No matter what the disaster – natural, man-made, or technological – there is a very real possibility that the health care infrastructure of a municipality, county, region, and/or state will be overwhelmed at one time or another.  Health care systems are "first receivers" for incidents of all sizes and varieties and can easily be thrown into chaos because of their typical inability to respond both quickly and effectively.   Most U.S. health care systems are already stretched to their limit on a daily basis, and for that reason alone the additional stress of an unexpected surge from a catastrophic event can quickly stretch their capacity beyond the normal breaking point.

The American College of Emergency Physicians (ACEP) defined surge capacity – in a 2004 Policy Statement  (Health Care System Surge Capacity Recognition, Preparedness, and Response) – as “a measurable representation of a health care system’s ability to manage a sudden or rapidly progressive influx of patients within the currently available resources at a given point in time.”  Surge capacity also can be defined as the maximum delivery of services that a system can provide if all available, or potential, resources – e.g., beds, equipment, supplies, pharmaceuticals, and personnel – are mobilized.  The surge of patients entering a hospital or emergency medical services (EMS) system following any large-scale incident has the potential, therefore, to be overwhelming to even the well-prepared system. 

In today's world, unfortunately, the creation of adequate surge capacity in a health care system is an absolute necessity, just as the ultimate goal during a surge situation is to do the most good for the most people – as well and as rapidly as possible. In the post-9/11 era there has been, in fact, a definitive shift away from individual care to population care.  To facilitate that shift, hospitals and other patient-care facilities should develop and institute the triage protocols required for the prompt recognition and isolation of those needing immediate care. This is particularly urgent in the event of an influx of patients presenting themselves to an emergency department/clinic with a communicable disease of public health significance that is either suspected or confirmed – e.g., an outbreak of severe acute respiratory syndrome (SARS) or pandemic influenza, or following a bioterrorist attack involving the plague or smallpox.

Acute, Chronic, and the Outward Characteristics of Each When examining the requirements for surge situations themselves and/or the capacity of health systems to handle such situations, one must consider two different types of incidents – “acute” and “chronic” – that could lead to those situations. Following is a brief description of each:

Acute Events – e.g., chemical attacks, explosive events, and even meteorological events such as tornadoes – will usually be defined by the following characteristics: hard hitting, immediate impact, the majority of casualties in a very short time frame, trauma to the health care system itself, and responses/reactions based on previous planning.

Chronic Events – e.g., a biological attack, a radiological release, and even a natural event such as flooding – will usually (but not always) display the following operational characteristics: slower moving, a gradually expanding impact, increasing effects, exponential increases in casualties, a surprised (and sometimes overwhelmed) health care system, responses/reactions based on planning, and an adaptation capability.

Both types of events have the potential to force a large number of patients, and their relatives, into the health care system.  For the most part, therefore, an effective surge plan should focus on: (a) Material resources – supplies and equipment including, but not necessarily limited to, beds, ventilators, and a broad and varied inventory of other health care instruments and devices; and (b) Staff (personnel) – the critical points here include ensuring that the staff has been cross-trained to handle a surge event and that there are enough staff members who are able to, and will, report to work even during an event that might affect them and/or their families personally. Meeting the latter requirement involves: (1) knowing how quickly the facility can notify and assemble additional necessary staff during a surge event; and (2) maintaining the appropriate training – particularly ICS (Incident Command System) training; HICS  (Hospital Incident Command System) training; and PPE (Personal Protective Equipment) training – for all levels of staff.

Structural Requirements – Plus the Overall Good of the Community The physical structure of a building is another extremely important planning factor.  Obviously, surge facilities should have the physical space needed to adequately handle not only the surge but also the management infrastructure needed to support surge operations, including planning for the implementation of alternative care sites (ACSs).

It is particularly important to remember that surge capacity in health care is about much more than simply having a few extra collapsing beds available and/or possessing the ability to recall personnel in the event of a large-scale incident. It is about having both a plan and a system already in place; about the training of personnel (utilizing the full spectrum of exercises – table top, functional, and full-scale) available; about understanding what went right and wrong during those exercises; and about having the ability, and the willingness, to modify the plan based on the lessons learned. 

Experience also has shown the need for close collaboration between EMS systems, hospitals, emergency management, and health departments to begin to build a realistic approach to surge capacity. The processes involved, however, require not only early assessments and meticulous curriculum development but also both effective training and outreach capabilities.

Developing a realistic surge capacity is clearly easier said than done. It involves a significant commitment of funds, time, public support, and political buy-in. Health system leaders must therefore be prepared to argue – and prove – that the development of a surge capacity is not simply a health issue but also, and primarily, a major community issue.

Having a surge capacity plan in place, well before a worst-case situation, will ultimately benefit the public under normal busy conditions as well as in the event of local or regional disasters that threaten the very survival of the community.  The ultimate vision must be a seamless system of health care surge capacity, throughout the country, that is capable of responding effectively and efficiently to public health emergencies of all types and all sizes, ranging from small but significant incidents to large-scale multi-casualty disasters.