The devastation of American cities caused by Hurricane Katrina, combined with World Health Organization warnings about the possibility of an influenza pandemic and a continued heightened awareness of potential terrorist attacks, raise new concerns about the ability of the healthcare system to effectively respond to disasters. During crises, healthcare organizations must act quickly to meet the demands of their communities.
Makeshift—or “surge”—facilities provide care for the surging number of patients until normal operations can resume. These care sites can’t be thought of in traditional terms of brick-and-mortar hospitals. Instead, surge facilities protect brick-and-mortar facilities from a surge of patients who do not require acute intervention, or to protect brick-and-mortar facilities attempting to recover from damage.
Hurricane Katrina demonstrated, however, that even those communities with comprehensive plans for emergency response face considerable difficulties when major parts of infrastructure for medical care are significantly damaged. If almost all healthcare capabilities in a neighborhood, city, or even an entire region are damaged and the water supply, sewage system, and electricity are affected, how do communities cope with the surge? Such destruction also may force surge facilities to continue operations for weeks or months—instead of the hours or days that have typically been contemplated in the past.
The challenge for healthcare organizations is to work with local, state, and federal officials to develop comprehensive plans for meeting medical needs during community-wide emergencies. This article explores the obstacles and strategies to developing comprehensive, community-wide emergency plans, how healthcare and community leaders can understand the role of surge facilities, and how to establish these critical links to maintaining care. The goal of emergency planning is mitigation, preparedness, response, and recovery. Surge facilities may have a role in most of the components of emergency planning.
Planning for Emergencies
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the federal government have long required thorough accreditation standards and Conditions of Participation, respectively, in order to help hospitals plan for emergencies. JCAHO, which has been actively involved in disaster preparedness for more than 30 years, increased its focus on emergency management in January 2001—nine months prior to the September 11 attacks on New York City and Washington, D.C. It has since worked even more closely with emergency management experts and healthcare organizations to make this issue a priority.
The resulting modified accreditation standards and overall guidelines developed by expert consensus reflect the need for hospitals and other healthcare organizations to be involved in community-wide planning, in addition to planning for an emergency at that particular institution.
Develop Emergency Management Plans
JCAHO’s Management of the Environment of Care (EC) standards call on hospitals to develop an emergency management plan that—among other requirements—ensures an effective response to emergencies through the implementation of the plan and execution of the plan by conducting emergency management drills. Hospitals also must participate with the community to establish priorities among potential emergencies, define the organization’s role in the community’s emergency management program, and link with the community’s command structure. (Note: EC.4.10, which addresses the entire topic of emergency management, also calls for hospitals to conduct a hazard-vulnerability analysis, which is discussed below.)
While recent national attention has focused on the emergencies created by Hurricane Katrina and the perceived lack of rapid federal response, JCAHO standards emphasize the need to consider a variety of natural or manmade events that suddenly or significantly disrupt the environment of care, disrupt care and treatment, and change or increase demands for the organization’s services.
Use an All-Hazards Approach
In order to plan for and respond to a variety of emergencies, hospitals must conduct a hazard vulnerability analysis (EC.4.10). This analysis is best done with community leadership to ensure that there is continuity at all levels of planning. This formal process for conducting a hazard vulnerability analysis has been a JCAHO requirement since 2001, although hospital standards previously had called for planning to address a variety of disasters.
The change in requirements simply provides a method—the hazard vulnerability analysis—for a hospital to focus attention on the disasters or catastrophes likely to have an effect on its operations. This analysis should be a dynamic document that is regularly reviewed and revised to reflect the latest information on the probability of events or threats and their effects.
By considering a complete list of potential hazards, hospital leaders can determine the effects that specific types of emergencies will have on their facility and the community. The hazard-vulnerabilities analysis also should take into account the fact that an emergency may have a cascading effect. Example: The hurricane in New Orleans did not initially cause as much damage as feared, but breaches in the levees from the hurricane’s rains caused massive flooding that resulted in nearly complete communications failures, loss of power, transportation breakdowns, and so forth.
After compiling as complete a list as possible of potential emergencies, hospital leaders [must work] with the community to prioritize the list considering likelihood and effect of such an occurrence. Then, the areas of vulnerability that most demand community and organizational attention can be addressed. Dealing with these issues requires hospitals to work with local and regional government agencies, emergency responders such as local fire and police departments, and other hospitals and healthcare organizations in the community.
By working together with other healthcare professionals and with community experts charged with responding to emergencies, hospitals can ensure that the full spectrum of likely emergencies and contingencies has been considered. The collaboration also allows the many organizations involved to understand their role in a larger crisis and anticipate how other partners will respond. An emergency affects the entire community, making it important for hospitals and other organizations to avoid “silo” approaches that leave each component of the community vulnerable if they are standing alone.
Recent experiences have shown that community-wide emergency management plans should include preparations to establish temporary healthcare facilities when a major disaster—or series of disasters as occurred in New Orleans—creates a surge of patients or cripples hospitals and forces patients and staff to evacuate. When an emergency occurs, the demands placed on a hospital escalate beyond the normal level of services required. Surge facilities provide care when permanent facilities exhaust their capacity or cannot operate because of damage or other conditions. Surge facilities also act as a buffer for lower acuity patients to protect the scarce resources of the operating hospital.
Some surges are such that a hospital can meet community needs within its own walls. For example, a hospital may be able to handle a commuter train accident that brings 30 injured patients through its doors. But, in many instances, economic factors operating over the past decade mean that hospitals are already operating at capacity and have little room for surge. Remember that “room” for surge is not just the number of beds, but the number of beds that can be adequately staffed and supplied. Where would patients already in an at-capacity organization go if a significant number of new patients—whether 30, 300, or 3,000—need treatment?
This scenario occurred during the aftermath of Hurricane Katrina when the Louisiana Department of Health and Hospitals (DHH) determined that it needed to establish an acute care surge facility at the Louisiana State University Pete Maravich Assembly Center in Baton Rouge because existing hospitals in the area would be inundated with patients.1
This recent example of coordination shows the imperative for hospitals and health officials to plan with community organizations to increase surge capacity at temporary locations. Off-site locations, which may be at facilities as diverse as civic centers, schools, or even veterinary hospitals, must be part of community-wide emergency management plans.
While there is general consensus about this idea and the need for a community-wide response plan to emergencies, a recent JCAHO examination of the issue reveals that there is no single model available today for surge facilities, but what is developing is a series of guidelines based on experience.2 Communities should study available examples of organizations that have faced with surge situations and then create contingency plans after assessing potential community needs and available resources.
While it is important for a hospital to take the initiative to consider surge capacity planning, no single hospital can by itself be expected to be able to address a large-scale emergency that sends large numbers of patients in search of healthcare. Securing temporary facilities, adequate staff, and critical supplies, equipment, and pharmaceuticals takes the concerted efforts of healthcare organizations, communities, and government agencies.
Hospitals must work with organizations such as hospital districts, state and county departments of health, the National Guard, various agencies charged with homeland security, medical schools, and so forth to plan for and operationalize surge capacity.
For example, the Commonwealth of Massachusetts maintains a statewide system to allocate surge capacity by identifying empty beds and distributing patients among existing hospitals.3 The very declaration of an emergency should automatically trigger government intervention necessary for surge capacity on the local, state, or federal level, as appropriate.
Components of Surge Facilities
Communities and healthcare planners preparing responses to a crisis must be innovative when considering how to accommodate a surge of patients. Surge facilities commonly fall into one of the following basic categories:
- Shuttered hospitals or closed wards;
- Facilities of opportunity, such as schools, hotels, conventions centers, and other types of buildings near a hospital that can easily be adapted during emergencies to treat unusually large numbers of patients;
- Mobile medical facilities; and
- Portable facilities.
Planning for locations is important, but it is important to remember that a surge facility is not so much a place as it is a capability. Wherever a surge facility is located, it must be equipped and staffed adequately. Beyond planning for the physical location of a surge facility, hospitals and communities must consider the other factors that will affect the ability to deliver care.
For example, will essential staff be available to treat patients? What might constitute essential staff? Surge capacity plans also must take into account the need to communicate with staff during times of crisis, transport staff, and make accommodations for staff who may be facing their own personal emergencies at home (i.e., damage to their homes or vehicles, concern for vulnerable family members, and so forth).
Creating plans to assist staff and their families during a crisis will ensure that vital members of the emergency response team are able and willing to perform their duties. The U.S. Department of Defense’s Modular Emergency Medical Stem can aid efforts to determine the number of staff necessary to effectively operate a surge facility. Other methods for securing the needed number of staff during an emergency include qualified volunteers from organizations such as the Medical Reserve Corps program, Civilian Emergency Response Teams, Disaster Medical Assistance Teams, health professional students, reserve military health providers, paramedics, and midwives. In addition, communities may consider training a pool of volunteers who could assist with surge healthcare needs by providing nonmedical support to healthcare providers.
Other critical considerations for hospitals and communities planning for surge capability include:
- Medical supplies and equipment: The Centers for Disease Control and Prevention (CDC) can provide necessary supplies through its Strategic National Stockpile program, but delivery may take days, as Hurricane Katrina demonstrated. Other potential sources of supplies, such as physician offices and medical supply houses, should be researched.
- Pharmaceuticals: Sufficient inventories to last for several days in the event of an emergency will help prevent problems, as will setting up contracts with pharmaceutical suppliers that take effect only during an emergency.
- Communication: The September 11 terrorist attacks and Hurricane Katrina demonstrated the fallibility of cellular phone and radio communications; multiple forms of communication (i.e., cellular, two-way radio, pagers, satellite, two-way phones, and so forth) are necessary to ensure that if one method fails, another is available.
- Data sharing: Hospitals must plan for how they will coordinate with local, state, and federal health agencies to conduct necessary work to care for patients.
- Sufficiency of care: During emergencies, surge facilities maybe able to treat each patient only until he or she can be transferred to an organization that provides an ideal level of care. Plans for surge capacity should take this possibility into consideration so agreements can be made in advance with other hospitals, while also ensuring that patients who need specific monitoring or ventilator assistance, for example, can be cared for until transferred.
Surge Facilities and the Joint Commission
The fact that surge facilities were forced to provide care for such an extended period of time following Hurricane Katrina has prompted the Joint Commission to consider establishing standards for this unique form of a healthcare organization. The standards might require surge facilities to comply with basic safety and quality expectations and help to ensure the public that care given at these temporary facilities is adequate. JCAHO is working on the standards with healthcare organizations that are developing plans for surge facilities so that any new requirements can be implemented quickly and with minimal cost.
Surge Facility, Emergency Management Resources
While healthcare leaders agree on the need for comprehensive emergency management plans, which include surge capacity, consensus on the necessary components and assigned accountabilities has been scarce. Hospitals have been left to use federal or state requirements, Joint Commission standards, and guidance from hospitals associations. The Joint Commission has worked over the past several years with experts in the public and private sectors to bring broader agreement and guidance on these issues.
Detailed information about what surge facilities are, the kind of planning that these alternate care sites require, how they can be set up, and who should be responsible for their establishment and operation is available through the JCAHO publication, Surge Hospitals: Providing Safe Care in Emergencies (available at www.jcaho.org/about+us/public+policy+initiatives/surge_hospital.htm). This Web-based publication describes the different types of surge facilities, such as shuttered hospitals, closed wards in existing hospitals, and mobile facilities, and the design considerations for each. It also explores the challenges of planning for, establishing, and operating surge facilities, such as obtaining sufficient staff, supplies and equipment, and providing safe care.
Lessons learned from healthcare organizations following Hurricanes Katrina and Rita along the Gulf Coast and into Texas are also included. These case studies specifically look at a surge facility established by the Harris County Hospital District at Reliant Arena in Houston, a surge facility at the Dallas Convention Center that treated more than 4,000 hurricane evacuees in during a single week, the Louisiana State University acute care facility mentioned earlier in this article, a field hospital set up in the site of a former retail store, and a healthcare shelter established in a Texas veterinary hospital to care for nursing home residents, pediatric burn patients, handicapped children, and home-health-care patients.
Beyond the very specific issue of surge facilities, JCAHO offers guidance on community-wide emergency management planning:
- Standing Together: An Emergency Planning Guide for America’s Communities provides detailed information about steps that communities must take to prepare for and successfully respond to major local and regional emergencies. The free planning guide, published in 2005, is the result of a two-year project that drew upon the expertise of front-line emergency responders, emergency preparedness planners, and public health and healthcare organization leaders. It’s available at www.jcaho.org/about+us/public+policy+initiatives/planning_guide.htm.
- Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems provides recommended strategies for developing community-wide preparedness. This free 2003 white paper is available at www.jcaho.org/about+us/public+policy+initiatives/emergency.htm.
The serious shortcomings of the nation’s emergency management planning capabilities were made evident by the events surrounding Hurricane Katrina. Hospitals, along with other types of healthcare facilities, must take an active role in all community-wide emergency planning activities to mitigate the effects on patient care. Communities and the healthcare organizations within them must plan to operate largely on their own for several days or even longer following a disaster. Surge facilities are a major component of these plans. Hospitals must prepare for the possibility that their buildings could be too damaged to function during, as well as after, a disaster.
Developing plans that allow for adequate patient care during emergencies requires hospitals and the communities that they serve to overcome barriers such as assigning responsibilities for planning, how to fund emergency readiness efforts, the specifics necessary to create effective planning and response processes, and how to coordinate with state and federal emergency management resources. This broad-based approach will help healthcare planners consider the challenges associated with major emergencies and develop appropriate plans to respond to such crises. TH
Cappiello is the vice president for Accreditation Field Operations at JCAHO. He is responsible for management of accreditation processes including survey functions, surveyor education, standards interpretation, staff education and training, and accreditation process improvement.
Contact the Joint Commission at www.jcaho.org or call (630) 792-5000.
- Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
- Surge Hospitals: Providing Safe Care in Emergencies. Joint Commission Resources, Oakbrook Terrace, Ill., December 2005.
- Use of a Former (“Shuttered”) Hospital to Expand Surge Capacity. Available at www.ahrq.gov/research/shuttered/shuthosp1.htm. Last accessed March 2, 2006.