HALIFAX, N.S. — Hospitals should plan on increasing their capacity by 110%–120% to cope with a major mass casualty.
An increase like that means significant changes in staffing, equipment, and prioritization of care—all of which are necessary to avoid being overwhelmed by a large disaster, Dr. Bruce Sawadsky said at the 11th International Conference on Emergency Medicine. “We might cause harm in terms of morbidity and mortality, but it's a risk we must take or we will be frozen in our ability to act,” Dr. Sawadsky cautioned.
Surge capacity is about the size of a hospital, not the size of the disaster, said Dr. Sawadsky, medical director of the Ontario Air Ambulance's Region One. “A surge can be four critically injured patients in a small-town hospital with one ventilator,” or dozens of patients in a large urban facility.
A minor surge will stress the emergency department, but can be completely handled within the hospital. A moderate surge overwhelms the hospital and mandates cooperation with other facilities in the community. A major surge, however, overwhelms the emergency medical services of the entire community and requires governmental assistance.
To cope with a major surge, hospitals should be able to expand their capacity by up to 120%, Dr. Sawadsky said. This is possible with preplanning that addresses bed space, staffing, equipment, and triage.
One of the most difficult concepts for medical workers is that levels of patient care will decline during a major surge. “In an event of this magnitude, the standard of care must be altered.”
Triage with this idea in mind will probably cause the most problems for staff, Dr. Sawadsky said. “You are trying to do the most good for the largest number of patients, and not focusing on individual patients who have little chance of a good outcome.”
Bed space will be at a premium. It's a given that patients will end up in hallways, both in the emergency department and on the floor. But finding space for everyone is possible with some planning. “Almost every hospital has wards that are not being used because of lack of staff. You can also double up ICU beds—one nurse watching multiple patients. You can use your recovery room as an intensive care unit, and use ward beds for critical care patients.”
Moving other patients will free up these beds, he said. “Have a preset plan for this, so you will know where you can send your long-term care and noncritically ill patients. It might be a nursing home or a high school gym.”
Noncritical emergency department patients also need to be dealt with. Ambulatory patients should probably be sent home; those who require minor trauma care, like a few stitches, should go to another facility.
Try to avoid moving any noncritical patients to other places within the hospital, however. “This can be a real bottleneck in getting critical care patients the care they need. Everyone who is not critically ill should go to an alternate care site.”
In terms of equipment during a surge, simplicity wins out over sophistication. “Higher volume means less sophistication. You are not going to have people with a lot of expertise to run these big sophisticated machines,” Dr. Sawadsky said.
Caches of emergency equipment in 50-patient bundles should be stored not only in the hospital, but also in multiple secure areas around the community. “There are always delays in getting to this equipment, so you need intense planning on how to move it quickly.”
During the event, a two-tier staffing hierarchy, with the more experienced staff overseeing the junior staff, will be most effective. Action cards should be drawn up during event planning, and are a great way to facilitate staff response. The cards outline exactly what every person will do, where they are to go, and who they will report to, and contain contact information for all staff.