Emergency Department Surge Capacity: There Ain’t None

[UPDATE 05-07-2008 Day Two of the Hearing is today with Michael Leavitt, Sec DHHS  and Michael Chertoff, Sec DHS testifying. The House Oversight and Government Reform Committee added their testimony and that of Dean Conway-Welch, and the links are at their names.

What comes through loud and clear is the BushCo loyalism of Chertoff: "not my responsibility - it's Mike's over at DHHS". And Leavitt spins his testimony through the sewage pipe of Republican framing:  "Medicaid creates a burden on the taxpayers, and it's only for Medicaid services.  Never mind that the US doesn't have extant bed or emergency department capacity.  Never mind that graduate medical education is going to be cut off at the groin, and never you mind that there is a baseline shortage of clinically expert trauma, emergency and critical care nurses and infrastructure to care for existing need and demand. Trust me - it will be just fine in a mass casualty.  I'm confident.  I don't have any facts, but I'm sure things will work out OK."

Conway-Welch's testimony is all about the effects of Medicaid cutbacks on just those things that Leavitt and Chertoff deny with wishful thinking and willful ignorance. One could make a case that they are criminally negligent and are committing fraud against the American citizenry. No wonder they testified on a separate day without any of the experts in the room.  They're naked - of facts, accuracy and good faith, and their Republican henchmen on the Committee are the only ones who will cover for them.]

[UPDATE: The Medicaid legislation in question is H.R. 5613, the Dingell-Murphy legislation, to stop the Medicaid cuts and protect the ability of safety-net hospitals with trauma centers to maintain this critical public health function, overwhelmingly passed in the house and sent to the Senate for completion. The Congress should also enact and fully fund the National Trauma Center Stabilization Act, H.R. 5942. I found one link to a comment made by Dr. Colleen Conway Welsh, the Dean of the School of Nursing at Vanderbilt University and an expert in emergency preparedness (yes, she IS a nurse):

"If Medicaid dollars are reduced in these three areas, a reduction in personnel and readiness will occur in our hospitals and emergency departments across the country," she said. "And even worse, it will occur in the midst of a serious and intractable nursing and nursing faculty shortage and limit our ability to respond to a disaster, particularly a blast or explosive injury with serious burns."]

If I can figure out how to do this, I’ll try to add some C-SPAN video of yesterday’s House Oversight and Government Reform testimony about the nation’s hospital emergency departments’ surge capacity in the event of a large scale emergency - what’s known in the trade as a “mass cas” - mass casualty event. But I’ve got links galore to testimony and to the emergency dpeartment surge capacity report, by Chairman Waxman, to the cities surveyed - Chicago, Washington DC, Denver, Houston, Los Angeles, Minneapolis, New York, and by experts, Hoffman, Meredith, Lewis and Kaplowitz. As usual, the sole nurse testifying didn’t make it to the published testimony yet, but I’ll add the link if it becomes available.

Witnesses testified at a hearing about the ability of hospitals and medical facilities to respond to large-scale disasters. Among the issues they addressed were emergency planning for natural disasters and terrorist attacks, current response plans, medical and personnel assets needed to meet demands of large surges in immediate care needs, and the current state of emergency care facilities. They also talked about the impact of current Medicaid regulations on the ability to provide emergency treatment.

Because I worked in NYC and have been involved in emergency preparedness post 9/11 for it, I include the snapshot for NYC that was part of the seven cities surveyed, and I think it’s right on target for its estimation of capacity and resource utilization:

SNAPSHOT OF EMERGENCY SURGE CAPACITY IN NEW YORK CITY

At 4:30 p.m. on Tuesday, March 25, 2008, the majority staff of the Committee on Oversight and Government Reform surveyed 34 Level I trauma centers in seven cities, including the New York City, New York area.1 Level I trauma centers are hospitals that have the staff and facilities to offer the most comprehensive, around-the-clock trauma care. This snapshot survey found that there was little or no emergency surge capacity — the ability to handle a sudden influx of casualties — in the Level I trauma centers in any of the seven cities.

Sixteen of the 21 Level I trauma centers that serve over 12.6 million residents in the New York City area participated in the survey. New York City is classified by the Department of Homeland Security (DHS) as a Tier I city — a designation given to “high-threat, high-density urban areas” that are at the “highest risk” for acts of terrorism.

The survey assessed the capacity of the Level I trauma centers in New York City to respond to a terrorist bombing of a size similar to the 2004 Madrid bombing. According to the Centers on Disease Control and Prevention, the 2004 Madrid bombing, in which over 2,000 were injured and more than 270 patients were taken to one hospital within 2.5 hours, is an appropriate standard for assessing mass casualty preparedness.

The survey found that on Tuesday, March 25, 2008, at 4:30 p.m. local time:

• More than half of the emergency rooms in the Level I trauma centers surveyed in New York City were operating above capacity. When an emergency room reaches “capacity,” new patients can be accommodated only in overflow spaces, such as hallways, waiting rooms, or administrative offices. Of the 16 Level I trauma centers surveyed in New York City, ten were operating over capacity, meaning they had no available treatment space in the emergency room to accommodate new patients. The average emergency room was operating at 114% of capacity in the Level I trauma centers in New York City.

• The total number of available treatment spaces in the emergency rooms of the Level I trauma centers surveyed in New York City was insufficient to respond to a Madrid event. After the Madrid attack, 270 victims were transported to one hospital for emergency care. New York City did not have sufficient treatment spaces in emergency rooms of their Level I trauma centers to handle the volume of victims treated at one Madrid hospital. In total, the emergency rooms in the 16 Level I trauma centers in New York City had only 56 available treatment spaces, less than 21% of the demands faced by a single hospital in Madrid on the day of the bombing.
1 Committee on Oversight and Government Reform Majority Staff, Emergency Surge Capacity: The Failure to Prepare for the “Predictable Surprise” (May 5, 2008). The other cities are Los Angeles, Chicago, Washington, D.C., Houston, Denver, and Minneapolis.
2 Department of Homeland Security, Tier I Urban Area Security Initiative Jurisdictions (online at www.dhs.gov/xlibrary/assets/grants-2007-program-overview-010507.pdf).
3 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. In a Moment’s Notice: Surge Capacity for Terrorist Bombings (Apr. 2007).

Surge capacity depends on more than sufficient space in the emergency room. A hospital must also be able to provide sufficient critical care and inpatient resources, such as beds in intensive care units and burn units, and general inpatient beds. If these beds are not available, patients who require hospitalization are frequently “boarded” in the emergency room until they can be moved to an intensive care unit or inpatient bed. On the day of the survey, there were also acute shortages of these critical care and inpatient beds in the hospitals surveyed.

• None of the Level I trauma centers surveyed in New York City had enough critical care capacity available to treat the casualties from a Madrid event. After the Madrid attack, 29 patients arrived at one hospital in critical condition. None of the Level I trauma centers surveyed in New York City had the critical care capacity to handle this volume of severely injured victims. On average, the trauma centers surveyed had an average of only five intensive care unit beds available. Two hospitals (13%) had no available intensive care unit beds.

• None of the Level I trauma centers had a sufficient number of regular inpatient beds available to absorb the casualties from a Madrid event. In Madrid, 89 casualties required admission to a hospital bed. No Level I trauma center surveyed had enough beds available to accommodate a surge of this size. On average, the Level I trauma centers in New York City had only 23 beds available.

After conducting the “snapshot” survey on March 25 at 4:30 p.m., the Committee staff sent follow-up questionnaires to the hospitals surveyed. Twenty-three of the hospitals responded to the questionnaire. Their responses indicate that the level of emergency care they can provide is likely to be further compromised by three new Medicaid regulations, the first of which takes effect on May 26, 2008. According to these hospitals, the new Medicaid regulations will reduce federal payments to their facilities by $623 million per year. If the states choose to withdraw their matching funds, the hospitals could face a reduction of about $1.2 billion. The hospitals told the Committee that these funding cuts will force them “to significantly reduce services” in the future and that “loss of resources of this magnitude inevitably will lead to curtailing of critical health care safety net services such as emergency, trauma, burn, HIV/AIDS, neonatology, asthma care, diabetes care, and many others.”

Twelve of the Level I trauma centers in New York City responded to this financial impact survey. Based on the estimates of the administrators who responded, these hospitals could lose a total of $384 million in federal funds each year as a result of these Medicaid regulations. If the state were also to withdraw matching funds, these two hospitals could lose as much as $768 million per year. (emphasis added)

There are many aspects to a locality’s ability to respond effectively to a widespread emergency situation, whatever the cause and nature of the problem. It’s a huge field of study, and a single blog post won’t do it justice. So instead, I’ll link to some primary sources as I mention some of the factors, and I’ll focus this post on what happens as soon as a “mass cas” is announced in a large academic teaching level one trauma center. Moreover, I’ll prognosticate on where the bottlenecks and system failures will occur inside the medical center walls and outside to its service area.

First off, emergency departments are almost universally overwhelmed and understaffed as they become the de facto shredded safety nets in the US non-system “system” of free market healthcare for the richest. Primary care providers - family physicians, general internists and pediatricians - are also on the front lines of those squeezed for “cost savings” while their more highly reimbursed brethren - largely the specialists and boutique hospitals and surgery centers - skim the remaining cream from the souring milk of healthcare reimbursement mechanisms.

But emergency departments, none the less, are expected to have all doors open and the wheels greased ready at a literal moment’s notice to accept surges of patients for days - weeks - on end. And while communities and regions drill for overall emergency preparedness, nowhere does the rubber meet the road as in the emergency department.

Most emergencies don’t conveniently occur during Monday through Friday administration carpet row business hours between 9 and 5. So for reality sake, let’s speak about a weekend evening event - one that occurs when staff is skeletal, services are constricted and daylight has wained.

For the sake of our post, let’s posit that a hurricane has struck land at an Eastern Seacoast city, and that in so doing, two passenger planes have crashed - one coming down on the runway, and the other going into the water just off the end of the runway. Simultaneously, flood walls are failing, and the city is experiencing rapidly flooding roadways with encroachment into the infrastructure: the subway is inoperable, buses can’t pass to evacuate residents, and trains can no longer run. The ferry system around the city is inoperable due to the high wind and waves. Sound familiar - I gave it a ring of Katrina, but as our populations are heavily concentrated on the coasts, the numbers lean in favor of this kind of event.

The city has declared a mass casualty, and the governor has been notified, as well as all of the local governmental, law enforcement, fire, emergency responder and hospital agencies. Residents have been instructed to evacuate from the three fourths of the city that are closest to the coast, and the remainder are being instructed to shelter in place.

Shortly after the first public announcements, one of the television stations reports the crashes of the two airplanes and intimates that it could be due to terrorism.

Now the roadways are clogged with all manner of vehicles. People are standing in the dark roadways calling out for rides from passersby. Dispatched police officers are attempting to divert traffic away from flooding and flooded areas, but are themselves being driven back by rising waters. A few inflatable craft and rowboats are being deployed for use by police.

Back at the trauma center, the nursing supervisor (this being off hours, there is no administrator in the house, and the nursing supervisor wears all of the hats: administrator on site, media relations, staffing coordinator and nursing director, among the most common), has pulled out the facility’s emergency preparedness policy and procedure manual based on HEICS, and she’s contacted the safety and security department, as well as the administrator on call and the emergency department. Because the hurricane has not abated, she has been working with shorter staffing than usual due to many staff being unable to travel to the hospital, and she has been making walking rounds to assure that all safety precautions during the hurricane have been followed - keeping patients away from windows, drawing curtains, moving patients to interior corridors, and deploying staff to reassure and comfort patients distressed from the noise of the storm.

The telephone system has just failed, and the power has flickered. She has contacted the building’s facilities personnel to assure that the backup generators are functional, and that the emergency phone system is operational. She has also been instituting the organization’s emergency call-in telephone tree to begin to call in available staff for the now declared emergency.

Meanwhile, the emergency department is communicating with the local emergency response team about receiving the casualties from both the hurricane (flood, electrocution and motor vehicle accident victims) and the aviation accident victims (burns, drowning, multiple trauma, prolonged extrication, crush injuries).

The nursing supervisor is continuing to follow the algorithm of the mass cas protocol and is toggling between communicating with the emergency department charge nurse about anticipated needs of inpatient beds, OR and PACU time and staffing, as well as emergency procurement of ventilators and other equipment needed to care for critically ill and injured patients. She is making lists of staff who can be transferred to the OR, PACU and critical care units by virtue of their clinical competence and availability. She is also making lists of patients who may be able to be discharged if they are deemed stable, have a means to travel outside the hospital and a place to go. If not, she is planning a holding area in unused waiting rooms for these patients to make room for the victims on the way.

Meanwhile, staff throughout the trauma center are being informed that a mass cas has been declared and that they will not be released from duty at the end of their scheduled shifts until relief staff arrives. The nursing supervisor is working with safety and security to create sleeping and rest places for staff in unused call rooms, former patient care areas and anywhere that cots or beds can be moved into place and where restroom and shower facilities are accessible to staff.

This is just the first fifteen minutes, folks.

But this is enough for you to get the underlying principle: the use and prioritization of scarce resources.

Interestingly, PhysOrg published a story yesterday about physicians’ triage list for use of scarce services and resources during a flu pandemic. A pandemic also qualifies as a mass casualty event, and so I include it here for your perusal.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn’t be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals “so that everybody will be thinking in the same way” when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

But wait, according to the Republican testimony yesterday, emergency departments are just empty and waiting for victims to appear on their doorsteps, and this is what yesterday’s testimony was refuting. The Washington Post reported it in terms of political affiliation, but this is not a political issue: it’s an issue of using already strained and overstretched resources which operate at over 100% capacity and expect them to do the impossible.

Hospitals in seven major U.S. cities would be overwhelmed if any of the cities were struck by a terrorist attack on the scale of the 2004 train bombings in Madrid, and shortages of emergency room capacity and intensive care beds will grow worse if Bush administration Medicaid changes are implemented, House Democrats charged yesterday.

In a survey by the House Committee on Oversight and Government Reform, more than half of 34 hospitals in five U.S. cities deemed at greatest risk of attack and two cities that will host this summer’s national political conventions said they had no emergency room treatment space available to accept severely injured patients.

[snip]

President Bush has threatened to veto legislation passed by the House last month that would impose a one-year moratorium on Medicaid reimbursement changes sought by HHS. States argue the changes would shift costs of the program to them, but the White House argues that states are padding their overall budgets with the reimbursements.

Planned changes to the program, which provides medical insurance for the poor, would eliminate reimbursement for residents and interns at teaching hospitals and payments to public hospitals. The Congressional Budget Office says the moves would reduce federal spending by about $17.8 billion over five years.

Jay Wayne Meredith, chairman of the general surgery department at Wake Forest University Baptist Medical Center, testified yesterday that the changes would cost his hospital $36 million, on top of $4.5 million it spends on its trauma center and $13 million to care for the uninsured. “We will go under,” he said, warning that the hospital would have to kill its trauma center. “I just beg you, stop the Medicaid cuts.”

[snip]

Hospital officials and Republican aides said the statistics are misleading because emergency room space and inpatient beds would be cleared in an actual emergency. Other cities surveyed were Chicago, Houston, Denver and Minneapolis.

Really? Emergency Room space and inpatient beds will be cleared in an emergency?
Well, fellas, I hate to tell you, but patients haven’t convalesced in hospitals since the early 1980s with the advent of prospective payment and HMOs. The only patients with a chance of being medically cleared would be the few referenced above: those stable, with a means of transportation and place to go.

In all likelihood, on a Saturday evening during a hurricane - or during any other mass casualty event, the last place law enforcement personnel want anyone is out on the street. So discharging them in all likelihood is fantasy and not feasible.

That means that the already present emergency department patients will be stabilized as rapidly as possible and dispositioned as discharged, but held in place - stay safe in the shelter of the hospital, or admitted and placed in the first available bed, which as you may remember from the top of the post - the hospital is already baseline short staffed due to the hurricane and weekend staffing pattern.

Then add trying to get additional staff, equipment and resources in when transportation has already been drastically curtailed, and you do the math. In all probability, only a few replacement staff will make it in, equipment will only be forthcoming if the suppliers haven’t made identical emergency supply contracts for the same stock of equipment with other local facilities, the just in time materials management systems will have depleted in-house stock to just a few days’ worth for an average daily census and not for a surge census, and resources will likely be scarcer - and not more robust - during and immediately after the hurricane and air crash victim rescue and recovery period.

Now back to our emergency department: Using the ICS - incident command system algorithms, the ED staff has cleared out all but a couple of patients, and it is doubling up resources in each trauma bay, as well as the medical resuscitation bays. Nurses from the PACU have come to the department to augment staff, and the critical care units are triaging patients as they can out of their units. Residents and interns are evaluating all patients throughout the institution for their stability, prognosis, resuscitation status and use of resources.

All of that information is being sent to the nursing supervisor in real time, and she is communicating with the emergency department attending physicians and charge nurse so that there is a working plan to triage and treat patients as they arrive.

One of the worries is about the number of ventilators that might be needed - especially in light of anticipated patients who are drowning victims, and the availability of them. Moreover, because of the nature of the injuries anticipated by the aviation victims, OR time, resources and critical care bed availability is going to be an issue.

As the first patients arrive via EMS and private cars, the emergency department goes into full mass cas operation, triaging and tagging patients by the nature of their injury, the severity and by prognosis. A supply of body bags and extra stretchers are nearby to take DOAs directly to the morgue, where they will be able to be identified and will be out of the way of the clinical staff.

Security staff maintain the morgue registry and oversee the access to it. There is no possibility of funeral homes or the coroner’s office of arriving to claim bodies during or immediately after the event.

And on it goes. But that’s reality. And that’s what the emergency departments face, regardless of the type of the event. There isn’t any flexibility and resilience in the ability of emergency departments to staff up and accommodate more patients. So when they arrive - and they will - patients will suffer and patients will die preventable deaths.

And what I didn’t spell out before, I will now: the primary resource that will determine who lives and who doesn’t is the availability of clinically competent registered nurses to provide the care from door to discharge for all of the patients. There are not enough professional nurses now, and in a large scale emergency, there will be even fewer than needed to adequate provide professional nursing care to patients. That, my friends, is in ever-increasing short supply.

Happy Nurses Week.

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