The Creation of New Surge Capacity

There is a saying in disaster-medicine circles that “all roads lead to the hospital.” That adage, well grounded in reality – particularly for the victims of natural or manmade disasters, including terrorist attacks – succinctly describes what is already a serious problem for the nation’s medical systems and a critical issue for preparedness planners.

The primary challenge facing planners as well as medical personnel is that the fiscal realities of U.S. healthcare have led to widespread use of an “economy model” of medical practice in which a system’s resources are scaled to the needs of an “average day” – however that nebulous term is defined. For practical purposes, this means that no additional hospital beds, or medical staff, usually will be available than the numbers typically required or “consumed” in an average working day at any U.S. hospital or other medical facility.

The same operational philosophy applies to medicines, medical equipment, and other physical assets and resources. Unfortunately – for practitioners as well as patients – so-called “just in time” inventory practices may be economically efficient, but they allow little surge capacity. The fact is, there already is a significant surge-capacity problem throughout the U.S. medical system that will all but guarantee the failure of any individual facility should it be challenged with overwhelming numbers.

Maximum Efficiency, Minimum Flexibility

In Allegheny County (i.e., the Pittsburgh area) of Western Pennsylvania, to cite but one example, there are an estimated 6,700 hospital beds currently available for the county’s approximately three million citizens. On a good day – defined as one during which a facility’s physical assets are being used with close to maximum efficiency – about 95 percent of those hospital beds are occupied. This means, though, that there is a “surge capacity” of only 335 beds – enough, in other words, for slightly less than one-hundredth of one percent of the remainder of the people in the area.     

To create additional surge capacity within any medical system – and/or throughout the entire U.S. medical system as a whole – there obviously must be some redistribution of medical care. To achieve that redistribution, though, without causing a number of other problems, requires a clear understanding of the various surge-capacity options that might be used. Among the most important of the factors to be considered in this process are the following:

  • Establishing a threshold:  The determination – before the outbreak of a crisis – of when a facility needs a surge strategy, and of which strategy to choose, must be defined by clear and defensible numbers.
  • Understanding the sometimes variable meaning of “medical utility”: The proper use of medical resources changes not only from one disease to another but also from treating a disease to dealing with an injury.
  • The proper role of medical ethics: In any major disaster, determining how to allocate what usually will be scarce medical resources means that some people may not receive the care they need, expect, deserve, and/or have paid for.  

From Normal to Triage In Three Uneasy Stages

By understanding these key points, various surge-capacity strategies can be developed to manage at least four stages of medical treatment in the aftermath of a disaster.  Stage I, which may be defined as “Normal Care,” would basically involve treating those individuals who could be cared for in addition to the average daily load of the medical facilities in the area. The Stage I ceiling would be 335 patients in the Allegheny County example cited earlier.

Stage II, which may be termed “Near-Normal Care,” would increase the number of patients who could be cared for by suspending normal operations, postponing or denying non-essential care for a limited period of time, providing care in atypical locations, and using relatively junior and less experienced medical personnel (under supervision, though, insofar as possible).

Stage III may be termed “Augmented Care” and could be defined as the number of patients cared for by augmenting community resources with “outside” assets, including those drawn from neighboring communities through mutual-aid agreements. Stage IV, the last in the escalating series, might require implementation of a “battlefield” type of triage system in which care may have to be denied entirely to some patients.

In this as in other triage situations, the case-by-case decisions on individual patients would have to be based strictly on medical utility and ethics. In any event, establishing when a specific strategy threshold has been reached is the essential first step required in medical planning for future disasters. Medical utility must be evaluated in each surge strategy because the use of scarce resources must be driven by decisions believed to have the greatest potential for achieving a good outcome.

There are three groups of medical patients who must be considered in a triage system governing the allocation of medical resources: (a) Those who are already ill, and in the hospital, and who might die if their care is reduced in scope or quality, or diminished in any of several other ways. (b) Victims of a disaster who are not yet in a hospital and whose principal immediate needs are a relatively moderate degree of medical care – and, probably, some emotional reassurance as well. (c) Other victims with high medical-resource needs and who require access to a medical facility to ensure their survival – or at least improve their chances for survival.

Sorting out which resources are provided to which patient is a complex problem, and should be based upon the individual patient’s likelihood of survival, the ethical concerns that must be considered, and the surge strategy that has been adopted – again, it is worth emphasizing, before a crisis occurs, rather than during the crisis or in the immediate aftermath.  

Medical Ethics and Political Procrastination

Medical ethics are a major consideration in this process because it is illegal in the United States to withhold or deny care to victims in need. But that is exactly what a medical system – more specifically, the medical personnel who first arrive on the scene – might have to do during or in the aftermath of a catastrophe affecting thousands or tens of thousands of citizens all at the same time. The use of junior – i.e., inexperienced and/or not fully qualified – medical personnel also is a regulatory infraction, as is the use of non-standard medical facilities.

How these and various related problems can or should be resolved has yet to be determined. Not quite five years after the terrorist attacks of 11 September 2001 there are still no surge-capacity laws on the books that tell first responders, and/or political decision-makers, how to redistribute scarce medical resources during times of crisis.

Note: Additional information on the altered standards of care that might be required during and after mass-casualty events is available at

Michael Allswede

Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.



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