1. Skills Station: Surge

2. Objectives
Utilize the four primary support elements that contribute to surge efficiency and effectiveness
Implement the various strategies that provide for contingency and crisis surge capacity for health care facilities
By the end of this skills station, you should be able to
Distinguish surge capacity from surge capability
Apply principles of surge response in a simulated exercise
Describe pitfalls in development of effective surge response

3. D I S A S T E R D I S A T E R etection ncident management
afety and security A
ssess hazards
upport [surge] T
riage and treatment E
vacuation R
ecovery
The DISASTER Paradigm™ provides a rapid framework for both planning and response in mass casualty events. Surge falls under Support in the context of health care facilities.

4. Surge Capacity Capability
ability to expand space for casualty flow, routine patient flow, staff, and supplies
Capacity
ability to provide necessary casualty care phased over time
Capability
Surge capacity is the ability of a facility to expand space for casualty flow to accommodate more than routine patient flow
Surge capability is the ability to provide necessary casualty care as phased treatments over time
Capability is more qualitative; capacity is more quantitative

5. Space, staff, supplies, systems
Surge Capacity
Conventional
Contingency
Crisis
Space, staff, supplies, systems
A national goal remains 20% bed augmentation for surge capacity
In many respects, surge can be framed as generating supply to meet demand
Ways to manage supply:
Free up existing space and capability (conventional)
Reverse triage: discharge least sick patients to generate bed capacity
Cancel elective surgeries & clinics
Discharge ER patients & move ICU patients
Generate new space & capability
Use existing monitored settings as ICUs (contingency)
Open alternate sites (flat space) within facility (crisis)
What are ways to manage demand?
Control influx of casualties
Initial triage outside facility
Security
Rapidly defined/created spaces

6. Goals Minimize mortality in critically injured
Maximize care delivered to casualty population
Injured by disaster
Regular emergencies

7. Situation Afternoon explosion 500 beds 2,000 casualties 100 ICU
200 dead
40 pediatric
Closest hospital
20 OR, 20 PACU
Near-full capacity
So, we are going to move through a scenario:
There has been an explosion this afternoon downtown
Media reports indicate 2,000 casualties, with 200 dead at the scene
Your hospital is the closest to the event and is near full capacity
Your hospital has 500 beds
100 ICU
40 pediatric
You have 20 operating rooms and 20 recovery room beds
You have 10 minutes before the first casualties arrive
What are your priorities?
Here come the casualties—cards begin to flip on the model

8. You have 10 minutes before first casualties arrive
You have 10 minutes before first casualties arrive. What are your priorities? What are your goals?
[Move the scenario quickly] You have 10 minutes before the first casualties arrive.
What are your priorities?
What are your goals?

9. Special Considerations and Pitfalls

10. Surge Capability Special Considerations
Special needs populations:
Children
Elderly
Medical needs
Disabled
Access
Psychiatric
Special casualty needs
Burn care
Critical care with ventilators
Surge capabilities address the needs of special populations at the extremes of age and those requiring dialysis
Ventilator management requires ventilators and professionals to run them
Sub-specialists include neurosurgeons, orthopaedists, and burn surgeons
Limits of surge capability move decision making into rationing; secondary casualty distribution to other available facilities is also an option

11. Time-Limited Mass Casualty
First wave: walking wounded and psychiatric arrive without EMS
Instant bottleneck
Security with redirected flow
Second wave: critically injured arrive via EMS
Screen casualties outside of ED
In a time-limited mass casualty event, casualties present in waves to hospitals.
The first wave is dominated by the walking wounded & psychiatric casualties. They present without EMS and can generate an instant bottleneck. Security is essential to redirect casualty flow and preserve the hospital for the critically injured/salvageable casualties.
It is paramount that critical care resources are saved for casualties with critical injuries.
The second wave includes more critically injured who arrive via EMS.

12. Minimize Hospital Contamination
Secondary contamination risk
Solutions:
Receive and screen casualties outside of ED
Decontaminate outside facility
Do not assume away the risk of contamination. The Tokyo subway sarin gas attack and SARS are disconfirming examples for such an assumption. Secondary contamination of health care facilities remains a significant risk.
Most casualties present on their own and away from scene decontamination efforts.
Solutions include planning for decontamination outside the facility, with casualty screening outside the ED as well.

13. Outcome Total casualties = ??? Critically injured = ?? Musculoskeletal
TM rupture
Blast lung
Head trauma
Operations in 24 hours = ??
[After the exercise, share this slide that highlights the outcomes from this real-world event]
There were 300 casualties, 30 (10%) of whom were critically injured
There were a total of 30 operations over the first 24 hours, most of which were urgent orthopaedic procedures

14. Pitfalls Mass provider, media, or worried-well incidents
Casualty flow bottlenecks
Definitive, rather than phased care process
No documentation (or over-documentation)
Consistent pitfalls in surge for mass casualty events include
Mass provider, media, & worried-well incidents: have a place for these groups to go
Casualty flow bottlenecks: remember, surge enables phased treatments over time, not definitive evaluation and management
Care process: routine care processes to definitive care do not enable greatest good for the greatest number of casualties; a phased care process is used whereby, initially, the least intervention is done to save and sustain as many lives as possible
Communication: simplify communication of casualty care

15. Questions?

16. Summary Four elements to surge capacity include: Space Staff Supplies
Systems
Manage surge demand and supply
Drills identify and avoid pitfalls
In summary:
Surge capacity increases usable casualty care space and mobilizes staff and resources; surge capability increases casualty care.
Both supply & demand must be managed.
The greatest pitfall is thinking of mass casualty management as business as usual. Surge increases care for the casualty population, not for the individual patient.