experience include the following:

  • The use of a self-contained mobile medical facility can be a significant asset in an austere environment with essentially no infrastructure; however, that asset must be deployed with "wraparound" logistics and must be truly self-sufficient to avoid becoming part of the burden on the requesting community. Logistical challenges diminished the intended capability of the tractor trailer medical unit. The prototypical unit proved to be less useful than originally planned and more than 95 percent of the patients were actually treated outside the unit in a tent style environment similar to Disaster Management Assistance Teams or the EMED + 25.
  • A heliport was set up given the fact that the main ground evacuation route was underwater. Air medical services played an important role in this instance, highlighting the need to include such services in planning efforts.
  • Issues of licensing, jurisdiction, malpractice, and reciprocity need to be addressed at the highest levels of government for the successful widespread use of similar mobile medical assets. EMACs give protection to assets owned by a State, but similar protection for non-State entities is less clear. Local medical assets that wish to deploy outside their jurisdiction must fall in line with the State system of emergency management to ensure proper asset placement and liability protection.

Converting Public Buildings to ACSs: Examples from Hurricane Katrina

During the response to Hurricane Katrina, there were many instances of converting public buildings to an ACS:

Reliant Arena Medical Clinic, Houston—Many thousands of evacuees from the New Orleans Super Dome and more than 700 patients from New Orleans hospitals were evacuated to Reliant City Astrodome in Houston. Fire department EMS personnel and clinicians from Baylor College of Medicine and the Harris County Hospital district oversaw medical operations at the Astrodome and established the Reliant Arena Medical Clinic. A triage system was set up to avoid persons directly dialing the 911 system and potentially overwhelming the Houston hospital system.

Convention Center Evacuee Medical Clinic, Houston—After the Astrodome reached capacity, a shelter was created at the George R. Brown Convention Center. In addition to health care professionals from the University of Texas Science Center at Houston, the clinic was staffed with volunteers, such as retired physicians from the Harris County Medical Reserve Corps.

Reunion Arena and Dallas Convention Center (DCC) Medical Unit, Dallas—Reunion Arena in Dallas was opened to accommodate more than 700 evacuees. As the Arena filled to capacity, the DCC was opened as a large shelter which housed 900-1,800 evacuees a night. A small aid station and standing ambulance were set up at the Reunion Arena, but a larger and more substantial medical clinic was set up at the DCC, encompassing more than 8,200 square feet of space. This clinic was administered by the University of Texas (UT) Southwestern Medical Center at Dallas and staffed by UT staff members as well as numerous volunteers.

Surge Hospital, Louisiana State University (LSU) Basketball Arena, Baton Rouge—The Louisiana Department of Health worked with LSU to establish an 800+bed surge hospital at the university's basketball arena and a special needs shelter in an adjacent field house. The surge hospital was an acute care center and received patients who had been evacuated by helicopter and ambulance from the disaster area and other health care facilities. The center was staffed initially by local Baton Rouge physicians and evacuated health care professionals. Additional medical staff members included those from the Illinois Medical Emergency Response Team, the New Mexico Disaster Medical Assistance Team, the U.S. Public Health Service, and other health care volunteers.

Shelter for Special Needs Evacuees, Tyler, TX—The Northeast Texas Public Health District worked with UT at Tyler to set up a special needs shelter at the university to accommodate special needs patients. Medical operations were overseen by the Texas Medical Rangers and additional staff members provided by the UT Health Center at Tyler.

Operation Safe Haven, Evacuee Processing Station and Medical Clinic, Denver—Through an EMAC agreement between Colorado and New Orleans, more than 300 displaced evacuees from New Orleans were transported to the former Lowry Air Force Base in Denver, now a part of the Colorado Community College System (CCCS). Using an ICS, the mothballed buildings were prepared for the first planeload of 150 evacuees within 24 hours by volunteers from various agencies, the CCCS, local utility companies, and work crews from local prisons for the first plane load of 150 evacuees. Medical operations included an initial triage station and a clinic in the evacuee dormitory that operated for 4 days until the evacuees were integrated into local Denver health clinics.

Planning and Coordination—The coordination of logistics, personnel, space, and supplies was critical in quickly responding to situational needs. This involved coordinating not just those entities responsible for responding to public health emergencies but included colleges, universities, and other potential community resources. Planners considered the order in which buildings would be used, first using a large arena with another site available if the numbers of evacuees became too large. In general, establishing personal relationships among various agencies and branches of government before a disaster strikes is critical to operating effectively during an MCE. A well-defined ICS was critical to operations in most localities; any agency or volunteer organization that is part of a response operation must have a basic understanding of ICS.

Public Health Considerations—Large arenas and convention centers are not equipped to handle evacuees for long periods of time. Shower facilities and other amenities are limited, and planners need to consider ways to address this in advance to avoid dangerous public health conditions. Medical staff needs for personnel hygiene also need to considered, such as showering and washing providers' clothing.

Security—In crowded conditions with large number of evacuees, it was important to maintain a sense of control and security. Uniformed staff members from area hospitals and other sources of security personnel were helpful in maintaining a sense of order. In some centers, National Guard soldiers and college ROTC cadets provided security. A safety officer should be designated to coordinate security activities in an ACS.

Transportation —Dedicated ambulances stationed at large evacuee centers helped to reduce demand on local EMS, which in turn freed the local EMS to respond to the community's needs and its 9-1-1 system. In general, the ACS clinical services helped to prevent local hospital systems from being overwhelmed.

Planning Medical Supplies, Pharmaceuticals, and Food Supplies—Small over-the-counter pharmacies in evacuee centers can help address simple pharmacy needs. Planners need to consider options and can coordinate with local pharmacies, hospitals, and local businesses to provide pharmaceuticals and other supplies. In Houston, arrangements were made with a chain pharmacy and local health care system to set up a full pharmacy at the ACS clinic. Ordering of purchased supplies should be handled through one person who is a designated purchasing authority to reduce potential confusion. Controlling access to the pharmacy and central supply is a critical security issue to be addressed in preplanning. In a sustained event, donor-fatigue can set in; mechanisms therefore should be considered for coordinating an uninterrupted supply chain and spreading the financial impact of volunteer supplies. In Baton Rouge, a resource book of each type of volunteered equipment was maintained so that providers had a ready source of information.

Shelter Expectations for Standards of Operation—Municipalities that contract out the management of shelters to outside organizations, such as ARC and faith- and community-based organizations, need to establish a set of standards for how shelters will be run. In Dallas, admitting and accommodating the immediate medical needs of evacuees at shelters became confusing due to varying admittance standards. In addition, planners need to consider how best to accommodate the existing homeless population in the shelters that are accepting incoming evacuees.

Credentialing—Credentialing is an important planning issue due to the potential for rogue clinics and medical providers to operate in the early stages of an event. Coordination of staff members under an ICS can address this issue. The U.S. Public Health Service addressed screening and credentialing of volunteer health care providers in Baton Rouge's ACS. The Texas Board of Medical Examiners was proactive in facilitating credentialing of out-of-State physicians.

Staff Considerations—Emergency physicians working to triage patients in ACS enabled the internists, pediatricians, and other primary care provides to focus on direct patient care. Volunteer health care providers play a valuable role, but clinic operations should not be run solely by a collection of volunteers. In addition, leaders must assess whether volunteers are being helpful and remove individuals who are not contributing to the overall mission. Some ACSs used a volunteer coordinator to manage the number of people who came to volunteer. In Dallas, a Web portal was set up to schedule physicians and coordinate staff members. Another consideration is that ACS leadership should have training in emergency management and disaster medicine; in some instances, it may become necessary to rotate some of the leadership positions to include personnel with more hospital administration experience. It is important to identify teams of personnel in anticipation of an event, allow them to evacuate their families, and provide shelter for the staff at an ACS, clinic, or hospital. Quiet and restricted access space needs to be provided to the health care staff so that lack of rest will not have a negative impact on the quality of care.

Patient Tracking and Documentation—Planners will need to consider how to use and coordinate patient-tracking data and coordinate across all agencies and organizations, such as the ARC, faith-based and community-based organizations and government-supported ACSs. Some of these organizations may have rules regarding information sharing that need to be considered in advance. A system for registering and tracking patients helps with making patient flow as efficient and orderly as possible. In Baton Rouge, a charge nurse station was established to track each patient and list providers that were on duty. A real-time census was performed every 8 hours to maintain accountability. In one center, a system of identification tags was useful for tracking patients.

Communications—In some ACS, HAM radio operators provided helpful supplemental communications. Having a number of handheld walkie-talkies also facilitated communications.

Patient Screening—Initial evaluation of evacuees is important to determine those people whose health conditions have deteriorated during travel to the ACS. A medical triage/evaluation station was used in Denver to conduct a more thorough screening of evacuees as they were being processed at the reception center.

Pediatric Populations—The involvement of pediatricians with experience in emergency management is helpful for planning for the numerous special considerations of pediatric evacuees. Early and accurate identification of children is crucial to alleviate confusion and additional suffering for families. It is important to keep in mind that children have special considerations in terms of decontamination and treatment due to the differences in their body size and metabolism.

Psychiatric Services—Evacuees from a major disaster have suffered a huge mental trauma. Some ACSs set up tents so that persons with psychiatric or stress issues could be attended to in a quiet and secluded location. The mental health of providers is important as well; in Baton Rouge, provisions were made for postincident debriefings and ongoing psychological support for health care providers.

Special Needs—Patients with special needs were directed to shelters that focused on their care instead of a regular shelter. In Texas, patients requiring special needs were redirected to a special needs shelter.

Accessibility—Some ACSs did not have wheelchair access and other accommodations for evacuees with disabilities. Temporary ramps and other adjustments can be made and need to be planned in advance.

Pets—A number of people arrived at shelters with their pets. Local animal shelters and animal response teams were used to register, evaluate, and house pets that arrived.

Go to Table 6.4: ACS Selection Matrix

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