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An old disaster medicine adage is that “all roads lead to the hospital” for the victims of natural or terrorist events. This reality is a serious issue for the medical systems within the United States and represents a critical issue for emergency physicians. The primary challenge is that the economic paradigm of healthcare has forced a “competitive model” of medical practice in which a system’s resources are scaled to the average day’s needs. No more beds or staff are available than what is typically necessary in an average day. “Just in time” inventory practices are an efficient strategy that minimizes storage costs through decreasing on-hand medications and supplies, but they allow little surge capacity. In contrast, Fire, Police and EMS are funded on the capacity model, meaning that these city services are funded for their expected needs in times of crisis, irrespective of their daily utilization. Recent funding has served to increase capacity in these civic services through homeland security grant programs, but minimal funding exists for the corresponding medical capacity expansion.

From 1992 to 2002, the number of emergency department visits increased 23% nationally, while the number of EDs decreased by 15% . The overcrowding of emergency departments is not only a cause of medical errors and decreased access but also decreases satisfaction of both patients and healthcare workers.

From a strategic perspective, overflow is currently managed by diversion of patients to less busy facilities. The weakness of the diversion strategy is that it depends on part of the healthcare system, other hospitals, to be unencumbered by their own increased volume, a situation that is increasingly rare.  The limits of diversion can be calculated and system failure predicted. For example, in Allegheny County of Western Pennsylvania (Pittsburgh), there are around 6,700 hospital beds for approximately 3 million inhabitants. On a good day, these hospital beds are 95% occupied leaving a “surge capacity” of 335 beds or enough for 0.01% of the population. Should there be a terrorist event on the scale of the 2004 Madrid train bombings (1,800 injured, 191 dead) or 2006 Mumbai train bombings (700 injured, 200 dead), the medical system would be in crisis, and may fail. Fewer emergency departments and more patients in combination with inflexible regulations constitute a “perfect storm” for emergency medicine.

Per EMTALA, hospitals are required to provide stabilization “within the staff and facility’s capabilities.” By better defining how staff and facilities are degraded by crisis events, it is possible to better define staff and facility capabilities and the strategies that work during crisis periods.

There are three basic medical surge strategies:
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Though some element of each of these strategies is written into every medical surge plan in US hospitals, EMTALA does not explicitly permit these strategies.

During a medical surge crisis, medical systems tend to function as close to normal as possible until some component fails. Once part of the system fails, the rest of the system is placed at risk. Because of their complexity and dependence on specialty and subspecialty resources, medical systems can be considered “brittle” systems. The goal for medical system’s surge planning should be to develop “graceful failure” methodologies in which the use of delay, degrade and deny strategies are coordinated and ethically and legally justified.

There are several steps in developing a “graceful failure” plan. They are:
Establishing a Threshold: When a facility needs to implement a surge strategy and which strategy to choose must be clearly defined.
Understanding Medical Utility: The potential life-saving use of medical resources changes from disease to disease and from disease to injury.
Using Medical Ethics: How to best utilize scarce medical resources means that some people may not receive care they need, expect, deserve or paid for.

By understanding these key points, surge capacity strategies can be developed in at least four stages:
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Once numerical thresholds have been established and the care objectives for each tier of response designated, detailed medical surge options can be developed. These detailed strategies alter normal medical facility functions based upon the type and scale of event and are implemented with the judgment of the medical person in charge of the response. It may be useful to think along several lines of analysis in developing detailed medical surge strategies.

These lines of analysis include:
(1) Personnel, (2) Information, (3) Tactics/Technology, and (4) Supply

Combining the basic strategies of delay, degrade and denial of care with the goals and objectives of care during increasing medical surge stress, modular surge plans of critical medical functions can be created. These strategies can be captured on a matrix (below).
 
click on image to view high res pdf
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In each cell of the matrix, any number of detailed surge options may be captured. Job actions sheets that alter individual functions can be incorporated into each cell and related to each surge option. Critical decisions on scarce resources can be identified and made based upon the greatest potential for good outcomes.

Ethical and Legal Challenges
The most concerning element of this analysis is “reverse triage” or withdrawal of care from individuals that are unlikely to survive and redistributing those resources to those more likely to survive as was done in New Orleans during Hurricane Katrina. Sorting out which resources go to which patient is ethically challenging. By laying out surge options in a modular format, ethical concerns may be identified and surge strategies developed and discussed in advance of the crisis. A modular format that maps these troubling decisions to increasing levels of overload can be used to better define staff and facility capabilities and thus be compliant with EMTALA.   

Despite our eight year investment in homeland security, the US has developed no “surge capacity” laws on how to ethically, legally and responsibly redistribute care in times of crisis.  Because of the unique role of emergency medicine in the response to medical surge issues, emergency physicians should take a lead role in the development of this area of practice, policy and law. 

For more information, the Institute of Medicine has published a guidance resource on altered standards of care during mass casualty events on its web site, www.iom.edu.

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