Surge CapacitySurge CapacityA Conceptual FrameworkA Conceptual Framework

Overview of the Science of SurgeOverview of the Science of Surge

Professor Dr. Kristi L Koenig, MD, FACEPProfessor Dr. Kristi L Koenig, MD, FACEPDepartment of Emergency MedicineDepartment of Emergency Medicine

Co-Director, EMS and Disaster Medical Sciences FellowshipCo-Director, EMS and Disaster Medical Sciences FellowshipDirector of Public Health PreparednessDirector of Public Health Preparedness

University of California at Irvine, School of MedicineUniversity of California at Irvine, School of MedicineOrange, California, USAOrange, California, USA

Surge CapacitySurge Capacity

What is it?What is it?– New terminologyNew terminology

A conceptA concept No standardized definitionNo standardized definition Difficult to describeDifficult to describe

– State of California 2007State of California 2007– Our simple approachOur simple approach

Three componentsThree components– The 3 S’sThe 3 S’s

Surge CapacitySurge Capacity 9 May 2007 9 May 2007

Ability of the Ability of the emergency-care systememergency-care system to to mobilize additional resources and mobilize additional resources and personnel quickly to deal with a sudden personnel quickly to deal with a sudden influx of influx of patientspatients

A New Concept for Surge CapacityA New Concept for Surge CapacityCo-AuthorsCo-Authors

Professor Dr. Tareg Bey, MD, FACEPProfessor Dr. Tareg Bey, MD, FACEP– Director of International Emergency MedicineDirector of International Emergency Medicine– University of California Irvine, School of MedicineUniversity of California Irvine, School of Medicine– Department of Emergency MedicineDepartment of Emergency Medicine

Donna F. Barbisch, DrHA, MPHDonna F. Barbisch, DrHA, MPH– Director, Institute for Global and Regional ReadinessDirector, Institute for Global and Regional Readiness– Retired Army Reserve 2-Star GeneralRetired Army Reserve 2-Star General– Washington, DC, USAWashington, DC, USA

Surge CapacitySurge CapacityWhen do you need it?When do you need it?

Required whenRequired when– Patient Patient care needs exceed care needs exceed resourcesresources– At a given point in timeAt a given point in time

Uncommon to exceed health and Uncommon to exceed health and medical resources within the United medical resources within the United StatesStates

550,000 deaths in US in less than 10 months4,000 deaths per day in the month of October

1918 Influenza Pandemic1918 Influenza Pandemic

Modern TimesModern TimesLack of Resources?Lack of Resources?

29 disasters in the United States29 disasters in the United States– 6% supply shortages6% supply shortages– 2% personnel shortages2% personnel shortages

Lack of a Lack of a management systemmanagement system to organize to organize available resourcesavailable resources

Hurricane KatrinaHurricane Katrina– An exception?An exception?

Surge CapacitySurge Capacity

Traditional focus has been on “stuff”Traditional focus has been on “stuff”– ““Dr. Koenig, how many ventilators should Dr. Koenig, how many ventilators should

we buy for the State of California?”we buy for the State of California?”– Purchasing pharmaceuticals and suppliesPurchasing pharmaceuticals and supplies

VentilatorsVentilators Antiviral MedicationsAntiviral Medications Decontamination EquipmentDecontamination Equipment Personal Protective EquipmentPersonal Protective Equipment

Preventing spread of the bird fluPreventing spread of the bird flu

Buying “stuff” is not enough!Buying “stuff” is not enough!

Surge CapacitySurge CapacityBackground ConsiderationsBackground Considerations

Managed Care and other cost-containment Managed Care and other cost-containment strategies have increased efficiency, howeverstrategies have increased efficiency, however– ““Just-in-time” systems lack excess capacityJust-in-time” systems lack excess capacity– Crowding in emergency health care systemsCrowding in emergency health care systems– Barely effective for day-to-day operationsBarely effective for day-to-day operations

Need a Need a Surge SystemSurge System for catastrophic events for catastrophic events

Catastrophic EventCatastrophic Event

When medical and health needs When medical and health needs exceed exceed resourcesresources at a given point in timeat a given point in time

NotNot the absolute number of patients the absolute number of patients Key point is whether system resources are Key point is whether system resources are

adequateadequate

Surge SystemSurge System3 Key Components3 Key Components

StuffStuff (supplies and equipment) (supplies and equipment)

Surge SystemSurge SystemKey ComponentsKey Components

StuffStuff (supplies and equipment) (supplies and equipment) Staff Staff (personnel)(personnel)– Behavioral issuesBehavioral issues– Will staff come to work?Will staff come to work?

Surge SystemSurge SystemKey ComponentsKey Components

StuffStuff (supplies and equipment) (supplies and equipment) Staff Staff (personnel)(personnel)– Behavioral issuesBehavioral issues

– Will staff come to work?Will staff come to work?

StructureStructure (2 components) (2 components)– Physical spacePhysical space

– Management infrastructureManagement infrastructure Incident Command SystemIncident Command System

Structure

Stuff

Staff

Surge SystemSurge System3 Components3 Components

Surge SystemSurge SystemGoalGoal

““Do the most good for the most people”Do the most good for the most people”– Shift from Shift from individualindividual care to care to populationpopulation carecare

Cardiopulmonary Resuscitation?Cardiopulmonary Resuscitation?

– ““Triggers” to shift to a Triggers” to shift to a “Crisis Standard of Care”“Crisis Standard of Care”

Surge SystemSurge SystemStandard of CareStandard of Care

Standard of CareStandard of Care**– Do not “alter” THE standard of care!Do not “alter” THE standard of care!– Goal to optimize Goal to optimize populationpopulation outcomes rather outcomes rather

than individual outcomesthan individual outcomes

**Koenig KL, Cone DC, Burstein JL, Camargo CA. Koenig KL, Cone DC, Burstein JL, Camargo CA. Surging to the Surging to the Right Standard of Care.Right Standard of Care. Acad Emerg MedAcad Emerg Med 2006 Feb;13(2):195-8. 2006 Feb;13(2):195-8.

Science of SurgeScience of Surge

Academic Emergency MedicineAcademic Emergency Medicine– May 2006 Consensus ConferenceMay 2006 Consensus Conference– Proceedings published November 2006Proceedings published November 2006

www.aemj.org/content/vol13/issue11www.aemj.org/content/vol13/issue11

Surge Capacity ResearchSurge Capacity ResearchFuture DirectionsFuture Directions

Create, evaluate, improve protocolsCreate, evaluate, improve protocols Develop readiness benchmarksDevelop readiness benchmarks Metrics to determine Metrics to determine triggerstriggers to implement to implement– Simple, all-hazardSimple, all-hazard– Fiscally viableFiscally viable

Surge CapacitySurge CapacityConclusionsConclusions

GoalsGoals– Augment patient treatment capacityAugment patient treatment capacity– Improve Improve populationpopulation health outcomes health outcomes

Surge SystemSurge System– StaffStaff– StuffStuff– StructureStructure

Physical InfrastructurePhysical Infrastructure Incident Command SystemIncident Command System

Selected ReferencesSelected References Kaji A, Koenig KL, Bey T. Surge Capacity for Healthcare Kaji A, Koenig KL, Bey T. Surge Capacity for Healthcare

Systems: A Conceptual Framework. Systems: A Conceptual Framework. Acad Emerg MedAcad Emerg Med 2006 2006 Nov;13(11):1157-59Nov;13(11):1157-59

Barbisch D, Koenig KL. Understanding Surge Capacity:  Barbisch D, Koenig KL. Understanding Surge Capacity:  Essential Elements. Essential Elements. Acad Emerg Med Acad Emerg Med 2006 Nov;13(11):1098-2006 Nov;13(11):1098-11021102

Schultz C, Koenig KL. State of Research in High Consequence Schultz C, Koenig KL. State of Research in High Consequence Hospital Surge Capacity. Hospital Surge Capacity. Acad Emerg Med Acad Emerg Med 2006 2006 Nov;13(11):1153-56Nov;13(11):1153-56

Kaji AH, Koenig KL, Lewis RJ. Current Hospital Disaster Kaji AH, Koenig KL, Lewis RJ. Current Hospital Disaster Preparedness. Preparedness. JAMA JAMA 2007 Nov 14.2007 Nov 14.