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Hospital Surge Capacity and Immediate Bed Availability
Topic Collection
July 10, 2024

Topic Collection: Hospital Surge Capacity and Immediate Bed Availability

 

Hospitals and healthcare coalitions are faced with significant challenges after natural or human-caused events or disasters. Surge planning is a critical component of every healthcare facility’s emergency plan and response as well as a core focus of the Hospital Preparedness Program cooperative agreement. Planning must accommodate both large volumes of patients (capacity) as well as certain patient groups and patients with specific injuries or exposures (e.g., pediatrics, burn, and HAZMAT).  These resources highlight recent case studies, lessons learned, tools, and promising practices for planning and improving response to a surge event with a focus on capacity for mass casualties.

Additional related resources may be found in the following ASPR TRACIE Topic Collections: Alternate Care Sites; Blood and Blood Products; Burns; Coalition Response Operations; Crisis Standards of Care; Disaster Ethics; Epidemic/Pandemic Flu; Explosives and Mass Shooting; Healthcare-Related Disaster Legal/ Regulatory/ Federal Policy; Homecare and Hospice; Pediatric; Virtual Medical Care; and Volunteer Management.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

 

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Must Reads

ASPR TRACIE. (2018). EMTALA and Disasters.
This fact sheet addresses several frequently asked questions regarding the Emergency Medical Treatment and Labor Act (EMTALA) and disasters and provides links to resources for more information, but is not intended to be used as regulatory guidance or in place of communications with or guidance from the Centers for Medicare & Medicaid Services (CMS) which oversee EMTALA compliance.
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ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: Expanding Traditional Roles to Address Patient Surge.
This ASPR TRACIE tip sheet (which is part of a series) describes the non-traditional role some anesthesiologists assumed following the October 2017 mass shooting in Las Vegas. It also lists possible non-traditional roles other providers (e.g., pediatric) can assume in similar incidents.
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ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: Hospital Triage, Intake, and Throughput.
This ASPR TRACIE tip sheet (which is part of a series) highlights tips for hospital patient triage, intake, and throughput specific to no-notice events (e.g., the Las Vegas mass shooting).
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ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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ASPR TRACIE. (2022). Considerations for the Use of Temporary Care Surge Sites for Managing Seasonal Patient Surge. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response.
This document describes the major considerations healthcare facility emergency planners must account for when determining patient surge management solutions for longer-duration events, such as weeks to months of managing seasonal illness surge. The term "surge site" is used to describe a non-patient care area either inside the walls of the facility or a site immediately adjacent such as a tent, trailer, or other mobile and temporary facility.
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ASPR TRACIE. (2023). Issue 18: Innovations in Health Care Surge Capacity Management.
The articles in this issue focus on the experiences and lessons learned by health care facilities and systems during the early phases of the pandemic and beyond, to include the “tripledemic” (respiratory syncytial virus, influenza, and COVID-19) that affected children across the U.S. in the winter of 2022-2023. We examine the history and evolution of the Southwest Texas Regional Advisory Council with a focus on their efforts to load patients during mass casualty incidents and public health emergencies. Subject matter experts from California discussed the unique characteristics and challenges faced by Imperial County and how tents and the use of an alternate care site bolstered patient care. Our final article highlights the experiences of a Navajo Area Indian Health Service hospital as they work around the clock to locate appropriate receiving facilities and provide care in place while simultaneously managing staffing shortages.
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Barbera, J.A. and Macintyre, A.G. (2009). Medical Surge Capacity and Capability: The Healthcare Coalition in Emergency Response and Recovery. U.S. Department of Health and Human Services.
The authors wrote this guide as a companion piece to the Medical Surge Capacity and Capability handbook, providing tips for developing, implementing, and maintaining effective healthcare coalitions.
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  • Alan Dixon We need a hospital & clinic directory app for first responders with expertise stat analytics per hospital clinic with search tool find by expertise & availability ~Alan Tyler Dixon https://asprtracie.hhs.gov/technical-resources/25/coalition-response-operations-including-mutual-aid/21 Sent from my iPhone
    11/24/2017 3:31:56 PM
Basavaraju, S.V., Hunt, R.C., Vikas, K., et al. (2010). In A Moment’s Notice: Surge Capacity for Terrorist Bombings: Challenges and Proposed Solutions. Centers for Disease Control and Prevention.
The authors synthesized comments from a series of expert panel meetings on identifying innovative strategies hospitals could adopt to address terrorism-related surge issues.
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Boyer, E.W., Fitch, J., and Shannon, M. (2009). Pediatric Hospital Surge Capacity in Public Health Emergencies. (Archived.) Agency for Healthcare Research and Quality.
The special medical needs of children make it essential that healthcare facilities be prepared for both pediatric and adult victims of bioterrorism attacks and other public health emergencies. Clinicians and hospital administrators may use the report’s recommendations to develop unique responses to mass casualty events involving pediatric patients.
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Einav, S., Hick, J., Hanfling, D., et al. (2014). Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4_supplement):e17S–e43S.
The authors list 22 suggestions specific to surge capacity and mass critical care under the following topics: stockpiling of equipment, supplies, and pharmaceuticals; staff preparation and organization; patient flow and distribution; deployable critical care services; and using transportation assets to support surge response.
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Fisher, S., Biesiadecki, L., and Schemm, K. (2014). Responding to Medical Surge in Rural Communities: Practices for Immediate Bed Availability. The National Association of County and City Health Officials.
The focus of this report is on immediate bed availability in rural healthcare settings. The authors conducted a literature review and synthesized data collected during interviews with representatives in four areas: Mississippi, Southwest Utah, Virginia, and Southeast Texas.
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Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
Chapter 7 of the framework, Hospitals and Acute Care Facilities, provides a high level of detail related to implementing surge strategies, including immediate bed availability.
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Healthcare Preparedness Coalition of Utah/Wasatch Counties. (2014). Regional Medical Surge Plan: Expanding Local Healthcare Structure in Mass Casualty Events.
This plan defines how healthcare and related organizations within this specific region will work together to prevent, mitigate, respond to and recover from a disaster that leads to a surge on healthcare facilities. It can be used by personnel in real emergencies and when conducting training, drills, and exercises.
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Hick, J., Einav, S., Hanfling, D., et al. (2014). Surge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters. Chest. 146(4_supplement): e1S–e16S.
This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care in disasters or pandemics.
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Kelen, G.D., McCarthy, M.L., Kraus C.K., et al. (2009). Creation of Surge Capacity by Early Discharge of Hospitalized Patients at Low Risk for Untoward Events. Disaster Medicine and Public Health Preparedness. 3(2 Suppl):S10-6.
The authors examined the effect of reverse triage (early patient discharge) on inpatient bed surge capacity and found that surge capacity may be greater than previously thought. They also emphasize the importance of hospitals being able to rapidly implement “surge discharge.”
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Lake, C. (2018). A Day Like No Other – Case Study of the Las Vegas Mass Shooting. Nevada Hospital Association.
This report was written to help hospital, healthcare coalition, and emergency management planners learn more about the actions taken, lessons learned, observations and hospital experiences that occurred after the Las Vegas mass shooting. Information was collected through interviews, facilitated discussions, field trips and the state's InfoXChange program. The author also highlights planning, exercises, and updated assumptions "based on the changing world and social environment in which we now live."
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Tadmor, B., McManus, J., and Koenig, K.L. (2006). The Art and Science Of Surge: Experience From Israel and the U.S. Military. Academic Emergency Medicine. 13(11): 1130-4.
According to the authors, the “art” of surge includes decisions, authority, and responsibility, and the “science” includes numbers and benchmarks. The authors share surge strategies used by the U.S. military and Israel that can be replicated by other healthcare systems.
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Watson, S., Rudge, J., and Coker, R. (2013). Health Systems’ “Surge Capacity”: State of the Art and Priorities for Future Research. The Milbank Quarterly. 91(1): 78–122.
The authors share the results of a literature review that included surge capacity, and conclude that more work needs to be done in the area of generating strong frameworks and data collection methods.
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Education and Training

Bentley, S., Iavicoli, L., Boehm, L., et al. (2019). A Simulated Mass Casualty Incident Triage Exercise: SimWars. MedEdPORTAL Publications. 2015;11:10065.
This article describes a multipatient simulation exercise that requires hospital medical providers to rapidly classify and disposition mass casualty incident (MCI) patients, using a format that allows two teams to participate in identical simulations coupled with active audience observation, followed by facilitated group discussion. All of the participants reported good/excellent ability to accomplish MCI initial triage and patient disposition after the exercise.
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National Disaster Medical System 2018 Exercise Workgroup, San Diego County Operational Area. (2018). Exercise Design Team Meeting Summary.
This resource includes information from the exercise design team meeting for a tabletop exercise followed by a functional/full-scale exercise that included activation of the local Federal Coordinating Center (FCC), medical facilities, local government jurisdictions, and health and medical community partners to test the coordination among partners when the National Disaster Medical System is deployed to assist with patient care following a mass casualty incident.
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* Rady Children's Hospital, San Diego (2011). Pediatric Surge Planning: Train the Trainer.
This online course provides an in-depth overview of the special considerations associated with pediatric surge planning. The authors describe hospital incident command system activation, specify tools and actions linked to pediatric surge, and provide tips for developing a surge plan.
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* Rucks, A., Baldwin, S., Beeman, K., et al. (2010). Multi-State, Multi-Organizational Solution to Limited Regional Pediatric Medical Surge Capacity in the Southeastern United States. Alabama Department of Public Health.
The speakers in this webcast share strategies for addressing obstacles associated with pediatric surge.
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Shasta County. (2016). Shasta Medical and Health 2016 Mass Casualty Incident Tabletop Exercise 2016 Situation Manual.
This resource is a completed Situation Manual containing objectives, scenarios, and detailed discussion questions by partner type (e.g., hospitals, clinics, and law enforcement) for a train derailment/chlorine spill in a city of about 100,000 persons.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Health Care Coalition Surge Test Tool.
This training video provides an overview of how to use the HHS ASPR Health Care Coalition Surge Test Tool that tests ability to find beds for patients evacuating coalition hospitals.The tool can be found at https://www.phe.gov/Preparedness/planning/hpp/Pages/coaltion-tool.aspx. Coalition members can access the Handbook for Peer Assessors and Trusted Insiders for the Coalition Surge Test here: https://www.phe.gov/Preparedness/planning/hpp/Documents/cst-manual-020717.pdf.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Hospital Surge Evaluation Tool.
This tool can be used by hospital emergency planners, administrators, and other personnel to both assess and enhance their facility’s mass casualty surge plans. Emergency department and inpatient personnel must find appropriate space for waves of incoming virtual patients. It includes evaluation tools specific to emergency department triage and hospital incident command.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). HPP Coalition Surge Test Webinar.
This presentation describes the Coalition Surge Test, an annual grant requirement for healthcare coalitions (HCCs) that tests a simulated evacuation for 20% of the HCCs acute care bed capacity. Lessons learned and best practices from HCCs that participated during a pilot phase, and guidance for using exercise tools, are also reviewed including the role of HCC in coordination of evacuation activities. A link to the archived webinar is included. (For post-webinar questions and answers, access: https://files.asprtracie.hhs.gov/documents/aspr-tracie-ta-coalition-surge-test-webinar-qa.pdf.)
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University of Michigan State Burn Coordinating Center. (2022). Emergency Burn Triage and Management.
This website offers a breadth of burn care information as well as free just-in-time training modules for hospital staff on the management of burn patients.
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Guidance and Guidelines

Administration for Strategic Preparedness and Response. (2016). Health Care Preparedness and Response Capabilities for Health Care Coalitions. U.S. Department of Health and Human Services.
These four capabilities (Foundation for Health Care and Medical Readiness; Health Care and Medical Response Coordination; Continuity of Health Care Service Delivery; and Medical Surge) can help the healthcare delivery system, including healthcare coalitions, hospitals, and emergency medical services, better understand their roles in preparing for and responding to emergencies that impact the public’s health.
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ASPR TRACIE. (2018). EMTALA and Disasters.
This fact sheet addresses several frequently asked questions regarding the Emergency Medical Treatment and Labor Act (EMTALA) and disasters and provides links to resources for more information, but is not intended to be used as regulatory guidance or in place of communications with or guidance from the Centers for Medicare & Medicaid Services (CMS) which oversee EMTALA compliance.
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ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: Hospital Triage, Intake, and Throughput.
This ASPR TRACIE tip sheet (which is part of a series) highlights tips for hospital patient triage, intake, and throughput specific to no-notice events (e.g., the Las Vegas mass shooting).
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ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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ASPR TRACIE. (2022). Considerations for the Use of Temporary Care Surge Sites for Managing Seasonal Patient Surge. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response.
This document describes the major considerations healthcare facility emergency planners must account for when determining patient surge management solutions for longer-duration events, such as weeks to months of managing seasonal illness surge. The term "surge site" is used to describe a non-patient care area either inside the walls of the facility or a site immediately adjacent such as a tent, trailer, or other mobile and temporary facility.
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ASPR TRACIE. (2022). Hospital Strain Mitigation Strategies.
This ASPR TRACIE technical assistance response describes strategies for addressing strain on U.S. hospitals (due in part to increases in seasonal respiratory viruses and issues with available space and staffing), including specific data points and operational strategies.
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Barbera, J.A. and Macintyre, A.G. (2007). Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies, Second Edition, September 2007. Washington, DC: U.S. Department of Health and Human Services.
This foundational document provides an overview of the Medical Surge Capacity and Capability (MSCC) Management System and describes how the model can be applied and integrated across six “tiers of response.”
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Barbera, J.A. and Macintyre, A.G. (2009). Medical Surge Capacity and Capability: The Healthcare Coalition in Emergency Response and Recovery. U.S. Department of Health and Human Services.
The authors wrote this guide as a companion piece to the Medical Surge Capacity and Capability handbook, providing tips for developing, implementing, and maintaining effective healthcare coalitions.
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  • Alan Dixon We need a hospital & clinic directory app for first responders with expertise stat analytics per hospital clinic with search tool find by expertise & availability ~Alan Tyler Dixon https://asprtracie.hhs.gov/technical-resources/25/coalition-response-operations-including-mutual-aid/21 Sent from my iPhone
    11/24/2017 3:31:56 PM
Basavaraju, S.V., Hunt, R.C., Vikas, K., et al. (2010). In A Moment’s Notice: Surge Capacity for Terrorist Bombings: Challenges and Proposed Solutions. Centers for Disease Control and Prevention.
The authors synthesized comments from a series of expert panel meetings on identifying innovative strategies hospitals could adopt to address terrorism-related surge issues.
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Boyle, A., Beniuk, K., Higginson, I., and Atkinson, P. (2012). Emergency Department Crowding: Time for Interventions and Policy Evaluations. Emergency Medicine International. .
This article discusses the causes and consequences of emergency department crowding, and interventions to address crowding at the hospital level, and at the policy level. Table 1 illustrates a comparison of emergency department crowding scales by calculation and outcome, and includes a notes section.
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California Department of Public Health. (2008). Standards and Guidelines for Healthcare Surge During Emergencies.
Together with a variety of stakeholders, the California Department of Public Health developed standards for healthcare facilities and communities to implement during surge events.
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Centers for Disease Control and Prevention (2015). Community Planning Framework for Healthcare Preparedness.
This document includes information to help planners enhance and/or develop a community's medical surge plans. It is organized into chapters, such as: Building Planning Teams and Coalitions; Models of Healthcare Delivery; Alternate Care Systems; Essential Healthcare Services; and Crisis Standards of Care. The chapter on coalitions defines roles and responsibilities for planning teams and coalitions, and the steps necessary to determine a community's healthcare needs.
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Centers for Medicare & Medicaid Services. (2009). Requesting an 1135 Waiver.
When the President declares a disaster or emergency under the Stafford Act or National Emergencies Act and the HHS Secretary declares a public health emergency (PHE) under Section 319 of the Public Health Service Act, the Secretary is authorized to take certain actions in addition to regular authorities. Under section 1135 of the Social Security Act, she/he may temporarily waive or modify certain Medicare, Medicaid, and Children's Health Insurance Program requirements to ensure that sufficient healthcare items and services are available to meet the needs of individuals enrolled in these programs in the emergency areas. CMS resources can also assist in response and recovery efforts.
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Centers for Medicare and Medicaid Service. (2009). Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Options for Hospitals During a Disaster.
This memorandum and associated fact sheet (from 2009) describes EMTALA requirements and flexibility for an appropriate Medical Screening Examination and options for hospitals experiencing an exceptional patient surge. Alternate screening sites on a hospital’s campus, referral to a hospital-controlled off-campus site, and referral to a community screening site are addressed in terms of an EMTALA obligation.
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Dichter, J., Kanter, R., Dries, D., et al. (2014). System-Level Planning, Coordination, and Communication: Care of the Critically Ill and Injured during Pandemics and Disasters: CHEST Consensus Statement.. Chest. 146(4 Suppl):e87S-e102S.
This article highlights consensus statements gathered from literature and expert opinion and classified under eight themes. The authors emphasize the importance of system-level surge planning, robust communication systems, realistic exercises, and support from the federal government.
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* Fisher, S., Biesiadecki, L., and Schemm, K. (2014). Responding to Medical Surge in Rural Communities: Practices for Immediate Bed Availability. The National Association of County and City Health Officials.
The focus of this report is on immediate bed availability in rural healthcare settings. The authors conducted a literature review and synthesized data collected during interviews with representatives in four areas: Mississippi, Southwest Utah, Virginia, and Southeast Texas.
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Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
Chapter 7 of the framework, Hospitals and Acute Care Facilities, provides a high level of detail related to implementing surge strategies, including immediate bed availability.
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Hick, J.L., Hanfling, D., Burstein, J.L, et al. (2004). Healthcare Facility and Community Strategies for Patient Care Surge Capacity. Annals of Emergency Medicine. 44(3): 253-61.
The authors of this review article describe the need to plan for scalable and flexible surge capacity within healthcare systems, community facilities, and selection of alternate care sites. Sample best practice solutions are presented to accommodate diverse needs and volumes of patients.
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Institute of Medicine. (2010). Medical Surge Capacity: Workshop Summary. The National Academies Press.
This report summarizes a workshop held in June 2009 to assess the capability of and tools available to federal, state, and local governments to respond to a medical surge. Strategies for the public and private sectors to improve preparedness for medical surge were also discussed.
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Institute of Medicine. (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. The National Academies Press.
This foundational document summarizes expert guidance specific to providing healthcare during a public health emergency or in the aftermath of a disaster, when resources are scarce. It is separated into seven volumes: Introduction and CSC Framework; State and Local Government; EMS; Hospital; Alternate Care Systems; Public Engagement; and Appendices.
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Kaji, A., Koenig, K.L., and Bey, T. (2006). Surge Capacity for Healthcare Systems: A Conceptual Framework. Academic Emergency Medicine. 14(1):22.
The difference between daily and disaster surge is highlighted by the authors who also provide an overview of the essential components of surge capacity and related planning tips.
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Kelley, K., Toscano, N., Gestring, M., et al. (2023). Disaster Planning for a Surgical Surge: When Mass Trauma Threatens to Overwhelm Your Operating Rooms. Trauma Surgery & Acute Care Open. 8. .
The authors encourage hospitals to develop emergency plans to help staff prepare for conducting multiple surgeries simultaneously post-incident. They list specific plan components (e.g., activation criteria, communication, space, staffing, and supplies) and suggest key stakeholders from both the surgery and anesthesia departments and operating room be part of the committee responsible for hospital incident command.
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Meredith, L., Eisenman, D., Tanielian, T., et al. (2010). Prioritizing "Psychological" Consequences for Disaster Preparedness and Response: A Framework for Addressing the Emotional, Behavioral, and Cognitive Effects of Patient Surge in Large-Scale Disasters. (Free registration required.) Disaster Medicine and Public Health Preparedness. 4(E1-E8).
The authors share guidance for healthcare facilities on how to manage the psychological aspects of large-scale disasters that might involve a surge of psychological casualties.
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Phillips, S.J., Knebel, A., and Johnson, K.. (2007). Mass Medical Care with Scarce Resources: A Community Planning Guide.
Chapter VI of this guide provides an overview of the issues surrounding non-federal, non-hospital-based alternative care sites (ACS). Different types of ACS are described, and factors associated with decision making during mass casualty events are highlighted. Sample case studies are also included including several from Hurricane Katrina.
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* The Joint Commission. (2006). Surge Hospitals: Providing Safe Care in Emergencies.
This document provides an overview of different types of surge hospitals, and discusses how they are managed and operated. Surge hospitals can include mobile medical facilities and portable facilities. Case studies from real events are included.
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Lessons Learned

Adalja, A. A., Watson, M., Bouri, N. et al. (2014). Absorbing Citywide Patient Surge during Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations. Annals of Emergency Medicine. 64(1): 66-73.e1.
The authors used a qualitative, interview-based method to study medical surge strategies used at hospitals receiving patients from evacuated healthcare facilities during and after Hurricane Sandy. One gap noted was a challenge associated with the increase in the number of dialysis patients sent to hospitals.
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* ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: Expanding Traditional Roles to Address Patient Surge.
This ASPR TRACIE tip sheet (which is part of a series) describes the non-traditional role some anesthesiologists assumed following the October 2017 mass shooting in Las Vegas. It also lists possible non-traditional roles other providers (e.g., pediatric) can assume in similar incidents.
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ASPR TRACIE. (2021). Innovations in COVID-19 Patient Surge Management (Tip Sheet).
This ASPR TRACIE tip sheet summarizes four healthcare executives’ experience with statewide patient surge management during COVID-19 and lessons learned gleaned from other resources. (Access the full report here: https://files.asprtracie.hhs.gov/documents/innovations-in-covid-19-patient-surge-management-final-508.pdf)
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ASPR TRACIE. (2023). The Evolution of Patient Load Balancing: The Southwest Texas Regional Advisory Council.
Regional patient load balancing is an art and science that has evolved across the U.S., particularly over the past few years. ASPR TRACIE interviewed Eric Epley of the Southwest Texas Regional Advisory Council— who was the Council’s first official hire in 1998 and currently serves as the executive director/chief executive officer (CEO)—to learn more about how the Council has evolved and promising practices in load balancing and other trauma-related efforts.
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Aucoin, R. (2006). Hurricane Katrina: One Hospital's Experience. Critical Care. 10(1): 109.
The author shares his hospital’s experiences preparing for, responding to, and recovering from Hurricane Katrina. He shares lessons learned regarding anticipating patient surge, relocating critical patients, and interagency communications.
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Boston Public Health Commission. (2013). 2013 Boston Marathon Emergency Support Function 8 (ESF-8) Public Health and Medical Planning, Response, and Recovery Operations (April 15-April 26): Final After Action Report.
This after action report provides an overview of the Boston Marathon bombing and the collaborative planning between public health and healthcare that occurred before and in the weeks just after the incident. The report focuses on 10 specific public health and healthcare capabilities and lists related observations, strengths, areas for improvement, and recommendations. There is “a particular emphasis on the recovery efforts and public health's role as it relates to mass care and human service efforts.”
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Caspers, C., Smith, S., Seth, R., et al. (2016). Observation Services Linked with an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster. (Abstract only.) Disaster Medicine and Public Health Preparedness. 10(3):405-10.
This article demonstrates the usefulness and diverse population base that can be cared for by an emergency department (ED) Observation Unit. The authors examine what happened in the absence of an ED through a retrospective review of such a model created after the destruction of the NYU Langone Medical Center ED during Hurricane Sandy.
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Eastman, A., Rinnert, K., Nemeth, I., et al. (2007). Alternate Site Surge Capacity in Times of Public Health Disaster Maintains Trauma Center and Emergency Department Integrity: Hurricane Katrina. (Abstract only.) Journal of Trauma. 63(2):253-7.
The authors examined an alternative site for medical care set up to serve Hurricane Katrina survivors from September 1 to 16, 2005. Their review of the data found that this type of care and surge capacity can help effectively deliver post-disaster medical care.
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Fagbuyi, D. B., Brown, K.M., Mathison, D.J., et al. (2011). A Rapid Medical Screening Process Improves Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus. Annals of Emergency Medicine. 57(1): 52-9.
The authors used a new rapid screening process to manage patient surge associated with the 2009 H1N1 pandemic and found that it—along with a slight increase in staffing—improved patient flow and had no effect on emergency room return rates within two or seven days.
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Fong, K., Summers, C., and Cook, T. (2024). NHS Hospital Capacity during COVID-19: Overstretched Staff, Space, Systems, and Stuff. BMJ. 385:e075613.
The authors offer lessons learned from the COVID-19 pandemic about how intensive care units in the United Kingdom managed patient surge. They note that while ICUs were able to expand their space, they lacked the staffing and supplies to use it effectively; patient surge occurred unevenly throughout the country but there was strain throughout the health care system; redeployment of staff to ICUs led to surgical backlogs; and health care workers became infected disproportionately and faced significant psychological harm. The authors encourage future responses to assess surge capacity and strain in other than numerical counts and to protect the well-being of staff.
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Kearns, R.D., Myers, B., Cairns, C.B., et al. (2014). Hospital Bioterrorism Planning and Burn Surge. Biosecurity Bioterrorism. 12(1):20-8.
This article discusses how using an all-hazards approach to bioterrorism response planning helped to prepare hospitals in the Raleigh/Durham, NC area to care for casualties from a plant explosion in June 2009. The rescue, response, and resuscitation of survivors by first responders and first receivers, as well as efforts to develop burn surge, are described.
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Lake, C. (2018). A Day Like No Other – Case Study of the Las Vegas Mass Shooting. Nevada Hospital Association.
This report was written to help hospital, healthcare coalition, and emergency management planners learn more about the actions taken, lessons learned, observations and hospital experiences that occurred after the Las Vegas mass shooting. Information was collected through interviews, facilitated discussions, field trips and the state's InfoXChange program. The author also highlights planning, exercises, and updated assumptions "based on the changing world and social environment in which we now live."
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* Menes, K., Tintinalli, J., and Plaster, K. (2017). How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History. Emergency Physicians Monthly.
Dr. Menes, the attending in charge of the Sunrise emergency department on the night of the incident, shares his experiences mobilizing plans and overseeing triage as patients arrived. He discusses running out of supplies and having to improvise and emphasizes the importance of eliminating “choke points” (e.g., staffing operating rooms and addressing triage challenges).
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* Rossberg, S., Thompson, C., and Williams, L. (2015). Addressing Surge in Rural and Frontier Communities. (Free registration required.)
In this webinar, speakers from Montana, Utah, and Washington share what they have learned from medical surge exercises and actual events in low population density areas.
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Satterthwaite, P. S. and Atkinson, C. J. (2012). Using 'Reverse Triage' to Create Hospital Surge Capacity: Royal Darwin Hospital's Response to the Ashmore Reef Disaster. (Abstract only.) Emergency Medicine Journal. 29(2): 160-2.
The article details a real-life reverse triage situation where a full hospital freed up 56 beds (16% of capacity) to treat casualties suffering from blast injuries.
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* Tadmor, B., McManus, J., and Koenig, K.L. (2006). The Art and Science Of Surge: Experience From Israel and the U.S. Military. Academic Emergency Medicine. 13(11): 1130-4.
According to the authors, the “art” of surge includes decisions, authority, and responsibility, and the “science” includes numbers and benchmarks. The authors share surge strategies used by the U.S. military and Israel that can be replicated by other healthcare systems.
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Terndrup, T., Leaming, J., Adams, R., and Adoff, S. (2012). Hospital-Based Coalition to Improve Regional Surge Capacity. The Western Journal of Emergency Medicine. 13(5):445-52.
The authors examined the effect of a newly-developed regional healthcare coalition (in south Central Pennsylvania) on six surge capacity-related objectives. In a two-year period, the healthcare coalition improved areas under all objectives. The authors also found that designating and training a coordinator for the state healthcare volunteer database contributed to a significant increase in volunteer registrations from the participating hospitals.
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* The Joint Commission. (2006). Surge Hospitals: Providing Safe Care in Emergencies.
This document provides an overview of different types of surge hospitals, and discusses how they are managed and operated. Surge hospitals can include mobile medical facilities and portable facilities. Case studies from real events are included.
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Pediatric

* Alameda County Public Health Department. (2017). Alameda County Operational Area Pediatric Medical Surge Plan and Resources.
This concise plan describes a tiered approach to meeting surge capacity needs during incidents with a disproportionately high number of pediatric patients. Jurisdictions may consider this approach when conducting their related planning activities.
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American Journal of Disaster Medicine. 12(4):203-226 (2017). Factors Associated with Preparedness of the US Healthcare System to Respond to a Pediatric Surge during an Infectious Disease Pandemic. Is our Nation Prepared? Anthony, C., Thomas, T.J, Berg, B.M., et al
The authors of this article conducted a literature review to assess efforts in the U.S. healthcare system and their level of preparedness for infectious pandemics resulting in a pediatric surge. Results indicated that the U.S. healthcare system is not adequately prepared and response plans should be updated to meet national guidelines.
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* ASPR TRACIE. (2019). Healthcare Coalition Pediatric Surge Annex Template.
This template provides general headers and descriptions for a sample healthcare coalition (HCC) Pediatric Surge Annex Template. The resources used to develop this template include sample HCC plans and the Health Care Preparedness and Response Capabilities.
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ASPR TRACIE. (2023). Managing a Pediatric Tripledemic: Lessons Learned from 2022.
During the winter months in 2022-2023, hospitals in the state of Washington were overwhelmed by pediatric patients suffering from influenza, COVID-19, and respiratory syncytial virus (RSV). In this article, subject matter experts provide an overview of the health care coalition, the state’s pediatric capabilities, and how they used their Medical Operations Coordination Center (MOCC) and health care coalitions to balance patient loads throughout the state during this “tripledemic.”
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* Campbell, C. (2010). The Benefits of Designing a Stratification System for New York City Pediatric Intensive Care Units for Use in Regional Surge Capacity Planning and Management. Journal of Community Health. 35(4):337-347.
The author describes her work designing a New York City pediatric intensive care unit (PICU) surge stratification system that can help physicians, hospitals, and city agencies with regional surge capacity planning for critical pediatric patients. This included identification of factors to be considered when developing a stratification system, and creation of a preliminary system of PICU stratification based on clinical criteria and resources.
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Centers for Disease Control and Prevention. (2010). Coordinating Pediatric Medical Care During an Influenza Pandemic: Hospital Workbook. U.S. Department of Health and Human Services.
This workbook was designed to assist hospitals in coordinating the care of pediatric patients during an influenza pandemic. The workbook guides hospitals in thinking about needed actions to inform their preparedness planning. NOTE: This resource is outdated, however it provides useful information that may still be relevant.
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Foster, C.E., Marquez, L., Davis, A.L., et al. (2020). A Surge in Pediatric Coronavirus Disease 2019 Cases: The Experience of Texas Children’s Hospital From March to June 2020. Journal of the Pediatric Infectious Diseases Society.
This article addresses pediatric patients from ethnically diverse communities presenting with COVID-19 symptoms. Results indicated that a high percentage of Hispanic children tested positive for COVID-19 and required hospitalization. However, most of the children in the study did not have complicated illnesses. Findings from this study could be applied to planning resources that support pediatric triage during infectious disease surge.
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Frost, P., Upperman, J., Lubin, B., et al. (2010). Pediatric Surge Planning: Solutions Within Reach. Contra Costa County Health Services.
This document contains presentations from a September 2010 workshop about pediatric surge planning. The importance of community hospitals in planning for and managing pediatric surge is emphasized, as are some limitations of the current system based on data from the State of California.
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Kanter, R.K. (2007). Strategies to Improve Pediatric Disaster Surge Response: Potential Mortality Reduction and Tradeoffs. Critical Care Medicine. 35(12):2837-42.
The author modeled the potential for disaster mortality reduction with two surge response strategies: 1) control distribution of pediatric disaster victims to avoid hospital overcrowding near the scene, and 2) expand capacity by altering standards of care to only “essential” interventions. Modeling results suggest that the application of these two strategies in combination could decrease pediatric mortality rates in large disasters.
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Kanter, R.K. and Moran, J.R. (2007). Pediatric Hospital and Intensive Care Unit Capacity in Regional Disasters: Expanding Capacity by Altering Standards of Care. (Abstract only.) Pediatrics. 119(1):94-100.
The authors used a simulation to determine how altered standards of care during a large-scale emergency or disaster could expand pediatric intensive care unit (PICU) beds and non-ICU beds. Modeling showed that altered standards could increase capacity, but that ICU beds would still be insufficient during large disasters.
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* Kelen, G.D., Troncoso, R., and Trebach, J. (2017). Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital. JAMA Pediatrics. 171(4):e164829.
The authors conducted a year-long retrospective study to assess the effect of reverse triage of patients from pediatric hospitals on surge capacity. They concluded that “reverse triage adds a meaningful but modest contribution and may depend on psychiatric space.”
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* Los Angeles County Emergency Medical Services Agency. (2016). Los Angeles County Pediatric Surge Plan. California Hospital Association.
This plan provides details on how each hospital within Los Angeles County would support a pediatric surge of patients, including surge targets, supplies, and patient types. This plan also includes parameters for transporting children from prehospital field operations to healthcare facilities and transferring patients among hospitals.
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* Minnesota Department of Health. (2019). Minnesota Pediatric Surge Primer.
This primer is geared for small community hospitals that do not usually provide pediatric trauma or inpatient services. It provides guidance that facilities and regions can follow to plan for pediatric patients in a mass casualty event.
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* Rady Children's Hospital, San Diego (2011). Pediatric Surge Planning: Train the Trainer.
This online course provides an in-depth overview of the special considerations associated with pediatric surge planning. The authors describe hospital incident command system activation, specify tools and actions linked to pediatric surge, and provide tips for developing a surge plan.
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* Rucks, A., Baldwin, S., Beeman, K., et al. (2010). Multi-State, Multi-Organizational Solution to Limited Regional Pediatric Medical Surge Capacity in the Southeastern United States. Alabama Department of Public Health.
The speakers in this webcast share strategies for addressing obstacles associated with pediatric surge.
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* Sills, M., Hall, M., Fieldstone, E., et al. (2011). Inpatient Capacity at Children’s Hospitals during Pandemic (H1N1) 2009 Outbreak, United States. Emerging Infectious Diseases. 17(9): 1685–1691.
The authors examined data from 34 U.S. children’s hospitals during the 2009 H1N1 pandemic and found that during the fall, occupancy was actually 6% lower than it was during the same period of the previous seasonal influenza period (95% and 101% respectively). Using this data, they built five models to project occupancy and better understand the impact a more virulent pandemic could have on a facility.
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* Stanislaus County Health Services Agency. (2019). Stanislaus County Healthcare Emergency Preparedness Coalition Pediatric Disaster Surge Plan.
This county-specific pediatric disaster surge plan supports the Stanislaus County Healthcare Emergency Preparedness Coalitions’ (SCHEPC) Medical Health Surge Plan. Integration of the hospitals with the State of California through multi-agency coordination mechanisms is demonstrated.
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Plans, Tools, and Templates

Administration for Strategic Preparedness and Response. (2021). National Health Security Strategy. U.S. Department of Health and Human Services.
The goal of the National Health Security Strategy (NHSS) is to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies. This webpage includes links to the full text of the strategy, an overview, the NHSS Implementation Plan, the NHSS Evaluation of Progress, and an NHSS Archive.
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* Alameda County Public Health Department. (2017). Alameda County Operational Area Pediatric Medical Surge Plan and Resources.
This concise plan describes a tiered approach to meeting surge capacity needs during incidents with a disproportionately high number of pediatric patients. Jurisdictions may consider this approach when conducting their related planning activities.
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* ASPR TRACIE. (2019). Healthcare Coalition Pediatric Surge Annex Template.
This template provides general headers and descriptions for a sample healthcare coalition (HCC) Pediatric Surge Annex Template. The resources used to develop this template include sample HCC plans and the Health Care Preparedness and Response Capabilities.
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ASPR TRACIE. (2019). Surge Discharge.
This overview can serve as a guide for hospitals looking to improve their surge discharge plan and should be tailored and adapted to the services and processes in place at the facility. It can also assist as a paper back-up in case electronic health record systems are down.
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ASPR TRACIE. (2023). Health Care Facility Onboarding Checklist.
During a pandemic or other emergency, healthcare facilities face significant challenges to quickly onboard additional healthcare providers when hospital admissions and ICU occupancy increase rapidly. This onboarding checklist can ensure new employees are compliant with administrative requirements, familiar with the mission and culture of the hospital, and understand expectations.
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ASPR TRACIE. (2023). Mass Casualty Hospital Capacity Expansion Toolkit (PDF).
Mass casualty incidents (MCIs) generally occur without warning. A concise, scalable surge response template can be a helpful quick reference to the hospital personnel tasked with expanding care capacity in the first hours of an MCI and can minimize ad hoc and potentially conflicting decisions about prioritization of space and strategies. This optional toolkit includes four sections to guide emergency department, general inpatient, and critical care space expansion and basic additional staffing needs in the event of patient surge. Access the Word version of this toolkit here: https://files.asprtracie.hhs.gov/documents/mass-casualty-hospital-capacity-expansion-toolkit---word-version.docx
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Association of Healthcare Preparedness Professionals. (2024). Nebraska MRS Rapid Discharge Plan Template.
This document can facilitate planning for rapid discharge of patients. It includes planning considerations for the facility and roles and responsibilities for staff. Forms such as rapid discharge paperwork, a discharge patient evaluation form, rapid discharge orders, prescription orders, and patient tracking forms are available at the end of the document.
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California Department of Public Health. (2018). 15 ’til 50 – Mass Casualty Incident Toolkit.
This webpage includes links to the toolkit and other resources (e.g., case studies, templates, and tools) designed to help hospital staff prepare for a surge of 50 patients shortly after mass casualty incident.
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California Hospital Association. (2013). Hospital Surge Plan Checklist and Resources.
This resource contains tools, examples, and guides to assist hospitals in developing and/or updating their plans for response to a significant surge event.
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California Hospital Association. (2014). Hospital Emergency Food Supply Planning Guidance and Toolkit.
This webpage includes links to the various components that comprise the toolkit (a guidance document, calculation tool, PowerPoint presentation, and videos). These materials can help hospital food services directors/dietitians plan for and track emergency food supplies and comply with regulatory requirements.
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California Hospital Association. (2016). Medical Surge Exercise Evaluation Guide Template.
This Exercise Evaluation Guide (EEG) template can be adapted for use by healthcare facilities when conducting medical surge exercises.
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Florida Department of Health. (2012). Hospital Mass Casualty Incident Planning Checklist.
This checklist is rooted in the “whole community approach” and provides step-by-step guidance for those planning for significant increases in demand as a result of a critical incident.
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Greater New York Hospital Association. (2019). Mass Casualty Incident Response Toolkit.
This comprehensive toolkit can help hospitals develop mass casualty incident plans. It includes operating room and critical care job action sheets and addresses many key issues across the spectrum of clinical care and incident response. The toolkit also incorporates current communication protocols and highlights lessons learned and promising practices from recent incidents.
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Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers *. (Free registration required.) Institute of Medicine: National Academies Press.
This toolkit contains key concepts, guidance, and practical resources to help individuals across the emergency response system develop plans for crisis standards of care. Chapter 7 includes sample indicators, triggers, and sample tactics for use in the transition from conventional surge to contingency surge to crisis surge, and a return from crisis response to conventional response (detailed specifically for emergency medical services using slow-onset and no-notice scenarios).
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Healthcare Preparedness Coalition of Utah/Wasatch Counties. (2014). Regional Medical Surge Plan: Expanding Local Healthcare Structure in Mass Casualty Events.
This plan defines how healthcare and related organizations within this specific region will work together to prevent, mitigate, respond to and recover from a disaster that leads to a surge on healthcare facilities. It can be used by personnel in real emergencies and when conducting training, drills, and exercises.
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Hick, J. (2010). CO-S-TR Guide for Initial Incident Actions.
This poster/reference card provides the key components of the CO-S-TR model which may be a helpful visual reference for hospital incident command personnel as they prioritize and address key components of surge capacity. "CO" stands for command, control, communications, and coordination; "S" refers to staff, stuff, space, and special (event-specific) considerations; and "TR" comprises tracking, triage, treatment, and transportation. These healthcare-specific considerations complement incident command.
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Hick, J. L., Barbera, J. A., and Kelen, G.D. (2009). Refining Surge Capacity: Conventional, Contingency, and Crisis Capacity. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3(2 Suppl): S59-67.
In this article, the authors suggest using a three-level surge capacity taxonomy (conventional capacity, contingency capacity, and crisis capacity) to bolster hospital surge planning.
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Hick, J.L., Koenig, K.L., Barbisch, D., and Bey, T.A. (2008). Surge Capacity Concepts for Health Care Facilties: The CO-S-TR Model for Initial Incident Assessment. (Abstract only.) Disaster Medicine and Public Health Preparedness. 2(Suppl 1):S51–S57.
The authors provide a framework and checklist for initial surge actions and areas of attention for a hospital in the first hour after a mass casualty incident.
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Illinois Department of Public Health. (2016). Burn Surge Annex.
This plan supports the Illinois Department of Public Health Emergency Support Function-8 (ESF-8) Plan, by providing a functional annex for all stakeholders involved in an emergency response within the state of Illinois and/or adjacent states in order to provide appropriate burn medical care to patients in Illinois during a burn mass casualty incident (MCI). It guides the state level response and provides local medical services guidance on the care of burn patients, including patient movement, recommendations for care, and resource allocation during a burn MCI that overwhelms the local health care system.
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Johns Hopkins University. (n.d.). PACER Disaster Planning Apps Suite. (Accessed 7/11/2019.)
These applications (developed by Johns Hopkins University) provide electronic models and simulated scenarios to assist hospitals with facility surge, mass casualty, and flu monitoring.
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Los Angeles County. (2017). Los Angeles County Medical and Health Operational Area Coordination Program-Healthcare Surge Planning Guide.
This guide describes overall coordination of healthcare surge activities in Los Angeles County, as well as setting-specific strategies to be implemented to increase surge capacity. It may be used as a reference for other jurisdictions when developing similar plans.
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* Los Angeles County Emergency Medical Services Agency. (2016). Los Angeles County Pediatric Surge Plan. California Hospital Association.
This plan provides details on how each hospital within Los Angeles County would support a pediatric surge of patients, including surge targets, supplies, and patient types. This plan also includes parameters for transporting children from prehospital field operations to healthcare facilities and transferring patients among hospitals.
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Medisys Health Networks. (2006). Ambulatory Care Network Integration into Hospital Surge Event Response. Center for Infectious Disease Research and Policy.
This report describes a process for integrating ambulatory care centers into hospital surge capacity response plans. This included identifying ambulatory care center assets to inform the development of a set of roles they may fill to support hospital emergency response. Portions of the document could be replicated and adapted to help hospitals integrate ambulatory care centers into their surge planning.
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Michigan Department of Health and Human Services. (2018). Michigan Immediate Bed Availability Decompression Strategy Guidelines and Toolkit.
Healthcare emergency planners can use the information in this state-based document to develop guidance and plans geared towards increasing bed availability during a medical surge. It includes helpful diagrams, checklists, calculations, and forms.
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* Minnesota Department of Health. (2019). Minnesota Pediatric Surge Primer.
This primer is geared for small community hospitals that do not usually provide pediatric trauma or inpatient services. It provides guidance that facilities and regions can follow to plan for pediatric patients in a mass casualty event.
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Moser, R., Jr., Connelly, C., Baker, L., et al. (2006). Development of a State Medical Surge Plan, Part II: Components of a Medical Surge Plan. (Abstract only.) Disaster Management & Response. 4(1): 19-24.
The authors summarize the main components of Utah’s medical surge plan and provide information on immediate bed availability, plan activation and response, and communications.
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Nevada Division of Public and Behavioral Health. (2016). Nevada Statewide Medical Surge Plan.
This state-level plan provides guidance for healthcare facilities in Nevada, allowing them to prepare to respond to planned and unexpected events that may necessitate a surge of hospital and other healthcare resources within the state. It outlines roles and responsibilities of each entity during the response phase.
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Northwest Healthcare Response Network. (2018). Regional Surge and Regional Surge Squared Functional Exercises: After Action Report (AAR)/ Improvement Plan (IP).
This After-Action Report/ Improvement Plan (AAR/IP) clearly describes the scenario, objectives, and outcomes from a full-scale exercise conducted in 2017 to test surge capacity and associated regional coordination among partners in the Northwest Healthcare Response Network, in coordination with the National Disaster Medical System. It may be referenced by other coalitions and/or facilities to develop their own respective AARs, as well as to develop scenarios and objectives for similar exercises.
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NYC Department of Health and Mental Hygiene. (2013). Patient Surge in Disasters: A Hospital Toolkit for Expanding Resources in Emergencies.
This toolkit, provides links to templates and other surge tools to help users determine their surge planning, staffing, and supply needs.
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Pollaris, G., Note, S., Desruelles, D., and Sabbe, M. (2017). Novel IT Application for Reverse Triage Selection: A Pilot Study. (Abstract only.) Disaster Medicine and Public Health Preparedness. 12(5):559-605.
The objective of this study was to develop and evaluate an evidence-based information technology application hospital administrators can use to assist with decision-making during the reverse-triage selection process in mass casualty incidents. The authors developed and used the “Reverse Triage Tool of Leuven” in a study, where they selected almost twice as many patients in the filtered group who qualified for early discharge compared with patients in the random group.
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* Stanislaus County Health Services Agency. (2019). Stanislaus County Healthcare Emergency Preparedness Coalition Pediatric Disaster Surge Plan.
This county-specific pediatric disaster surge plan supports the Stanislaus County Healthcare Emergency Preparedness Coalitions’ (SCHEPC) Medical Health Surge Plan. Integration of the hospitals with the State of California through multi-agency coordination mechanisms is demonstrated.
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Thomasian, N., Madad, S., Hick, J., et al. (2021). Hospital Surge Preparedness and Response Index. (Abstract only.) Disaster Medicine and Public Health Preparedness. 15(3):398-401.
This all-hazards template (developed by a group of emergency management and disaster medicine experts from the U.S.) can provide hospital administrators a "snapshot" of current capacity and help improve planning by linking action items to institutional triggers across the surge capacity continuum.
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Toerper, M.F., Kelen, G.D., Sauer, L.M., et al. (2017). Hospital Surge Capacity: A Web-Based Simulation Tool for Emergency Planners. (Abstract only.) Disaster Medicine and Public Health Preparedness. 18:1-10 .
The authors describe their experience with using the publicly available simulation tool called ‘Surge’ (accessible at http://www.pacerapps.org) to investigate various response strategies to increase surge capacity during an acute mass casualty incident for large urban, midsize community, and small rural hospitals. They found that combining all response strategies simulated surge capacity between 30% and 40% of staffed beds, with the greatest impact of response strategies seen in the large urban hospital simulation.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Coalition Surge Test: An Exercise for Assessing and Improving Health Care Coalition Readiness.
This resource is the Handbook for Peer Assessors and Trusted Insider for the Coalition Surge Test. Healthcare coalitions can use this no-notice exercise to identify gaps in surge planning related to evacuating patients. The exercise tests a coalition’s ability to locate appropriate destinations for patients in a simulated evacuation of patient care facilities.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Hospital Surge Evaluation Tool. U.S. Department of Health and Human Services.
This tool can be used by hospital emergency planners, administrators, and other personnel to both assess and enhance their facility’s surge plans. It includes evaluation tools specific to emergency department triage and hospital incident command.
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Washington State. (2017). ESF 8: Public Health, Medical, and Mortuary Services, Appendix 2-Medical Surge Response.
This plan describes roles and responsibilities of each major public health, healthcare, and emergency medical services (EMS) partner in Washington State during each phase of response to a medical surge incident. It may be used as a model for other jurisdictions when developing similar plans.
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Resource Allocation

* ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: Expanding Traditional Roles to Address Patient Surge.
This ASPR TRACIE tip sheet (which is part of a series) describes the non-traditional role some anesthesiologists assumed following the October 2017 mass shooting in Las Vegas. It also lists possible non-traditional roles other providers (e.g., pediatric) can assume in similar incidents.
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Bayram, J., Sauer, L., Catlett, C., et al. (2013). Critical Resources for Hospital Surge Capacity: An Expert Consensus Panel. PLoS Currents.
The authors convened an expert consensus panel representing health providers, administrators, emergency planners, and specialists, and asked them to review four disaster scenarios and prioritize 132 hospital resources. The number of hospital resources considered to be critical varied by scenario: 58 for the pandemic influenza scenario, 51 for radiation exposure, 41 for explosives, and 35 for nerve gas scenario.
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Corcoran, S., Niven, A., and Reese, J. (2012). Critical Care Management of Major Disasters: A Practical Guide to Disaster Preparation in the Intensive Care Unit. (Abstract only.) Journal of Intensive Care Medicine. 27(1):3-10.
In this article, the authors provide a summary of the threat of major disasters and an overview of mass critical management to help intensive care unit directors prepare their teams for similar events.
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Dichter, J., Devereaux, A., Sprung, C., et al. (2021). Mass Critical Care Surge Response during COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings from the Task Force for Mass Critical Care. (Added 9/9/2021) Chest Journal .
This article presents ten new suggestions from the Task Force for Mass Critical Care based on the response to COVID-19 to help hospitals and communities operationalize strategies to avoid crisis standards of care. These suggestions focus on staffing, load-balancing, communications, and technology.
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Duncan, E., Colver, K., Dougall, N., et al. (2016). Consensus on Items and Quantities of Clinical Equipment Required to Deal with a Mass Casualties Big Bang Incident: A National Delphi Study. BMC Emergency Medicine. 14: 5.
The authors asked 32 experts in the UK who had clinical experience with mass casualty incidents (MCI) to rank medical items necessary to treat 100 patients at the scene of a MCI. The experts achieved consensus on 134 items (54%); findings can be used to support MCI resource allocation planning.
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Einav, S., Hick, J., Hanfling, D., et al. (2014). Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4_supplement):e17S–e43S.
The authors list 22 suggestions specific to surge capacity and mass critical care under the following topics: stockpiling of equipment, supplies, and pharmaceuticals; staff preparation and organization; patient flow and distribution; deployable critical care services; and using transportation assets to support surge response.
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Einav, S., Limor Aharonson-Daniel, L., Weissman, C., et al. (2006). In-Hospital Resource Utilization during Multiple Casualty Incidents. Annals of Surgery. 243(4): 533–540.
Data from patients admitted to six Level 1 Trauma Centers in Israel just after a mass casualty incident allowed the authors to develop related guidelines for hospitals to activate in the event of similar events.
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Griffiths, J.L., Estipona, A., and Waterson, J.A. (2011). A Framework for Physician Activity During Disasters And Surge Events. (Abstract only.) American Journal of Disaster Medicine. 6(1):39-46.
The authors highlight the roles physicians can play during surge events (e.g., assisting with reverse triage and patient flow).
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Hanley, M.E. and Bogdan, G.M. (2008). Mechanical Ventilation in Mass Casualty Scenarios. Augmenting Staff: Project XTREME. Respiratory Care. 53(2):176-88.
Non-respiratory therapy staff can be trained to augment staff and help patients in respiratory failure after a critical incident.
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* Menes, K., Tintinalli, J., and Plaster, K. (2017). How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History. Emergency Physicians Monthly.
Dr. Menes, the attending in charge of the Sunrise emergency department on the night of the incident, shares his experiences mobilizing plans and overseeing triage as patients arrived. He discusses running out of supplies and having to improvise and emphasizes the importance of eliminating “choke points” (e.g., staffing operating rooms and addressing triage challenges).
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National Academies of Sciences, Engineering, and Medicine. (2020). Rapid Expert Consultation on Staffing Considerations for Crisis Standards of Care for the COVID-19 Pandemic (July 28, 2020).
This resource builds upon prior consultation (issued on March 28, 2020) and focuses on Crisis Standards of Care and staffing needs--including deployment and allocation of expert clinical staff--to ensure the care of COVID-19 patients.
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Smith, D., Paturas, J., Tomassoni, A., and Albanese, J. (2011). Resource Allocation: An Approach for Enhancing Hospital Resiliency. (Abstract only.) Journal of Business Continuity and Emergency Planning. 5(2):140-9.
This article describes a model for evaluating and assigning staff for emergency response in the hospital setting to achieve surge capacity using only internal resources. The authors designate those staff that are not assigned to an emergency support function to augment those that are.
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Stratton, S.J. and Tyler, R.D. (2006). Characteristics of Medical Surge Capacity Demand for Sudden-Impact Disasters. Academic Emergency Medicine 13(11):1193-7.
Using data from “established databases and published reports,” the authors examined both the baseline capacity of U.S. healthcare facilities and the length of time it took for external facilities to provide assistance after a no-notice critical incident. They concluded that communities should plan to maintain their provision of medical services without assistance for at least 24, and as much as 96 hours, after such an incident.
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* Tadmor, B., McManus, J., and Koenig, K.L. (2006). The Art and Science Of Surge: Experience From Israel and the U.S. Military. Academic Emergency Medicine. 13(11): 1130-4.
According to the authors, the “art” of surge includes decisions, authority, and responsibility, and the “science” includes numbers and benchmarks. The authors share surge strategies used by the U.S. military and Israel that can be replicated by other healthcare systems.
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Rural/Frontier

ASPR TRACIE. (2023). Augmenting Rural Hospital Capacity in California: Lessons Learned from COVID-19.
The COVID-19 pandemic challenged all aspects of health care, and rural areas were hit particularly hard. Many rural hospitals do not have the capacity to accommodate patient surge, may not have the on-site capabilities to treat very ill patients, and may be challenged with providing care in place versus transferring patients, especially during a pandemic. ASPR TRACIE met with subject matter experts from California who helped manage the response to the pandemic across the state to learn more about how they worked with hospital staff particularly in Imperial County (a rural area bordered by San Diego, Riverside, and Yuma [Arizona] counties, and Mexico) to augment capacity and accommodate patient surge.
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ASPR TRACIE. (2023). Issue 18: Innovations in Health Care Surge Capacity Management.
The articles in this issue focus on the experiences and lessons learned by health care facilities and systems during the early phases of the pandemic and beyond, to include the “tripledemic” (respiratory syncytial virus, influenza, and COVID-19) that affected children across the U.S. in the winter of 2022-2023. We examine the history and evolution of the Southwest Texas Regional Advisory Council with a focus on their efforts to load patients during mass casualty incidents and public health emergencies. Subject matter experts from California discussed the unique characteristics and challenges faced by Imperial County and how tents and the use of an alternate care site bolstered patient care. Our final article highlights the experiences of a Navajo Area Indian Health Service hospital as they work around the clock to locate appropriate receiving facilities and provide care in place while simultaneously managing staffing shortages.
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ASPR TRACIE. (2023). Managing Patient Surge in Rural Areas: Experiences from Gallup Indian Medical Center.
In many rural areas, patient transfer is a common practice, though often strained by various factors (e.g., distance to receiving hospitals, geography, available mode of transport, and available staff to treat, transport, and receive patients). ASPR TRACIE met with Dr. Emily Bartlett, an emergency medicine physician who has worked at the Gallup Indian Medical Center in New Mexico (GIMC) since 2020 to learn more about how the center determined which patients to transport and which to treat in place as they overcame related challenges (e.g., no available beds in the region, not enough staff to accomplish patient transport). She was joined by Brandon Wyaco, Public Information Officer from the Navajo Area Indian Health Service.
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* Fisher, S., Biesiadecki, L., and Schemm, K. (2014). Responding to Medical Surge in Rural Communities: Practices for Immediate Bed Availability. The National Association of County and City Health Officials.
The focus of this report is on immediate bed availability in rural healthcare settings. The authors conducted a literature review and synthesized data collected during interviews with representatives in four areas: Mississippi, Southwest Utah, Virginia, and Southeast Texas.
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Mason, W., Randolph, J., Boltz, R., et al. (2014). Rural Coalition Development and Immediate Bed Availability. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This 90-minute webinar reviews the unique challenges of building and operating healthcare coalitions in rural settings. Speakers discuss policy and partnership lessons learned from a disaster in Arkansas; bed surge and mass fatality support and coordination best practices from a Greyhound bus disaster in Pennsylvania; Community Assessment Tool (CAT) implementation in Nebraska; and rural healthcare coalition development strategies used in Missouri.
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* Rossberg, S., Thompson, C., and Williams, L. (2015). Addressing Surge in Rural and Frontier Communities. (Free registration required.)
In this webinar, speakers from Montana, Utah, and Washington share what they have learned from medical surge exercises and actual events in low population density areas.
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Studies

Abir, M., Choi, H., Cook, C., et al. (2012). Effect of a Mass Casualty Incident: Clinical Outcomes and Hospital Charges for Casualty Patients Versus Concurrent Inpatients. Academic Emergency Medicine. 19(3):280-6.
The authors conducted a retrospective study of administrative hospital claims in a state that experienced a mass casualty incident involving more than 200 casualties. They found that--when adjusted for severity of illness--both casualty and non-casualty patients had significantly longer lengths of stay and higher charges than traditional patients during non-surge periods.
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Bayram, J. D., Zuabi, S., and Subbarao, I.. (2011). Disaster Metrics: Quantitative Benchmarking of Hospital Surge Capacity in Trauma-Related Multiple Casualty Events. (Abstract only.) Disaster Medicine and Public Health Preparedness. 5(2):117-24.
The authors complemented a literature review with mathematical modeling to illustrate the importance of quantitatively benchmarking various components of hospital bed surge capacity.
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* Campbell, C. (2010). The Benefits of Designing a Stratification System for New York City Pediatric Intensive Care Units for Use in Regional Surge Capacity Planning and Management. Journal of Community Health. 35(4):337-347.
The author describes her work designing a New York City pediatric intensive care unit (PICU) surge stratification system that can help physicians, hospitals, and city agencies with regional surge capacity planning for critical pediatric patients. This included identification of factors to be considered when developing a stratification system, and creation of a preliminary system of PICU stratification based on clinical criteria and resources.
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Curran, M., Howley, E., and Duggan, J. (2016). An Analytics Framework to Support Surge Capacity Planning for Emerging Epidemics. (Abstract only.) DH '16 Proceedings of the 6th International Conference on Digital Health Conference, Pages 151-155.
The authors provide an overview of system dynamic modeling and how it can be used to predict epidemics (when used in conjunction with surveillance systems, sentinel data, and other tools). The authors suggest a way to synthesize the concepts and highlight future work that can help with resource allocation in surge events.
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Davis, D. P., Poste, J.D., et al. (2005). Hospital Bed Surge Capacity in the Event of a Mass-Casualty Incident. (Registration required.) Prehospital Disaster Medicine. 20(3): 169-76.
The authors sought a more accurate way to determine hospital bed surge capacity by using physician and nurse manager assessments (instead of traditional cross-sectional hospital census data).
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DeLia, D. (2006). Annual Bed Statistics Give a Misleading Picture of Hospital Surge Capacity. (Abstract only.) Annals of Emergency Medicine. 48(4):384-8, 388.e1-2.
According to the author, surge capacity estimates should include daily variation in patient volume and within-year variation in bed supply; relying simply on the latter may provide inaccurate estimates.
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Ebrahimian, A., Ghasemian-Nik, H., Ghorbani, R., and Fakhr-Movahedi, A. (2018). Development a Reverse Triage System Based on Modified Sequential Organ Failure Assessment for Increasing the Critical Care Surge Capacity. Indian Journal of Critical Care Medicine. 22(8): 575-579.
The authors studied the use of the Modified Sequential Organ Failure Assessment (MSOFA) for increasing critical care surge capacity, with the goal of developing a tiered reverse triage system. They concluded that the MSOFA score could be part of a system for reverse triage of critical care patients.
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Jenkins, P., Richardson, C., Norton, E., et al. (2015). Trauma Surge Index: Advancing the Measurement of Trauma Surges and Their Influence on Mortality. (Abstract only.) Journal of the American College of Surgeons. 221(3): 729-738.
The authors developed the Trauma Surge Index and used it with an established definition of mass casualty events to examine recent hospital surges. They found that patients admitted during high-surge period had higher mortality than those admitted during low-surge periods.
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Kelen, G.D., McCarthy, M.L., Kraus C.K., et al. (2009). Creation of Surge Capacity by Early Discharge of Hospitalized Patients at Low Risk for Untoward Events. Disaster Medicine and Public Health Preparedness. 3(2 Suppl):S10-6.
The authors examined the effect of reverse triage (early patient discharge) on inpatient bed surge capacity and found that surge capacity may be greater than previously thought. They also emphasize the importance of hospitals being able to rapidly implement “surge discharge.”
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* Kelen, G.D., Troncoso, R., and Trebach, J. (2017). Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital. JAMA Pediatrics. 171(4):e164829.
The authors conducted a year-long retrospective study to assess the effect of reverse triage of patients from pediatric hospitals on surge capacity. They concluded that “reverse triage adds a meaningful but modest contribution and may depend on psychiatric space.”
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Lennquist Montán, K., Riddez, L., Lennquist, S. et al. (2017). Assessment of Hospital Surge Capacity Using the MACSIM Simulation System: A Pilot Study. (Abstract only.) European Journal of Trauma and Emergency Surgery. 43(4): 525–539.
The authors tested a manual simulation system to assess surge capacity in a hospital using data from a real world response. They concluded that the model is valid, and that surge capacity should be determined by multiple, interacting hospital functions, which could each be limiting factors at different points in response.
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Love, J., Karp, D., Delgado, M., et al. (2016). National Differences in Regional Emergency Department Boarding Times: Are US Emergency Departments Prepared for a Public Health Emergency? (Abstract only.) Disaster Medicine and Public Health Preparedness. 10(4):576-582.
The authors examined differences in patient boarding times in U.S. areas at risk for public health emergencies. They found that 86% of at-risk hospital referral regions had high boarding times (suggesting greater vulnerability), though it is important to note the limitations associated with drawing conclusions solely based on daily capacity.
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Mills, A., Helm, J., and Wang, Y. (2017). Surge Capacity Deployment in Hospitals: Effectiveness of Response and Mitigation Strategies. (Free registration required.) Department of Operations and Decision Technologies, Kelley School of Business, Indiana University.
The authors used operations modeling to assess the effects of “coordinated discharge” (i.e., coordinated between the Emergency Department and In-patient units) during the response phase, and “workflow smoothing” (i.e., managing elective demand in the in-patient units) during the mitigation phase, on surge capacity. They concluded that hospitals with higher utilization and shorter lengths of stay would benefit more from workflow smoothing, and hospitals with lower utilization and longer lengths of stay would benefit more from coordinated discharge.
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Morton, M., DeAugustinis, M., Velasquez, C., et al. (2015). Developments in Surge Research Priorities: A Systematic Review of the Literature Following the Academic Emergency Medicine Consensus Conference, 2007-2015.. Academic Emergency Medicine. 22(11):1235-52.
This literature review of more than 60 articles related to surge metrics found that while disaster simulation studies have advanced the study of disaster surge, use of reverse triage approaches and altered standards of care, as well as Internet-based tools such as Google Flu Trends, have also proven effective. The authors note that more work needs to be done regarding standardizing research methodologies and outcomes and validating disaster surge metrics.
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Pfeifer, J. and Roman, O.. (2016). Tiered Response Pyramid: A System-Wide Approach to Build Response Capability and Surge Capacity.. Homeland Security Affairs. 12(Article 5).
The authors share their view on the limitations of the traditional response triangle used for disaster planning and suggest planners use a system-wide Tiered Response Pyramid to increase response capabilities and surge capacity for large scale disasters.
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Pollaris, G. and Sabbe, M. (2016). Reverse Triage: More Than Just Another Method. (Abstract only.) European Journal of Emergency Medicine. 23(4):240-247.
The authors reviewed articles on reverse triage from 2004-2014 and found that, at most, 10-20% of hospital total bed capacity can be made available within a few hours. They note that reverse triage could be a response to Emergency Department (ED) crowding, as it gives priority to ED patients with urgent needs over inpatients who can be discharged with little to no health risks.
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Sheikhbardsiri, H., Raeisi, A.R., Nekoei-Moghadam, M., and Rezaei, F. (2017). Surge Capacity of Hospitals in Emergencies and Disasters With a Preparedness Approach: A Systematic Review. Disaster Medicine and Public Health Preparedness. 11(5):612-620.
The authors reviewed 17 studies related to surge capacity and provide recommendations to improve preparedness in 4 areas: staff; stuff; structure; and system.
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* Sills, M., Hall, M., Fieldstone, E., et al. (2011). Inpatient Capacity at Children’s Hospitals during Pandemic (H1N1) 2009 Outbreak, United States. Emerging Infectious Diseases. 17(9): 1685–1691.
The authors examined data from 34 U.S. children’s hospitals during the 2009 H1N1 pandemic and found that during the fall, occupancy was actually 6% lower than it was during the same period of the previous seasonal influenza period (95% and 101% respectively). Using this data, they built five models to project occupancy and better understand the impact a more virulent pandemic could have on a facility.
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Soremekun, O.A., Zane, R.D., Walls, A., et al. (2011). Cancellation of Scheduled Procedures as a Mechanism to Generate Hospital Bed Surge Capacity-A Pilot Study. (Abstract only.) Prehospital Disaster Medicine. 26(3): 224-9.
The authors examined the impact of delaying hospital procedures on immediate bed availability.
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TariVerdi, M., Miller-Hooks, E., and Kirsch, T. (2018). Strategies for Improved Hospital Response to Mass Casualty Incidents. (Free registration required.) Disaster Medicine and Public Health Preparedness. 19:1-13.
The authors used a whole-hospital simulation model to replicate staff, resources, and space as would be found in an urban hospital, to test surge capacity and capability for different mass casualty incidents under varying conditions. They found that “an acceptable service level could be achieved by implementing only 2 to 3 of the 9 studied enhancement strategies.”
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Watson, S., Rudge, J., and Coker, R. (2013). Health Systems’ “Surge Capacity”: State of the Art and Priorities for Future Research. The Milbank Quarterly. 91(1): 78–122.
The authors share the results of a literature review that included surge capacity, and conclude that more work needs to be done in the area of generating strong frameworks and data collection methods.
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This ASPR TRACIE Topic Collection was refreshed and comprehensively reviewed in November 2018 by the following experts (listed alphabetically): Eric Alberts, BS, CEM, CHEP, CHPP, FPEM, FPEM-HC, SEM, Orlando Health, Inc. (Hospital System); Virginia Ashby Sharpe, Ph.D., Acting Executive Director, National Center for Ethics in Health Care, Veterans Health Administration; Lynn Bergero, MHSA, Independent Consultant and CERT Volunteer; Barbara Citarella, RN, BSN, MS, CHCE, NHDP-BC, National Healthcare Disaster Professional, President, RBC Limited Healthcare & Management Consultants; Craig DeAtley, PA-C, Director, Institute for Public Health Emergency Readiness, MedStar Washington Hospital Center; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Richard Hunt, MD, HHS/ASPR. Office of Emergency Management; Mark Jarrett, MD, MBA, MS, SVP & Chief Quality Officer, Associate Chief Medical Officer, Northwell Health, Professor of Medicine, Zucker School of Medicine at Hofstra/Northwell; Jodi Keller, RN, Associate Director of Healthcare Emergency Preparedness, Central Ohio Trauma System; James Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Heath System; Jeff Rubin, PhD, CEM, Emergency Manager, Tualatin Valley Fire & Rescue; Mary Russell, EdD, MSN, Healthcare Emergency Response Coalition of Palm Beach County, FL; and Judy Seaberg, RN, PHN, MS, Health Care Preparedness Program Manager, Minnesota Department of Health.

The Collection was originally comprehensively reviewed in 2015 by the following experts (listed alphabetically): John Hick, MD, HHS ASPR and Hennepin County Medical Center. Additional assistance was provided by Alicia Livinski, Biomedical Librarian, HHS National Institutes of Health, and Anthony McIntyre, MD, George Washington University.

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