Biosecurity and Bioterrorism. Volume 6, Number 4, 2008 © Mary Ann Liebert, Inc. DOI: 10.1089/bsp.2008.1029
A catastrophic emergency, such as a large-scale bioattack, a natural disaster, or a severe influenza pandemic, will likely overwhelm hospitals and other traditional healthcare facilities. Hospitals will need to increase their surge capacity, but other measures may be required for communities to meet the increased demands that will be placed on the medical system.1 One way to meet this need may be to provide medical care in alternative care facilities, such as mobile field hospitals, schools, shuttered hospitals, stadiums, arenas, or other available facilities. The federal government, state and local public health agencies, and the Joint Commission all have called for hospitals and communities to make plans for alternative care facilities for the delivery of medical care in a disaster or a severe pandemic.
This approach sounds logical and straightforward, and there is a long history of providing medical care in nonhospital settings dating back to the Civil War, the influenza pandemic of 1918, and, more recently, in the aftermath of Hurricane Katrina.2,3 But would this strategy be helpful if a 1918-like pandemic overwhelmed our medical system today? What would be the most effective concept of operations for an alternative care facility in an influenza pandemic? What would be the scope of care and the types of patients best treated in this nonhospital setting? What type of facility would be appropriate, what equipment would be required, and, most important, who would take care of the patients in such a facility at a time when medical staff in hospitals, clinics, and emergency departments will be stretched thin by increased numbers of patients and absenteeism among their ranks?
As Cinti and colleagues report in this issue of the journal,4 defining the concept of operations, the scope of care, the equipment requirements, and the roles and responsibilities of staff in a nonhospital setting in a pandemic is much more difficult than it initially appears. They report on their efforts over a 3-year period to plan for an alternative care facility in an offsite setting near the University of Michigan Hospital System—a large, tertiary care academic medical center—and the lessons learned from 2 functional exercises used to evaluate the operation of this facility. They chose to design and test a model for an alternative care facility that would function as an inpatient unit for 200-250 influenza patients. Their facility, called an acute care center (ACC), was located in a campus recreation building near the medical center and was designed to provide care for noncritical patients, including administering IV fluids, IV and oral antibiotics and antivirals, and oxygen and breathing treatments but not mechanical ventilation or high levels of oxygen. The facility would be activated when the medical center neared 120% capacity. Part of the unit was designed to function as an overflow hospital medical floor, and another section was dedicated to palliative care for the terminally ill.
The functional exercises they carried out quickly revealed some of the important problems with the concept of operations and the scope of care they planned to provide. The building chosen did not have adequate bathroom facilities or air conditioning. The admission process initially included nursing triage and medical screening, but they found that this diverted resources and slowed down patient movement into the ACC. In the second exercise, this process was modified to allow direct admission to the center, but the success of this approach was predicated on discouraging patients from self-presentation through the use of public announcements, which may or may not be realistic. Communication within the ACC and with outside entities was problematic despite redundancy in equipment. Designing and testing an oxygen delivery system took a great deal of effort, and it was concluded that a larger system would have to be purchased for this facility at a cost of about $50,000.
An effective staffing strategy proved to be the most difficult problem to address. The initial concept was to rely on emergency medicine physicians and nurses, but it became clear that emergency department staff would be unavailable during a true pandemic because they would be needed in EDs and urgent care centers. The plans for extensive oxygen therapy necessitated including more respiratory therapists. Palliative care and fatality management resources would likely be needed in both the medical center and the ACC, and it was concluded that patients requiring palliative care, who are likely to be more seriously ill, would be more appropriately cared for in the hospital and not the ACC. They also considered using a staffing plan that relied on hospitalists and resident physicians, but the same issue of the competing demands of the hospital on their depleted ranks in a pandemic is likely to emerge were this staffing model to be used.
In 2006, after reviewing pandemic influenza plans from the U.S., Canada, the UK, and Hong Kong, our group identified several uses for alternative care facilities: (1) as overflow hospitals providing a full range of care; (2) for patient isolation and an alternative to home care for infectious patients; (3) for expanded ambulatory care; (4) for provision of care to recovering noninfectious patients; (5) for limited supportive care for noncritical patients (as in the plan considered in the Cinti et al. report); (6) as primary triage and rapid patient screening centers; and (7) for quarantine.5
Because of many of the same staffing and logistical issues uncovered in this report of the Michigan experience, we concluded that hospitals, rather than alternative care facilities, should remain the focal point for all critically ill patients. Our view was that alternative care facilities would be most useful as primary triage and screening sites for initial assessment and/or as sites for providing limited supportive care for suspected influenza patients. Medical care for large numbers of sick patients, including oxygen delivery with or without mechanical ventilation, would be more feasible to deliver in hospitals than in alternative care facilities, although hospitals would need to make major adjustments in operations, including changing staffing patterns; using converted clinics, flat spaces, and diagnostic suites within the hospital structure; and more aggressively increasing surge capacity to 150% to 200% of normal capacity, rather than switching to use of alternative care facilities at an arbitrary 120% of capacity trigger.
The report by Cinti and colleagues is a valuable, clear view of the details and challenges inherent in planning for an alternative care facility. Work like this, reporting actual efforts to plan and test such facilities, adds to our understanding of the issues and should prompt a reevaluation of assumptions about the role of alternative care facilities in the care of sick patients during a pandemic.
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Franco C, Toner E, Waldhorn R, Maldin B, O’Toole T, Inglesby TV. Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror 2006;4(2):135-146.
Cinti S, Wilkerson W, Holmes JG, et al. Pandemic influenza and acute care centers: taking care of sick patients in a nonhospital setting. Biosecur Bioterror 2008;6(4):335-344.
Lam C, Waldhorn R, Toner E, Inglesby TV, O’Toole T. The prospect of using alternative medical care facilities in an influenza pandemic. Biosecur Bioterror 2006;4(4):384-390.