Catastrophic care - When hospitals are overwhelmed
Paul E Pepe MD MPH FACEP FCCM, Professor of Medicine, Surgery, Public Health and Chair, Emergency Medicine, The University of Texas Southwestern Medical Centre and the Parkland Health and Hospital System (TSMC&PHHS), Dallas.
He is also Director of the City of Dallas Medical Emergency Services for Public Safety, Public Health and Homeland Security.
In traditional civilian multiple casualty incidents (e.g., bombings, explosions, rail mishaps and aircraft crashes), most patients are killed outright or survive with less serious injuries that are not immediately life-threatening. While many of these problems can eventually lead to permanent disability and death, classically, only a small percentage of patients have immediate life-threatening critical illness or injury. In light of these observations, one would surmise, intuitively, that disasters should be manageable, particularly in most urban settings where the highest risks for such traditional disasters reside. Compared with only a half century ago, most western nations now enjoy a relative plethora of modern, highly-equipped hospitals that offer specialised emergency departments (EDs), trauma centres and intensive care units.
Despite this optimistic view, on a day-to-day basis, most hospitals lack bed capacity and are severely understaffed, especially in their EDs and ICUs. Hospitals are facing increasing volumes of more acutely ill and injured patients and these daily challenges contribute to delays in patient care and they often limit the efficacy, efficiency, and continuity of emergency care operations. It is clear therefore that with such day-to-day over-crowding, delays and inefficiencies will be exacerbated further by the sudden influx of large patient volumes that may occur as the result of natural, unintentional or intentionally-created disasters. In addition, for a multitude of reasons, compared with 50 years ago, the threat of catastrophic disasters continues to escalate dramatically, along with the numbers of persons who will be affected, both directly and indirectly.
Worse yet, recent experiences and evolving threats demonstrate that our modern, sophisticated medical care facilities may be totally inadequate for managing disasters in the future. Underscoring this point was the recent sudden displacement of tens of thousands of persons with chronic serious illnesses and special medical needs in the wake of Hurricanes Katrina and Rita that struck the southern tier of the United States (US). Likewise, the recent experiences with SARS and the threat of worldwide pandemic also make it clear that our currently overwhelmed resources may very well be crippled under such circumstances. This concern will be especially true if medical care workers become ill, as they were with SARS.
Although it has been speculated that the past smallpox case fatality rate of 30% might be mitigated by modern medical care, it does not take into account the numbers of patients requiring critical care to produce that life-saving. Despite modern care facilities, a dramatic genetic shift in influenza strains accompanied by brisk worldwide dissemination in the modern age of rapid, mass world travel, would be insidious. Entire populations could be affected in a matter of months, or even weeks. Even if only 1% of a population required critical care, our healthcare facilities and providers would be overwhelmed (e.g. 10,000 critical care beds for a population of 1 million). The insidious consequences of nuclear explosions are, in many respects far more unimaginable.
The need to further evolve responses to major disasters
Traditionally, in most venues, planning for increases in patient volumes have included several strategies such as: 1) cancelling elective procedures and treatments; 2) expedited, early discharge of hospitalised patients who have more stable medical conditions, and 3) reconfiguration of patient holding areas to become temporary patient care wards. Unfortunately, the recent imperatives to increase use of out-patient treatment centres, minimally invasive surgical techniques, and early hospital discharge have only served to drastically reduce the use of hospital in-patient wards and therefore their availability for surge capacity.
Immediately following the August 2005 landfall of Hurricane Katrina, and without the benefit of previous planning, alternate-site medical surge facilities (convention centres and sports arenas) had to be implemented, within a matter of hours, to provide timely care for thousands and thousands of Gulf Coast evacuees in settings far from the destroyed sites. On average, these centres, spread across the southern US, Texas and other more distant sites, managed to care for twice as many patients each day as they would have at their already-overwhelmed emergency departments and ICUs. Few of these patients had their existing medications, medical records or even the telephone availability of their own healthcare providers. Furthermore, since this surge population was comprised of elderly displaced citizens, underserved segments of society, and individuals with special needs, it created unanticipated, novel stresses on the impacted healthcare community. In turn, healthcare practitioners, administrators, legislators, and regulators will now have to formally consider new models for disaster medical care.
Accepting a sufficiency of care model
The fundamental change needed in healthcare delivery during episodes of excessive demand in an environment of limited resources is the implementation of a ‘sufficiency of care model’. This is distinctly different from the usual tenants of the ‘standard of care’ model that is based solely on the premise of a minimal acceptable level of quality healthcare delivery. For example, the use of simple cots and bag-valve devices instead of approved hospital beds and ventilators, or limitations in climate control and altered provider-to-patient ratios, are but a few of the many elements that may require modification during periods of excessive patient care demand in a resource-constrained environment. In these cases, licensing, regulatory, or accreditation standards, however reluctantly, must be modified.
For example, many plans for pandemics propose the concept of home-based care, utilising either indirect medical care via electronic means or direct medical care via roaming, community-based medical teams. Healthcare facilities and normally-compulsive healthcare providers will likely be reluctant to implement the necessary strategies as outlined. However, during conditions of extreme surge demand, the clinical paradigm of doing the greatest good for the greatest number of potential survivors must drive decision-making.
Examples of entry, expand and exit strategies
In addition to sufficiency of care, there are many potential strategies for handling significant surge capacity demands. These strategies may be categorised into three general groups: entry, expand and exit. ‘Entry’ strategies refer to reducing or limiting entry of surge patients to hospitals through strategies such as cancelling elective admissions or out-patient procedures and establishing surge capacity facilities outside of the traditional hospital base. The inclusion of specialty facilities such as long-term acute care, nursing home and other rehabilitative facilities is potentially useful. Effective risk communication is also an important ‘entry’ factor. The ability to deliver succinct, timely public information messages through the media may significantly reduce unnecessary or untimely arrival of large numbers of the ‘worried well’ in the general population. Even preventive recommendations for cough etiquette, compulsive hand cleansing and self-quarantine can be very useful. Detection and medical decontamination capabilities are also a vital ‘entry’ strategy in terms of limiting facility closure due to contamination.
Strategies that increase internal facility capacities and capabilities are considered to be part of the ‘expand’ group. This would include the creation of alternate treatment areas by increasing the in-patient bed capabilities through the use of hallways, auditoriums, or out-patient beds. Other ‘expand’ strategies include pre-designated assignments for various patient types to various destination hospitals, as well as accessory, off-site caches of immediately accessible supplies, scalable personnel rosters, and many of the traditional ‘disaster plan’ initiatives discussed previously. In the long term, hospitals may need to re-consider architectural designs and significant infrastructure changes.
Early, rapid patient discharge is an example of the strategies to be implemented in the ‘exit’ group. Transferring post-operative patients to facilities that lack operative resources but possess post-operative care capabilities is another. Limiting care services to essential services only is also an ‘exit’ strategy. Other strategies include: delayed orthopaedic fracture management, delayed primary closure of wounds, and modified intensive care admission criteria. Caution is warranted in the strategy of limiting care when inevitable services are delayed. During prolonged periods of surge demand, patient arrival volumes will be cyclic. The next wave of arrivals is likely to be compounded, or exponentially increased, as patients previously delayed will continue to seek access to healthcare.
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