Surge Capacity

     The attacks of 9/11, the anthrax incidents that followed, SARS, Hurricanes Katrina and Rita and other events have shaken our nation's healthcare infrastructure, including EMS systems. Every day we face the possibilities of further disasters, outbreaks and terrorist acts. As first responders to incidents of all sizes and varieties, EMS systems are heavily impacted by these events. We can easily be thrown into chaos through a lack of ability to respond.

     The populations we serve remain vulnerable because of our lack of surge capacity. Most EMS systems are stretched to their limits on a daily basis, and the additional stress of an unexpected surge from a catastrophic event can be overwhelming. Without proper planning, systems can fail. So what should EMS know about surge and surge capacity? How does it impact us, and what can we do about it?

SURGE CAPACITY

     A surge is a sudden or unexpected increase in patient volume that has the potential to severely challenge or exceed the capacity of the healthcare system. The American College of Emergency Physicians (ACEP), in a 2004 policy statement entitled Health Care System Surge Capacity Recognition, Preparedness, and Response, defines surge capacity as "a measurable representation of 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." Surge capacity can also be defined as the maximum delivery of services a system can provide if all its available and potential resources are mobilized.

     Surge capacity is a necessity. This was emphasized in the Institute of Medicine's 2006 Emergency Medical Services at the Crossroads report: In its recommendations for achieving its vision of a 21st century emergency care system, the IOM targets enhancing the disaster preparedness of EMS systems through increased funding and training of personnel.

     A number of states have addressed EMS surge capacity and developed plans. One of the most comprehensive is the EMS Surge Capacity Planning Kit released in 2006 by the Georgia Division of Public Health, which includes planning worksheets for personnel and other resources, sample memoranda of understanding to utilize and various appendixes, including scenarios and a planning kit evaluation. Another example is the North Dakota Department of Health's Public Health and Medical All Hazards Plan, which, among aspects such as prepositioning of medical resources and hospital surge capacity, references EMS in regard to personnel training, development of mutual aid agreements, identification and use of nontraditional transportation (e.g., school buses), creation of regional equipment caches and development of regional response teams.

SYSTEM REALITIES

     Most EMS systems run at or above full capacity on a daily basis. Long waits for ambulances are common in many parts of the country. In some cases, patients with high-priority medical complaints must wait for available ambulances to be dispatched. This problem is compounded by full-capacity emergency departments diverting ambulances and long waits to turn over EMS patients to ED staff. Such circumstances are hard on personnel and potentially hazardous to patients. At the same time, we're dealing with understaffed EMS systems that are trying to find and keep employees, limited budgets and a shortage of providers to hire in many parts of the country. As well, demand for EMS continues to increase in many areas. The aging of our population, fragmentation of healthcare and lack of places to go besides EDs for acute medical issues will continue to result in increasing call volumes and turnaround times in many systems.

     These are our day-to-day realities. So what happens when—during, say, the busiest time of the busiest day of the week, with all of our resources deployed—the unthinkable occurs? It could be any type of large-scale incident: terrorist attack, bridge collapse, building fire or multi-vehicle crash. How will an EMS system react? Will it be able to react at all? Where will it find that needed surge capacity?

     There are no easy answers to these questions. The answers will also be system-dependent. Rather than looking outward for solutions, EMS systems must carefully examine their own internal organizational strengths and weaknesses. We've seen time and time again that waiting for state and federal assets to solve immediate problems in large-scale emergencies simply isn't realistic. Therefore, EMS systems must make heavy investments in their own personnel, policies and equipment. This means making arrangements in advance, establishing MOUs and solid mutual aid agreements. It means stockpiling key equipment. Older vehicles no longer in service can be transformed into MCI vehicles, loaded and ready to go with the supplies staff will need to care for large numbers of patients. Larger systems may need to invest in additional equipment such as triage tents and MCI command vehicles to aid in managing large-scale incidents. These preparations can also entail taking equipment you may have previously discarded and keeping it around for surge events.

     But surge capacity not only means amassing stuff, it also means making more of the resources you have now. Providers need to be well trained and supervised to function efficiently. Training should include an emphasis on multicasualty scenarios: rapid and effective triage techniques (including the use of tags, tarps and other system-specific adjuncts), field treatment, communications and interagency cooperation.

SURGE CAPACITY PLANNING

     The concepts of surge capacity and what your agency, in concert with mutual aid agencies, hospitals and public health entities, will be doing during an incident where surge capacity is required needs to be consistently drilled under a variety of conditions. A critical element of this planning is your supervisory staff being well versed in the incident command system and their own roles and responsibilities in a major incident, as well as how their roles relate to others in the larger incident command structure. This can be done by ensuring that staff employ ICS in their day-to-day activities, so they'll be comfortable with it during a major incident.

POLICY ISSUES

     Policy issues likely to arise during a crisis must be considered and frequently revisited. These include how the communications center will handle the increase in call volume, and what happens if call-takers can't keep up or the system fails. Details related to calling in off-duty personnel and holding over on-duty employees should be resolved before an incident occurs.

     For EMS systems with unions, labor representatives are a necessary inclusion in the planning process. Discuss with area hospitals an appropriate means for distributing patients based on the hospitals' capacities and resources. Mutual aid agreements with other EMS systems should be established and interagency drills conducted so that issues such as triage systems, overall interoperability and communications and command structures are worked out in advance.

SUPPLIES

     To meet surges, EMS systems must have adequate supplies, especially for BLS care. These include stockpiles of backboards and other spinal immobilization devices, trauma dressings, splints and blankets. Ample quantities of disposable gloves, gowns, facemasks and disinfectants should be available for response to infectious outbreaks, as well as appropriate protective clothing and respirators for chemical threats. There should also be a mechanism in place to restock ambulances as they run out of equipment. This can occur in multiple locations.

     In larger systems, strategies may include predeployment of caches at several locations as a way to minimize resupply times and keep transport vehicles in service. Most systems have at least some reserve vehicles to meet routine needs; however, if there's a marked increase in patients needing transport, this reserve may not be sufficient. Because purchasing additional backup vehicles may be cost-prohibitive, work at identifying alternative means of transportation, such as the use of local transit buses for lower-acuity patients. Highly regarded systems like Boston EMS have utilized this solution effectively.

CONCLUSION

     It's critical to remember that surge capacity in EMS systems is about more than just having an extra few ambulances or the ability to recall personnel. It is about having a plan and a system in place, and being well-versed in them. Experience has shown the need for collaboration between EMS systems, hospitals, public health systems and health departments to build a realistic approach to surge capacity. The process involves needs assessments, curriculum development, training and outreach. This could mean thinking way outside the box—a paper published last summer in the American Journal of Disaster Medicine, for instance, suggested enlisting untapped medical resources like dentists to complement more traditional emergency responders.

     Developing surge capacity is easier said than done. It involves a significant commitment of money and time, public support and political buy-in. The role EMS plays in disaster planning and response is tremendous—and one that every member of the EMS community must be aware of and speak out about to our local, state and federal leaders. EMS leaders must be prepared to demonstrate that surge capacity isn't just an EMS issue; it's a community issue. Developing it will ultimately benefit the public under busy conditions and in the case of disasters that threaten survival.

EMS-Specific Challenges

     An April 2007 CDC report entitled In a Moment's Notice: Surge Capacity in Terrorist Bombings discusses some of the challenges EMS will face in responding to a terrorist bombing. Clearly, providers will face these same challenges when responding to most mass-casualty incidents requiring surge capacity. They include:

     • Personal protection

     Currently, there is no unified approach to protect rescuers or stage a response. When do appropriate concerns for scene safety and the potential for secondary explosive devices hinder the initial response? Who determines appropriate levels of PPE to be donned by personnel during a response?

     • Decontamination

     Though treatment will be delayed, decon may be imperative. Uniform policies and protocols for personnel and patients should be established for all scenarios.

     • Incident command

     Interoperability between prehospital and hospital command structures is a challenge. This manifests not only in the technical aspects of radio interoperability, but also in the interdisciplinary aspects of communications plans. A unified incident command structure must be incorporated into healthcare and EMS practice. Further, EMS must be designated as part of the field response command structure.

     • Field triage

     Although multiple triage systems are used across the country, there is no agreed-upon methodology for field triage during disasters.

     • Transportation methods

     Even the best-prepared systems might experience issues with patient transportation during disasters. Alternative transportation methods can be utilized for stable patients.

     • Destination decisions

     Determining appropriate destinations in the aftermath of a large event may be difficult, especially if the initial scene size-up has not been performed.

     • Hospital evacuations

     Whenever EMS transfers patients from hospitals to free up acute care beds, normal EMS functions are adversely affected.

     • Sustainability of operations

     Providing personnel with needed support (physical and emotional) and maintaining facilities, equipment and supplies after an event is an ongoing challenge.

Raphael M. Barishansky, MPH, MS, CPM, is director of EMS for the Connecticut Department of Public Health. A frequent contributor to and editorial advisory board member for EMS World, he can be reached at rbarishansky@gmail.com.

Jessica Langan, BS, MPA, has been involved in emergency medicine for eight years, the last five as a paramedic in New Jersey. She also conducts WMD training for the Department of Homeland Security.