2LT Laura CookmanJim Holliman, M.D., F.A.C.E.P., Program ManagerAfghanistan Health Care Sector Reachback ProjectCenter for Disaster and Humanitarian Assistance Medicine(CDHAM)Professor of Military and Emergency MedicineUniformed Services University of the Health Sciences (USUHS)Clinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.

Hospital Surge Capacity :

Lessons from Israel

February 2010

Lecture Objectives

• To define surge capacity and surge capability• To outline the basic principles of surge

capacity including the 3 S’s and patterns of sudden impact versus prolonged events

• To outline Israel’s disaster response plans with suggestions of what can be applied to the United States (U.S.)

• To identify challenges facing the U.S. in disaster planning

Definition of Surge by Webster’s Dictionary1

“to rise suddenly to an excessive or abnormal value”

Definition of Surge Capacity2

“a healthcare system’s ability to manage a sudden or rapidly

progressive influx of patients within the currently available resources at a

given point in time” : American College of Emergency Physicians

(ACEP)

Definition of Surge Capability3

“refers to the ability to manage patients requiring unusual or very specialized

medical evaluation and care” :U.S. Department of Health and Human

Services (HHS)

U.S. Department of Homeland Security (DHS) Defined Critical

Infrastructure and Key Resources

• Agriculture and Food • Energy

• Banking and Finance • Government Facilities

• Chemical • Healthcare and Public Health

• Commercial Facilities • Information Technology

• Communications • National Monuments and Icons

• Critical Manufacturing • Nuclear Reactors, Materials & Waste

• Dams • Postal and Shipping

• Defense Industrial Base •Transportation Systems

• Emergency Services • Water

DHS Critical Infrastructure and

Key Resources Sectors

Demand > Supply

The Basic Problem for Disaster Planning :

The 3 S’s

(And maybe there should be a 4th “S”: System)

From Koenig and Schultz’s Disaster Medicine, 20104

Surge Capacity

Sudden Impact EventEarthquake, hurricane, bomb, chemical

attack

Prolonged Event Pandemic Influenza, Bioterrorist

attack, outbreak

Staff

Stuff

Structure

System

Can lead to…

Sudden Impact Event versus Prolonged Event

Sudden Impact Event

Earthquake, hurricane, bomb, chemical

Prolonged Event

Pandemic Influenza, Bioterrorist attack

From Barbisch and Koenig5

IsraelBackground Information6

• Area : 20,330 sq. km (7,850 sq. miles)• Population : 7.23 million• Similar to New Jersey in size &

population

Key Differences vs. U.S.:• Health insurance for all residents• One national Emergency Medical Service (EMS)

– Magen David Adom (“Red Star of David”)• No military hospitals

– General hospitals treat both civilian and military casualties

• History of repetitive attacks on country– Since independence in 1948 : 7 major conflicts fought– Terrorist suicide bombs, rocket attacks, etc.

The Middle East

Peleg K, Kellermann A. Enhancing hospital surge capacity for mass casualty events.

JAMA 2009; 302(5): 565-567.

Excellent Summary Reference

Peleg and Kellerman’s List of Key Planning Principles7

1. Nationally coordinate resources.

2. Establish goals and prepare standard operation procedures.

3. Constantly monitor surge capacity.

4. Design expandable facilities.

5. Coordinate EMS with healthcare facilities.

6. Avoid ED crowding and promptly clear EDs.7. Reinforce medical workforce and designate adjoining

site to treat pts with minor injuries.8. Designate a triage hospital.9. Practice, practice, practice.

1. Nationally Coordinate Resources

• Supreme Health Authority– Defines and enforces the nation’s

health policies for disasters and mass casualty events

• Result of having centrally coordinated authority is clear command, control and communication

• Stockpiles prepositioned at each hospital and some national distribution centers

2. Establish goals and prepare standard operation procedures

(SOPs)• National standard

– Every hospital must be prepared to care for additional 20 % of normal hospital capacity

• SOPs– Based on national

doctrine written by Israeli Ministry of Health (MOH)

– Uses internal and external call-up systems

– Standard procedures for each hospital nationally

3. Constantly monitor surge capacity

• Standard format• Daily report to

MOH– Inpatient and

Intensive Care Unit (ICU) occupancy by specialty

– Hospital’s overall bed capacity

– Number of patients receiving ventilator support out of ICU

4. Design Expandable Facilities

• Capability to quickly expand in Mass Casualty Event (MCE)

Edith Wolfson Medical Center’s Basement 500 Bed Expansion

Emergency Department

Examples of expandable facilities

Left : Rambam Hospital, Haifa, Israel

Right : Sheeba Tel HaShomer Hospital, Tel Aviv

5. Coordinate Emergency Medical Services (EMS) with

healthcare facilities• EMS coordinated by

national and regional command & control centers– Command and control

center notifies the hospitals closest to event

• Distributes severely injured casualties among several hospitals

• EMS liaison at each receiving hospital

6. Avoid Emergency Department (ED) crowding and

promptly clear EDs• Israeli hospitals aim to keep ED clear • No boarding• In Israel it takes 10-15 minutes to CLEAR ED

after MCE• Nearest hospitals notified by EMS

Tel Aviv Sourasky

Medical Center

7. Reinforce medical workforce and designate adjoining site to

treat patients with minor injuries

• Nonemergency physicians and other health care providers report to staging area next to ED

• Patients with minor injuries and psych trauma placed in temporary walk-in clinic in close proximity to ED

8. Designate a triage hospital

• When casualties overwhelm resources, the hospital stops functioning as an admitting hospital and converts to a triage hospital

9. Practice, practice, practice

• Annual Drills : Nationally coordinated• MOH determines scope, type and

timing• Evaluators at each hospital• After action review (AAR) following

drill

Other Lessons from Israel

• Maintenance of outdated ambulances as “back-up” vehicles for MCE’s

• Extensive use of case simulation training for EMS personnel

• Armored ambulances

Israeli EMS Simulation Training

Simulation Training Center at Sheeba Medical Center in Tel Aviv

Israeli Armored Ambulances

Armored Corps Museum, Latrun, Israel

New MDA armored ambulance (2010)

Application of the Israeli lessons learned to the

United States

Application to U.S.:1. Nationally coordinate

resources• National Response Framework (NRF)8

– Guide to how the Nation conducts all-hazards response– Gives authority to organizations– 15 Emergency Support Functions (ESFs)

• ESF # 8 : Public Health and Medical Services; Department of Health and Human Services (HHS)

• National Disaster Medical System (NDMS)5

– Partnership between Department of Health and Human Services (HHS), Departments of Defense (DOD), Veterans Affairs (VA), Federal Emergency Management Agency (FEMA)

– Coordinating agency is HHS– 3 primary missions: field medial response, patient

transport, and definitive care• Strategic National Stockpile (SNS)

– Designed to supplement and re-supply state and local governments with medical material supplies

– Federal Medical Stations : designed to provide for 250 non-acute and special needs patients over 30 days

Application to the U.S.:1. Nationally coordinate resources (continued)

• However must consider…– State sovereignty : U.S., unlike Israel, has

50 sovereign states – Communication : Different organizations

must learn to communicate with one another

• New Idea :– Give authority to members of the

organizations that are coordinating with other organizations

– Instead of DOD calling the Pentagon with HHS’s request, have the Pentagon send a DOD member with authority to allocate Pentagon resources

Application to the U.S.:2. Establish goals and

prepare SOPs

• Establish goals – No national standard for surge

capacity – Blanket 20 % for all hospitals may

not be appropriate for U.S. with diverse geographical and population distribution

– Resources / needs should be assessed

Application to the U.S.:2. Establish goals and

prepare SOPs (continued)• Prepare SOPs :

– Joint Commission does some of this, however broad.• Plan must contain 4 components of Comprehensive Emergency

Management (Mitigation, Preparedness, Response, Recovery)• Must include hospital emergency incident command system

(HEICS)• Hospitals required to test emergency management plan 2x /

year either in response to actual emergency or planned exercise

• Must conduct at least one exercise / year that includes an influx of actual or simulated patients

• If defined role in the community, must participate in at least 1 community exercise a year (table top ok)

• Planned activities must be based on hazard vulnerability analysis

• Evaluate key components • Identify strengths / weaknesses

– More guidance on SOPs ; no JCAHO requirement for surge capacity

– Tabletops are helpful, however actual live drills should be conducted regionally every few years

Application to the U.S.:3. Constantly monitor surge

capacity

• No national requirement for hospitals to report capacity– Exceptions

• Federal hospitals• ICU beds : if all ICU beds are closed then ED may go on

diversion

• Absolutely essential to know what resources are in case of a disaster; once the disaster happens it is too late to determine surge capacity of nearest hospitals

• Develop National Capacity Monitoring Tool– Medical Capability Assessment and Status Tool (MCAST)

• Sponsor federal and non-profit hospitals to report capacity• Under development

– Record capacity status of each hospital so that if an event happens patient delivery can be coordinated based on status

Application to the U.S.:4. Design Expandable

Facilities• ED Design Guide by ACEP9

– Decontamination shower / area addressed but no room allocated for “surge”

• Structure Lacking– 1990 to 1999 hospitals lost 103,000 staffed medical-

surgical beds & 7,800 ICU beds10

– 2001 study : 38 % ED directors reported doubling up patients in exam rooms and 59 % reported using hallway stretchers11

– Must address staff issue also; empty beds do not take care of patients

• In U.S. there is limited space and financial resources– Adjust existing structures rather than build new

structures– Use of outside facilities i.e., schools, churches12 – Hospitals can work together: share resources and

capability status in case of a disaster

Application to the U.S.:4. Design Expandable Facilities

(continued)

• An example of a federal, a military, and a private hospital working together13

– In Bethesda, Maryland : National Naval Medical Center (NNMC), Suburban Hospital Healthcare System (SHHS), and the National Institutes of Health Clinical Center (NIHCC)

– Have conducted 4 complex drills to test communication, coordination, planning, and educational efforts

From Henderson et al

Application to the U.S.:5. Coordinate EMS with the

Healthcare Facilities

• “EMS system models in the U.S. are numerous and varied making a fully encompassing description impossible”14

• Governmental and privately supported• Most coordinated by state or region

– No national coordination• Attempt made to distribute severely injured

casualties by chief EMS officer on site– However no national surge monitor (unsure of what

area hospitals’ capacities are)• No EMS liaison at each hospital

– This could benefit U.S. system

Application to the U.S.:6. Avoid ED crowding and promptly

clear EDs

• Over ½ of all EDs are at or over capacity– National Hospital Survey 200715 : 65 % of urban

hospitals at or above; 73 % of teaching hospitals at or above

• Ambulance Diversion– 56 % of urban and 64 % of teaching hospitals have

been on ambulance diversion in past year– 13 % of urban hospitals have spent 20 % or more

time on diversion• Boarding is a Big Problem in U.S.

– 22 % of patients in emergency department had already been admitted but were waiting for an inpatient bed11

– Real world example: Dr. Jim Holliman while working at Hershey Medical Center in Hershey, Pennsylvania reported for a day shift and of the 45 available beds in the ED, 42 were occupied by already admitted patients

Application to the U.S.:6. Avoid ED crowding and promptly

clear EDs (continued)

• How can the U.S. handle a surge of patient’s if we operate at or above capacity on a daily basis ?

• Need solutions for ED crowding • Must be a hospital approach and

therefore a hospital priority– Patients admitted to inpatient

services should be held and cared for in an inpatient setting and not in the ED (“duh”)

Application to the U.S.:7. Reinforce medical workforce and

designate adjoining site to treat patients with minor injuries

• Reinforce medical workforce– Staff already in short supply

• 116,000 RN vacancies as of December 200615 with projected 400,000 by 2020

• 55 % of hospitals experienced gaps in specialty coverage for the ED

– Increased difficulty maintaining physician ED call coverage

– More than a third of hospitals now pay extra for some physician specialty ED call coverage

– Coverage issues are most prevalent in orthopedics and neurosurgery

– Disaster plans may erroneously assume 100 % attendance of staff during disaster

• The percent of healthcare workers who show up depends n their perceived risk to themselves and their families

• Adjoining site– Several disaster plans contain a plan for this and

recognize the importance of having separate area to treat patients

Application to the U.S.:8. Designate a triage

hospital• Not done in the U.S.• Emergency Medical Treatment and Labor

Act (EMTALA)– Est. 1986; Federal law that requires anyone

coming to an emergency department to be stabilized and treated, regardless of citizenship, legal status or ability to pay

– Every patient presenting to ED wishing to be treated must be seen and evaluated; only if stable or written consent can they be transferred

– Agency for Healthcare Research and Quality (AHRQ)16 : “Recommendation : Federal officials should specifically address EMTALA-related issues, rather than waiting for a mass casualty "test case".”

– This needs to be clarified before a MCE

Application to the U.S.:9. Practice, practice,

practice• Per the Joint Commission’s

requirements 2 drills done per year

• 1 has to involve the community however this can be a table top

• Broader multi-institution regional drills ought to be conducted more frequently

Unique Planning Challenges for the U.S.

1. 50 Sovereign states2. “Staff,” “Structure,” and “Stuff”

shortages3. Public / private hospitals4. Uninsured patients5. Financial constraints 6. No national surge capacity monitoring

system7. Voluntary and not mandatory 8. No frequent repetitive domestic

events

1. 50 Sovereign States

• 50 sovereign states within United States

• Medical and nursing licensing is state based

• Requires coordination of federal, regional and state resources

• Activation of federal resources and National Guard dependent on state governor

2. “Staff,” “Structure,” “Supply” Shortages

• Structure– Majority of hospitals function at or greater than capacity (AHC

2007 survey)– 1993 to 2003 : ED visits increased 26 % however number of

EDs decreased by 14 %. National survey of 250 EDs : 28 % of ED directors reported doubling up patients in exam rooms and 59 % of directors reported using hallways as patient care areas

– Ambulances on diversion• Staff

– Nursing shortage: as of December 2006, hospitals had an estimated 116,000 nurse vacancies

– Approximately 55 % of EDs have gaps in specialty coverage (esp. orthopedics and neurosurgery)

• Supply– “Just-in-time” basis– Expensive to stock and keep updated excess supplies

Problem: “Disasters are local” with an “erosion” of hospital capacity

3. Public / Private Hospitals

• Large, complex healthcare system(s) in the United States– Nonprofit– Private for-profit– Government

• Generally, poor communication between facilities

• No national requirements to develop integrative disaster plans or to report surge capabilities (with exceptions)

4. Uninsured patients

• In U.S. unlike Israel health insurance is a privilege and not a right

• Over 43 million U.S. residents under 65 years old lack health coverage17

– $99 billion spent in 2001 for uninsured• Included out of pocket expenses, insurance

payments if insured for part of the year, worker’s compensation, charity

– $30 billion annually to compensate hospitals and clinics for services provided to the uninsured (IOM)

– $5 billion annually donated by physicians

5. $$$$$

• Uninsured driving up healthcare costs

• Money not being allocated specifically for surge

• Much of healthcare expenses related to behavioral problems (obesity, violence, smoking, driving while intoxicated, etc.)

6. No national surge capacity monitoring

system• Unlike Israel only federal hospitals

are required to report hospital surge capacity daily

7. Voluntary not mandatory

• No national requirement for surge capacity

• Joint Commission : has several requirements for hospitals but very general

8. No frequent repetitive domestic events

• Although the U.S. has had several MCE including 9/11 and Hurricane Katrina, it is not at the same frequency as Israel

• Unfortunately we become complacent with day-to-day activity

• Often takes a disaster to motivate change

One Lesson Israel Could Learn from the U.S.

• Better security and “chemical proofing” of major EMS dispatch and communication facilities

Tel Aviv MDA Dispatch Center with open unguarded doors

IPRED Conference

• International Preparedness and Response to Emergencies & Disasters

• Tel Aviv, Israel• 11 to 14 January 2010• Organized by the State of Israel Ministry of

Health and the Israeli Defense Forces Home Front Command

• Over 750 attendees • International Attendance : 30 countries

– Israel, U.S., Germany, U.K., Italy, Kenya, Jordan, etc.

IPRED Conference Hall

Orange Flame Drill 4

• National project held every 2 years• Simulated bioterrorism event• Integrates all regional components of the

medical and interface agencies that cope with such an event in the first 48 hours from its detection

• Participating regional institutions in 2010 included :– 3 acute care hospitals, 14 civilian and 3 military

primary care clinics, the Regional Health District bureau, EMS services, police force, Home Front Command district, Local Municipalities and additional first responders

• Participation of the IPRED delegates

Orange Flame Drill 4

• This year smallpox outbreak affecting ~1000 people + isolation and treatment of ~20,000 people + national vaccination campaign

Day 1

• Detection Phase– HMO clinic

• Magen David Adom (EMS) control center

• Outbreak Phase– Wolfson Medical Center

Detection Phase

Magen David Adom

Magen David Adom

Outbreak Phase

Wolfson Medical Center, Tel Aviv

Outbreak Phase

Outbreak Phase

Day 2

• International Press Conference• Operation of Centers for Mass

Immunization and Prophylaxis

International Press Conference

Mass Prophylaxis

Mass Prophylaxis

Summary of Lessons the U.S. can learn from Israel regarding surge

capacity…

1. National Coordination : absolutely key; ensure clear communication and give individuals from national organizations that are communicating with one another the authority to make decisions and allocate resources.

2. Goals & SOPs : Should have surge capacity national requirement based on individual hospitals and not blanket set percentage; More guidance on standard operating procedures from hospitals.

3. Monitor surge: Need for national surge capacity reporting and monitoring.

4. Expandable facilities : ED planning should include area for expandable facilities; additionally work with local community and area hospitals to design disaster plans.

5. Coordinate EMS : Have EMS liaison at hospital; ensure city/regional center is coordinating various EMS units responding to disaster.

6. Avoid ED crowding : Decrease ED crowding / boarding ; must be hospital response.

7. Reinforce medical workface : Increase RN training positions at schools. 8. Designate a triage hospital : EMTALA needs to be addressed with

regards to what happens during MCE.9. Practice, practice, practice : don’t wait until actual disaster !

References1. Merriam-Webster online dictionary. “Surge” definition. Available:

http://www.merriam-webster.com/dictionary/surge. Accessed January 24, 20102. ACEP. “Health Care System Surge capacity Recognition, Preparedness, and Response.” Available:

http://www.acep.org/practres.aspx?id=29506. Accessed on January 24, 2010.3. HHS. Medical Surge Capacity Capability Handbook. Available:

http://www.hhs.gov/disasters/discussion/planners/mscc/index.html. Accessed on January 24, 2010. 4. Koenig, KL & Schultz, CH. (Eds). (2010). Disaster Medicine Comprehensive Principles and Practices.

CITY: STATE: PUBLSHER. 5. Barbisch, DF & Koenig, KL. Understanding surge capacity: essential elements. Acad Emerg Med 2006:

13: 1098-1102.6. CIA-The World Factbook. Israel. Available:

https://www.cia.gov/library/publications/the-world-factbook/geos/is.html. Accessed on January 15, 2010.

7. Peleg, K & Kellermann, AI.Enhancing hospital surge capacity for mass casualty events. JAMA. 2009; 302(5):565-567.

8. FEMA. National Response Framework. Available: http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf. Accessed on January 19, 2010.

9. Huddy, J. Emergency Department Design A Practical guide to planning for the future. ACEP 2002. \10. CDC. Department of Health and Human Services. Data and Statistics.11. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emergency department crowding: a point in

time. Ann Emerg Med 2003; 42(2):167-172.12. Kanji, AH, Koenig, KL, Lewis, RJ. Current hospital disaster preparedness. JAMA. 2007. 298 (18): 2188-

2190.13. Henderson, DK et al. Bethesda hospitals’ emergency preparedness partnership: a model for Tran

institutional collaboration of emergency responses. Disaster Medicine and Public Health Preparedness, 2009.3(3):168-173.

14. Pozner, CN, et al. International EMS systems: The United States: past, present, and future. Resuscitation. 2004; 60: 239-244.

15. American Hospital Association. National Health Survey 2007. 16. Agency for Healthcare Research and Quality. Reopening Shuttered Hospitals to Expand Surge

Capacity. Available at: http://www.ahrq.gov/research/shuttered/shuthospapd2.htm. Accessed on January 29, 2010.

17. Institute of Medicine. Consequences of Uninsurance. Available at: http://www.iom.edu/Activities/HealthServices/InsuranceStatus.aspx. Accessed on January 27. 2010.

Special thanks to the faculty and staff at CDHAM including Dr. Jim Holliman, Dr. Carlos Williams, Dr. Kevin Riley and Dr. J.D. Malone

and finally, from Tel-Aviv University, Israel, Dr. Kobi Peleg

Acknowledgements

Hopeful sign from a refugee camp in

Kabul

QUESTIONS ?

Thanks for Your Attention