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Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Online Only Articles |

Surge Capacity PrinciplesSurge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement FREE TO VIEW

John L. Hick, MD; Sharon Einav, MD; Dan Hanfling, MD; Niranjan Kissoon, MBBS, FRCPC; Jeffrey R. Dichter, MD; Asha V. Devereaux, MD, MPH, FCCP; Michael D. Christian, MD, FRCPC, FCCP; on behalf of the Task Force for Mass Critical Care
Author and Funding Information

From Hennepin County Medical Center (Dr Hick), University of Minnesota, Minneapolis, MN; Shaare Zedek Medical Center (Dr Einav), Hebrew University Faculty of Medicine, Jerusalem, Israel; Inova Health System (Dr Hanfling), Falls Church, VA; George Washington University (Dr Hanfling), Washington, DC; BC Children’s Hospital and Sunny Hill Health Centre (Dr Kissoon), University of British Columbia, Vancouver, BC, Canada; Allina Health (Dr Dichter), Minneapolis, MN; Aurora Healthcare (Dr Dichter), Milwaukee, WI; Sharp Hospital (Dr Devereaux), Coronado, CA; Royal Canadian Medical Service (Dr Christian), Canadian Armed Forces and Mount Sinai Hospital, Toronto, ON, Canada.

CORRESPONDENCE TO: John L. Hick, MD, Hennepin County Medical Center, 701 Park Ave S, Minneapolis, MN 55415; e-mail: John.hick@hcmed.org


FUNDING/SUPPORT: This publication was supported by the Cooperative Agreement Number 1U90TP00591-01 from the Centers of Disease Control and Prevention, and through a research sub award agreement through the Department of Health and Human Services [Grant 1 - HFPEP070013-01-00] from the Office of Preparedness of Emergency Operations. In addition, this publication was supported by a grant from the University of California–Davis.

COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

DISCLAIMER: American College of Chest Physicians guidelines and consensus statements are intended for general information only, are not medical advice, and do not replace professional care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this consensus statement can be accessed at http://dx.doi.org/10.1378/chest.1464S1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(4_suppl):e1S-e16S. doi:10.1378/chest.14-0733
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BACKGROUND:  This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS:  The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel.

RESULTS:  This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure).

CONCLUSIONS:  Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.

Figures in this Article
Role of Critical Care in Disaster Planning

1. We suggest hospital and local/regional disaster committees include a critical care expert to optimize critical care surge capacity planning.

Surge Continuum: Conventional, Contingency, and Crisis Care

2. We suggest utilization of the existing framework for surge response that recognizes the shift in surge response across thresholds that distinguish conventional surge from contingency surge from crisis surge and delivery of crisis care is important in ensuring consistency in planning for critical care surge response.

Targets for Surge Response

3. We suggest in the presence of a slow-onset, impending disaster/threat, targets for surge capacity and capability be focused, where possible, on projected patient loads.

4a. We suggest hospital critical care resources be able to expand immediately by at least 20% above the baseline ICU maximal capacity for a conventional response.

4b. In a contingency response, we suggest hospital critical care resources be able to expand rapidly by at least 100% above the baseline ICU capacity to meet patient demand using local and regional resources.

4c. We suggest hospital critical care resources be able to expand by at least 200% above baseline ICU capacity to meet patient demand in a crisis response using any combination of local, regional, national, and international resources.

5. We suggest more prolonged demands on critical care compared with the demands placed on other sections of the hospital (ie, days rather than hours) be taken into consideration when resuming routine hospital activities that may require ICU support.

Situational Awareness and Information Sharing

6. We suggest facilities, coalitions, and other components of the emergency response system, including those related to government entities, study how information about patients, events, and epidemiology are shared on a routine basis and during a major incident. Information technology should be leveraged to provide better indicators, more rapid alerting, and better patient data to facilitate decision-making.

7. We suggest the ability to provide dynamic forecasting of the functioning and sustainability of the supply chain be supported by hospitals.

Mitigating the Impact on Critical Care

8a. We suggest medically fragile patients be supported and protected by pre-event planning for ongoing medical support in the community to mitigate their reliance on hospital-based resources during a disaster event.

8b. We suggest local and regional authorities be responsible for integration of preventive community medical support in the plans to treat medically fragile patients during disasters.

8c. Given a situation where mitigation measures fail, medically fragile patients and victims of a disaster or pandemic should be given equal consideration for access to ICU resources.

Planning of Surge Capacity for Unique Populations

9a. We suggest regional planning include the expectation that the hospital be able to provide initial stabilization care to unique populations that they may not normally serve such as pediatric, burn, and trauma patients.

9b. We suggest access to regional expertise for care of all patients who require specialty critical care services, including participation in the planning phase and access to just-in-time consultation for care coordination during a response.

Service Deescalation and Engineered Failure

10a. We suggest hospitals adopt a process of engineered systems cessation when the staff and/or material resources required for the ongoing critical care of a small number of patients could be used to save a greater number of lives.

10b. We suggest hospital cessation of the delivery of critical care services be considered if such endeavors are likely to entail significant personal risk to the treating team despite the availability of personal protective equipment and appropriate medical countermeasures.

10c. We suggest a hospital’s decision to restrict or expand the delivery of critical care be made as part of a local/regional decision-making process, with consultation and input provided by hospital ICU leadership.

This article focuses on key operational strategies and conceptual frameworks for the expansion of intensive care services in hospitals that customarily provide such care in the developed world. This may include expanding critical care surge capacity and extending critical care service capabilities or may require the limitation and scaling back of such services in disasters. The suggestions in this article are important for all involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, and public health or government officials. Although it is important for all providers to be familiar with all aspects of surge response, Table 1 provides an overview of the suggestions most of interest to each group. A companion article in this guideline by Einav et al1 addresses specific resources and tactics that describe the logistics required to support critical care surge capability.

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TABLE 1 ]  Primary Target Audiences for Suggestions

The methods used by the task force in developing the suggestions in this article were consistent with the policies of the American College of Chest Physicians (CHEST) Guidelines Oversight Committee. The Surge Capacity topic panel convened in June 2012 and first developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Searches were limited from January 1995 to October 2012; English-language articles were included, and non-English language articles were excluded. A total of 1,444 articles were identified. The results were reviewed for relevance to the topic and the articles screened by two topic editors (J. L. H. and S. E.) for inclusion. The lead topic editor (D. H.) was responsible for resolving the results where initial consensus was not achieved. Seven hundred twenty-seven articles were deemed relevant to the subject of surge capacity planning and response. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. (See the “Methodology” article by Ornelas et al2 in this consensus statement.) (e-Appendixes 1 and 2 provide lists of key questions, key suggestions, and corresponding search terms and results.)

Role of Critical Care in Disaster Planning

1. We suggest hospital and local/regional disaster committees include a critical care expert to optimize critical care surge capacity planning.

Input from critical care physicians often is excluded in preparations for and organization of hospital disaster surge response plans because of an emphasis on emergency and surgical services preparedness activities. However, critical care services often are significantly affected during disasters or pandemics. For example, critically injured patients may comprise 26% of the patient load during terrorist bombings (a nearly four-fold increase over conventional traumatic injury),3 and pandemic influenza has accounted for > 15 times the ICU admissions compared to seasonal influenza.4 Critical care services are an integral part of a continuum of care to decrease mortality, and hence, early involvement of critical care services in preparedness activities is necessary.

Critical care physician input into the planning process is required from local and regional levels to ensure that key considerations (eg, issues with staff transfer, specific resources that may be required, transfer considerations for ICU patients) are addressed, that valid assumptions are being used in planning and policies, and that a mechanism exists during an event for their expertise to be incorporated into response actions. This may include providing input on evacuation decisions and resource distribution, sharing treatment information between facilities, or developing common treatment or triage policies. Modeling has shown that maximizing available regional resources can have a significant impact on the ability to cope with large volumes of pediatric ICU patients.5-7

Surge Continuum: Conventional, Contingency, and Crisis Care

2. We suggest utilization of the existing framework for surge response that recognizes the shift in surge response across thresholds that distinguish conventional surge from contingency surge from crisis surge and delivery of crisis care is important in ensuring consistency in planning for critical care surge response.

Disasters affect critical care in many ways, depending on the onset, impact, and duration of the incident (Table 28).9 The impact of the event will drive peak demand at the facility, whereas the scope of the event (local, regional, or national) will dictate available options for supplies and patient transfers. Sudden-impact disasters (Table 3) challenge facilities with the immediate arrival of casualties and place demands on space, staff, and supplies—the key logistical components of surge capacity.10,11 Sudden-impact disasters may affect ED services, which are of short duration, but the impact of even sudden disasters on critical care and surgical services may last days or even weeks.12-15

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TABLE 2 ]  Surge Continuum Taxonomy

Definitions from Hick et al.8

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TABLE 3 ]  Challenges and Considerations Affecting Critical Care in Disasters

Fortunately, mass casualty incidents involving > 40 victims are rare, occurring only 10 to 15 times per year on average in the United States.16 Mass causality modeling17,18 and practical expectations19-21 (including hospital requirements in Israel) both agree that a 20% surge capacity will accommodate most acute incidents. Thus, it is unusual for a typical mass casualty event to exceed available community resources.22 However, failure to plan for a larger incident will result in an inadequate response because it is not possible to cope with an event of unusual size with usual practices. Effective hospital preparedness programs correlate with lower rates of hospital mortality in major disasters compared with lesser prepared facilities.23 Slow-onset, anticipated disasters (Table 3), such as hurricanes or pandemics, offer the opportunity to prepare, make proactive decisions, and mitigate impact, but these pose unique challenges of maintaining a sustained surge response over many days, often with limited or no resources. In most mass casualty incidents, demands are met by delivering conventional care with occasional contingency measures.24 However, delivery of critical care in non-ICU environments carries some risk to patients25 (Fig 1).

Figure Jump LinkFigure 1 –  A framework for critical care surge capacity planning, outlining the conventional, contingency, and crisis surge responses. PACU = postanesthesia care unit.Grahic Jump Location

Although most disasters can be managed with conventional or contingency care, in specific circumstances (Table 4), a crisis response may be required. In these cases, a crisis situation exists when a resource or resources are in such shortfall that decision-making moves from patient-centered to population-centered; maximizing the use of available resources to save more lives. This shift may necessitate resource triage. A substantial number of publications since 2008 have focused on crisis care applicable to critical care planning.8,36-38

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TABLE 4 ]  Situations Potentially Requiring a Crisis-Level Surge Response
Targets for Surge Response

3. We suggest in the presence of a slow-onset, impending disaster/threat, targets for surge capacity and capability be focused, where possible, on projected patient loads.

4a. We suggest hospital critical care resources be able to expand immediately by at least 20% above the baseline ICU maximal capacity for a conventional response.

4b. In a contingency response, we suggest hospital critical care resources be able to expand rapidly by at least 100% above the baseline ICU capacity to meet patient demand using local and regional resources.

4c. We suggest hospital critical care resources be able to expand by at least 200% above baseline ICU capacity to meet patient demand in a crisis response using any combination of local, regional, national, and international resources.

5. We suggest more prolonged demands on critical care compared with the demands placed on other sections of the hospital (ie, days rather than hours) be taken into consideration when resuming routine hospital activities that may require ICU support.

Surge capacity and capability planning should be conducted with specific and achievable targets for increasing patient care services.39 Sudden-onset disaster events are characterized by the need to triage (primary and secondary triage), admit, and stabilize a high volume of patients over a brief time frame (hours) in the ED. Patients admitted to the ICU are fewer than those treated in the ED but occupy ICU beds 10 to 100 times longer (days to weeks) than the time they spent in the ED.12-15 In the presence of a slow-onset, impending disaster or pandemic, targets for surge capacity and capability should be focused, where possible, on projected patient loads.

The targets for conventional care (at least 20% beyond usual capacity) are generally achieved using resources immediately available within the facility (vacant beds, discharge of patients to lower-intensity care units, cancellation of procedures)40 and should be achieved within a 2-h period. Depending on the role of the hospital in community response (eg, the only level I trauma center or pediatric facility in the area) and the hazards identified in the community (eg, risk for earthquake, terrorism), it may be prudent to plan for additional conventional capacity. Contingency care (100% beyond usual capacity or two times the usual ICU beds) typically requires care to be provided in nontraditional areas (postanethesia care unit, operating rooms) using community or regional resources and should be achieved with adequate preplanning of supplemental equipment (monitors, beds, and ventilators) within 12 h of the event. A key factor that may limit achieving this goal is the availability of ventilators, requiring anesthesia machines and regional stockpiles to be used.41 Crisis care (200% beyond usual capacity or three times the usual ICU beds) will most likely require access to outside resources, such as strategic national stockpiles, and will likely require 48 to 72 h to achieve. The facility should identify what spaces would be used and what supplemental supplies (monitors, beds, and ventilators) would be required to minimize delays if occasion warrants.42

With current practices of just-in-time staffing and supplies, few facilities have a large number of readily available resources for critical care in disaster situations.43 This makes participation in regional coalitions imperative to leverage regional resources when local resources are insufficient.44-47 Further discussion of the importance of coalitions and regional response may be found in the article “System Level Planning, Coordination, and Communication” by Dichter et al48 in this guideline.

Hospitals that are affected by a disaster and have moved to contingency or crisis care response mode are expected to engage community partners to request resources or transfer patients to facilities with available resources. However, during the 2009 influenza A(H1N1) pandemic, certain health-care facilities were considering triage of extracorporeal membrane oxygenation and mechanical ventilation without being aware that these resources were available at other local facilities (N. Lurie, MD, MSPH, Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, personal communication, January 2013).

Prior to an event, critical care physicians should understand how their hospital participates in the response process and how their response tiers represent geographically layered entities that range from the local hospital and health-care coalitions and regional authorities, to regions, state/province, interstate/province, and national authorities (Fig 2). Understanding the resources available at each level and how they are accessed is necessary to exchange information and obtain resources quickly during an event. These mechanisms, including exercises with a critical care component or focus, should be tested a priori.

Figure Jump LinkFigure 2 –  Various tiers of authority are involved in health-care surge response. Not all jurisdictions have Regional Health Authorities, in which cases, health-care coalitions work directly with the state or province. Hosp = hospital. (Adapted from the Medical Surge Capacity and Capability Handbook.49)Grahic Jump Location
Situational Awareness and Information Sharing

6. We suggest facilities, coalitions, and other components of the emergency response system, including those related to government entities, study how information about patients, events, and epidemiology are shared on a routine basis and during a major incident. Information technology should be leveraged to provide better indicators, more rapid alerting, and better patient data to facilitate decision-making.

7. We suggest the ability to provide dynamic forecasting of the functioning and sustainability of the supply chain be supported by hospitals.

Timely and ongoing provision of incident updates to hospitals allows the facility to tailor its response to the demands of the incident. Awareness of other critical care resources in the area allows the facility to balance demand by either providing or requesting assets, depending on the impact at their facility and other facilities. Decisions regarding the implementation of mass critical care and the levels and types of care anticipated will rely on the timely exchange of information that facilitates situational awareness and the specific needs for critical care services as the event unfolds.

The ability to provide such situational awareness relies on well-established systems of both hardware (eg, radio, Internet-based information exchange) and software (ie, the systems and policies that define the process and scope of information exchange between facilities and agencies). A mechanism must also be in place for hospitals to obtain validated information from public safety sources and a process (hospital coalition staff, other resources) to filter what is relevant (eg, street closures that will have an impact on staff response) and provide timely, accurate, and useful updates to facilities.

Alerting hospitals about an event should occur by predetermined, redundant methods to ensure receipt of the information. How notification is triggered and the response engendered at the hospital should be part of a structured process. The hospitals should consider available indicators (disease incidence, reports of events in the community, etc) and define appropriate trigger thresholds for hospital notification and activation of its disaster plan as well as for engaging regional hospital coalition partners. A thorough discussion of indicators and triggers published by the Institute of Medicine38 may be a valuable resource for communities to define or reevaluate the indicators they use and the actions they take in response.

Monitoring of indicators and resources, such as available ICU beds, should be standard daily practice so that in the event of a disaster, incident managers are aware of their facility’s capacity and when they should call for assistance. Available, staffed beds are important but serve as only one indicator of capacity once a disaster plan is activated. Hence, updates from facilities are important to define the actual capacity of the system and balance this against the demands of an evolving incident.

What additional information is tracked (ventilators, medications, and staffing) depends on local policies, processes, and the specifics of the event. For instance, more-frequent discussion and information sharing must occur if facilities are operating in crisis mode or if the event is prolonged. Definitions and categorization of the information collected should be understood and accurate to be of use during an event; otherwise, the information collected will be inconsistent or misleading.50-52 These efforts at the coalition level must be closely integrated with the incident management processes of the jurisdiction to ensure coordination of efforts and congruency of priorities, including participation of the coalition in a Joint Information System.

Mitigating the Impact on Critical Care

8a. We suggest medically fragile patients be supported and protected by pre-event planning for ongoing medical support in the community to mitigate their reliance on hospital-based resources during a disaster event.

8b. We suggest local and regional authorities be responsible for integration of preventive community medical support in the plans to treat medically fragile patients during disasters.

8c. Given a situation where mitigation measures fail, medically fragile patients and victims of a disaster or pandemic should be given equal consideration for access to ICU resources.

Critical care resources are finite, and there will always be situations in which hospital resources will be insufficient to meet demands. To avert or delay this situation, prevention of excessive patient loading and advocacy for prevention and early treatment of illness and injury to forestall progression of illness are important (Table 5).

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TABLE 5 ]  Mitigating Factors on Critical Care Demand

Medically fragile patients (home-bound patients reliant on critical care equipment or specialized care or treatment and long-term-care facility residents) are likely to deteriorate during disasters due to decreased access to medications and medical support in the community.73,74 Preventable increases in use of hospital-based resources by medically fragile patients can blunt the surge response. Therefore, every effort should be made to encourage patient and caregiver preparedness and enhance the ability of shelters and long-term-care facilities to provide care during and after an event.75 Critical care physicians should ensure that patients on home oxygen or ventilation (including noninvasive ventilation) have contingency plans for loss of power and that community shelters can provide care because these patients can place severe demands on hospital resources following blackouts and natural disasters.76,77 However, when such patients present to acute care facilities during disasters, they should be triaged and treated similarly to any other patient presenting for care.

When mitigation of impact is not successful in preserving adequate resources, we suggest the common strategies of conserve, substitute, adapt, reuse, and reallocate from the 2008 series continue to be used to proactively and fairly preserve or extend the availability of resources (Table 6). Before instituting resource-sparing strategies, hospitals should exhaust all avenues to obtain supplies from partners in their health-care coalition or other neighboring health-care facilities.

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TABLE 6 ]  Example Strategies for Addressing Resource Deficits and Usual Associated Response Categories
Planning of Surge Capacity for Unique Populations

9a. We suggest regional planning include the expectation that the hospital be able to provide initial stabilization care to unique populations that they may not normally serve, such as pediatric, burn, and trauma patients.

9b. We suggest access to regional expertise for care of all patients who require specialty critical care services, including participation in the planning phase and access to just-in-time consultation for care coordination during a response.

Certain patient groups may require specialized equipment (eg, those with morbid obesity78), and some may require both equipment and expertise (usually provided at specialty centers). Although most hospitals that provide critical care do not serve specialty patients, such as burn, trauma, maternity, or pediatric patients, during a disaster, all hospitals should be prepared to receive, stabilize, and treat these populations for the first 48 h.79-85 This involves basic supply preparedness as well as ensuring that staff members have basic training and some quick-reference resources available to care for these patients. An overview of key considerations for regional plans is outlined in Table 7 and an in-depth discussion of critical care surge planning for special populations is presented elsewhere in this supplement.93

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TABLE 7 ]  Key Considerations for Regional Plans

Specialty regional plans, such as for burns, trauma, and pediatrics, should be organized similarly to general systems, with similar regional coordinating entities, thresholds, activation plans, use of subject matter experts, and planning and training resources. This common framework helps to promote familiarity of roles and expectations and may improve event performance.

Service Deescalation and Engineered Failure

10a. We suggest hospitals adopt a process of engineered systems cessation when the staff and/or material resources required for the ongoing critical care of a small number of patients could be used to save a greater number of lives.

10b. We suggest hospital cessation of the delivery of critical care services be considered if such endeavors are likely to entail significant personal risk to the treating team despite the availability of personal protective equipment and appropriate medical countermeasures.

10c. We suggest a hospital’s decision to restrict or expand the delivery of critical care be made as part of a local/regional decision-making process, with consultation and input provided by hospital ICU leadership.

In certain settings, the resources required to provide critical care may represent such a disproportionate investment of time and available resources that providing full intensive care support is judged inappropriate. This is different from situations in which a select resource is unavailable, as discussed in the “Triage” article by Christian et al94 in this guideline, or a situation in which critical care is chronically constrained, such as a in a developing nation experiencing a disaster, which is discussed in the “Resource-Poor Settings: Infrastructure and Capacity Building” article by Geiling et al39 in this guideline.

Hospital services, including critical care, should not continue per usual or cease completely in a binary fashion. Rather, engineered failure should occur, with restriction of certain services that consume the most time and resources first followed by others as the situation worsens.95,96 The process may be thought of as akin to shutting down certain high-demand circuits to preserve an electrical system.

Orderly deescalation of services preserves the ability to provide essential services by preventing catastrophic failure of the system and redirects resources for the response. In some acute disasters that directly affect the facility, planned deescalation may not be possible. General considerations when assessing resource commitments are presented in Table 8.97 Use of these categories of resource commitment has also been used in prior nuclear incident modeling.98 Overall approaches to decrease demand entail two components: (1) decreasing existing demands on the system, thereby freeing capacity for surge response, and (2) diverting new demands for services away from the system, thus preventing the consumption of that resource. Often, there is a reflex response to cancel all elective surgeries and close all outpatient clinics. This is easier to operationalize in a sudden isolated surge event but much more complex in a prolonged surge situation.

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TABLE 8 ]  Key Components To Consider When Assessing Resource Commitments

(Adapted from US Dept. of Defense Common User Database.97)

Specifically, decisions about which services can or will be provided and which cannot or will not be provided should be based on a consideration of (1) the consequence to patients of suspending or delaying the service, (2) the resource requirements of that service, and (3) the ability to provide the resources in the context of altered standards of care99 (Fig 3). Health-care coalitions or regional health authorities should have a central committee imbued with adequate situational awareness that will inform (or make, depending on authority) decisions regarding the deescalation and reestablishment of services. Ideally, these activities should be supported at a national level, when possible, by professional societies developing classifications for prioritizing patients.

Figure Jump LinkFigure 3 –  Matrix for deescalation planning.Grahic Jump Location

In certain scenarios (Table 9100), it is not prudent to expend significant staff time, expertise, and resources on a few patients (eg, those receiving extracorporeal membrane oxygenation33,101-103) when many other patients are in need of and could benefit from stabilization care to prevent multiorgan failure. A process to determine which therapies will continue to be offered and which require restriction to allow critical care resources to be redeployed should be in place. The decision to limit critical care services should always be made jointly between the hospital incident commander and the critical care services leadership in coordination with the health-care coalition or regional health authority. Some events are so overwhelming and immediate that the clinician has no choice but to deescalate care (eg, a bomb or natural disaster destroys a significant portion of the facility, posing an imminent threat); however, in all other situations, decisions to deescalate should be made in concert with other elements of the emergency response system and not by individuals or clinical teams alone (see the “Legal Preparedness” article by Courtney et al104 in this consensus statement).

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TABLE 9 ]  Scenarios Where Deescalation of Critical Care Services May Be Considered

When such a situation arises, it should be communicated to the regional hospital coalition and ideally to public health and other jurisdictional agencies. Importation of resources and transfer of patients to other areas should be exhausted as options before restrictions on care are made. Restrictions generally should be the least restrictive to meet the incident demands and should be lifted as soon as resources allow.

Most of the suggestions regarding surge preparation and response would benefit significantly from rigorous scientific research to build a base of evidence to guide effective surge capacity development. Formal study of the role of critical care physicians in disaster leadership would enhance their involvement and effectiveness in these situations. In addition, most of the suggestions regarding the capacity required to respond to specific situations are purely theoretical and would benefit from verification of realistic targets for surge capacity using mathematical modeling. Simulation research informed by modeling can be used to determine a hospital’s ability to achieve targets and how best to implement strategies most effectively. In virtually every disaster, communication and information exchange is a challenge. There is a significant need for psychology, sociology, and information technology researchers to collaboratively develop and test tools to improve communication and information exchange during disasters. The importance of critical care is increasingly recognized and integrated into disaster management systems, presenting an opportunity to develop novel approaches to other areas of disaster management. Similarly, situational awareness of critical care resources is a key component of mounting an effective response during a disaster or pandemic. Research is required to develop useful tools for real-time tracking and dissemination of critical care resources. Furthermore, in the event of an overwhelming disaster or pandemic requiring critical care services to be scaled back, good evidence is lacking about the best manner in which to implement engineered failure to minimize harm overall and most effectively preserve the remaining functions within the system.

Critical care services should accommodate a spectrum of incident impacts and provide conventional, contingency, and crisis care. As a hospital moves to contingency and crisis care, health-care coalition and jurisdictional entities become partners in maximizing capacity and capabilities and provide regional consistency of care. Appropriate incident notification and ongoing situational awareness, resource tracking and management, and transfer management are roles coalitions or regional governments play to achieve the greatest good for the greatest number of people. Reducing the impact on hospital and critical care services is a key factor in preserving capacity. All hospitals should be prepared to care for trauma, burn, and pediatric patients in case an event overwhelms or incapacitates a key specialty center. In certain situations, the resources required to provide critical care may be better applied to other patients or victims, and critical care may be limited to free up these resources. This should be a joint institutional and regional decision and, thus, relies on strong facility and regional command, control, and communication systems to consider and implement these shifts in care.

Author contributions: J. L. H. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. J. L. H., S. E., D. H., N. K., J. R. D., A. V. D., and M. D. C. contributed to the development of PICO (population, intervention, comparison, and outcome) questions, expert opinion suggestions, study concept and design, and data acquisition, analysis, and interpretation based on the Delphi process; J. L. H., S. E., and D. H. contributed to the literature review and drafting of the manuscript; And N. K., J. R. D., A. V. D., and M. D. C. contributed to the critical revision of the manuscript for important intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Hanfling is a consultant on anthrax management for GlaxoSmithKline plc. Dr Einav has received grant funding unrelated to this consensus statement. Drs Hick, Kissoon, Dichter, Devereaux, and Christian have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The American College of Chest Physicians was solely responsible for the development of these guidelines. The remaining supporters played no role in the development process. External supporting organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.

Endorsements: This consensus statement is endorsed by the American Association of Critical-Care Nurses, American Association for Respiratory Care, American College of Surgeons Committee on Trauma, International Society of Nephrology, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Society of Hospital Medicine, World Federation of Pediatric Intensive and Critical Care Societies, World Federation of Societies of Intensive and Critical Care Medicine.

Other contributions: The opinions expressed within this manuscript are solely those of the author (M. D. C.) and do not represent the official position or policy of the Royal Canadian Medical Service, Canadian Armed Forces, or the Department of National Defence.

Additional information: The e-Appendixes can be found in the Supplemental Materials section of the online article.

Collaborators: Executive Committee: Michael D. Christian, MD, FRCPC, FCCP; Asha V. Devereaux, MD, MPH, FCCP, co-chair; Jeffrey R. Dichter, MD, co-chair; Niranjan Kissoon, MBBS, FRCPC; Lewis Rubinson, MD, PhD; Panelists: Dennis Amundson, DO, FCCP; Michael R. Anderson, MD; Robert Balk, MD, FCCP; Wanda D. Barfield, MD, MPH; Martha Bartz, MSN, RN, CCRN; Josh Benditt, MD; William Beninati, MD; Kenneth A. Berkowitz, MD, FCCP; Lee Daugherty Biddison, MD, MPH; Dana Braner, MD; Richard D Branson, MSc, RRT; Frederick M. Burkle Jr, MD, MPH, DTM; Bruce A. Cairns, MD; Brendan G. Carr, MD; Brooke Courtney, JD, MPH; Lisa D. DeDecker, RN, MS; COL Marla J. De Jong, PhD, RN [USAF]; Guillermo Dominguez-Cherit, MD; David Dries, MD; Sharon Einav, MD; Brian L. Erstad, PharmD; Mill Etienne, MD; Daniel B. Fagbuyi, MD; Ray Fang, MD; Henry Feldman, MD; Hernando Garzon, MD; James Geiling, MD, MPH, FCCP; Charles D. Gomersall, MBBS; Colin K. Grissom, MD, FCCP; Dan Hanfling, MD; John L. Hick, MD; James G. Hodge Jr, JD, LLM; Nathaniel Hupert, MD; David Ingbar, MD, FCCP; Robert K. Kanter, MD; Mary A. King, MD, MPH, FCCP; Robert N. Kuhnley, RRT; James Lawler, MD; Sharon Leung, MD; Deborah A. Levy, PhD, MPH; Matthew L. Lim, MD; Alicia Livinski, MA, MPH; Valerie Luyckx, MD; David Marcozzi, MD; Justine Medina, RN, MS; David A. Miramontes, MD; Ryan Mutter, PhD; Alexander S. Niven, MD, FCCP; Matthew S. Penn, JD, MLIS; Paul E. Pepe, MD, MPH; Tia Powell, MD; David Prezant, MD, FCCP; Mary Jane Reed, MD, FCCP; Preston Rich, MD; Dario Rodriquez, Jr, MSc, RRT; Beth E. Roxland, JD, MBioethics; Babak Sarani, MD; Umair A. Shah, MD, MPH; Peter Skippen, MBBS; Charles L. Sprung, MD; Italo Subbarao, DO, MBA; Daniel Talmor, MD; Eric S. Toner, MD; Pritish K. Tosh, MD; Jeffrey S. Upperman, MD; Timothy M. Uyeki, MD, MPH, MPP; Leonard J. Weireter Jr, MD; T. Eoin West, MD, MPH, FCCP; John Wilgis, RRT, MBA; ACCP Staff: Joe Ornelas, MS; Deborah McBride; David Reid; Content Experts: Amado Baez, MD; Marie Baldisseri, MD; James S. Blumenstock, MA; Art Cooper, MD; Tim Ellender, MD; Clare Helminiak, MD, MPH; Edgar Jimenez, MD; Steve Krug, MD; Joe Lamana, MD; Henry Masur, MD; L. Rudo Mathivha, MBChB; Michael T. Osterholm, PhD, MPH; H. Neal Reynolds, MD; Christian Sandrock, MD, FCCP; Armand Sprecher, MD, MPH; Andrew Tillyard, MD; Douglas White, MD; Robert Wise, MD; Kevin Yeskey, MD.

Einav S, Hick JL, Hanfling D, et al. Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e17S-e43S. [CrossRef] [PubMed]
 
Ornelas J, Dichter JR, Devereaux AV, Kissoon N, Livinski A, Christian MD. Methodology: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):35S-41S. [CrossRef] [PubMed]
 
Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A. The special injury pattern of terrorist bombings. J Am Coll Surg. 2004;199(6):875-879. [CrossRef] [PubMed]
 
The ANZIC Influenza Investigators. Critical care services and 2009 influenza H1N1 in Australia and New Zealand. N Engl J Med. 2009;361(20):1925-1934. [CrossRef] [PubMed]
 
Kanter RK. Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs. Crit Care Med. 2007;35(12):2837-2842. [CrossRef] [PubMed]
 
Kanter RK. Pediatric mass critical care in a pandemic. Pediatr Crit Care Med. 2012;13(1):e1-e4. [CrossRef] [PubMed]
 
Kanter RK, Moran JR. Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care. Pediatrics. 2007;119(1):94-100. [CrossRef] [PubMed]
 
Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3(suppl S1):S59-S67. [CrossRef] [PubMed]
 
Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—a functional impact approach: the PICE system. Acad Emerg Med. 1996;3(7):723-727. [CrossRef] [PubMed]
 
Barbisch DF, Koenig KL. Understanding surge capacity: essential elements. Acad Emerg Med. 2006;13(11):1098-1102. [CrossRef] [PubMed]
 
Hanfling D. Equipment, supplies, and pharmaceuticals: how much might it cost to achieve basic surge capacity? Acad Emerg Med. 2006;13(11):1232-1237. [CrossRef] [PubMed]
 
Mahoney EJ, Harrington DT, Biffl WL, Metzger J, Oka T, Cioffi WG. Lessons learned from a nightclub fire: institutional disaster preparedness. J Trauma. 2005;58(3):487-491. [CrossRef] [PubMed]
 
Shirley PJ. Critical care delivery: the experience of a civilian terrorist attack. J R Army Med Corps. 2006;152(1):17-21. [CrossRef] [PubMed]
 
Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219-2225. [CrossRef] [PubMed]
 
de Ceballos JP, Turégano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M, Martin-Llorente C, Guerrero-Sanz JE. 11 March 2004: The terrorist bomb explosions in Madrid, Spain—an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005;9(1):104-111. [CrossRef] [PubMed]
 
Auf der Heide E. Disaster Response: Principles of Preparation and Coordination. Ford Island, HI: Center for Excellence in Disaster Management and Humanitarian Assistance; 1989.
 
De Boer J. Order in chaos: modelling medical management in disasters. Eur J Emerg Med. 1999;6(2):141-148. [CrossRef] [PubMed]
 
Bayram JD, Zuabi S, Subbarao I. Disaster metrics: quantitative benchmarking of hospital surge capacity in trauma-related multiple casualty events. Disaster Med Public Health Prep. 2011;5(2):117-124. [CrossRef] [PubMed]
 
Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253-261. [CrossRef] [PubMed]
 
Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA. 2009;302(5):565-567. [CrossRef] [PubMed]
 
Tadmor B, McManus J, Koenig KL. The art and science of surge: experience from Israel and the U.S. military. Acad Emerg Med. 2006;13(11):1130-1134. [CrossRef] [PubMed]
 
Quarentelli EL. Delivery of Emergency Medical Care in Disasters: Assumptions and Realities. New York, NY: Irvington Publishers; 1983.
 
Bissell RA, Pinet L, Nelson M, Levy M. Evidence of the effectiveness of health sector preparedness in disaster response: the example of four earthquakes. Fam Community Health. 2004;27(3):193-203. [CrossRef] [PubMed]
 
Rivara FP, Nathens AB, Jurkovich GJ, Maier RV. Do trauma centers have the capacity to respond to disasters? J Trauma. 2006;61(4):949-953. [CrossRef] [PubMed]
 
Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477-1483. [CrossRef] [PubMed]
 
Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59(3):177-187. [CrossRef] [PubMed]
 
Aucoin RG. Hurricane Katrina—one hospital’s experience. Crit Care. 2006;10(1):109. [CrossRef] [PubMed]
 
Kirsch TD, Mitrani-Reiser J, Bissell R, et al. Impact on hospital functions following the 2010 Chilean earthquake. Disaster Med Public Health Prep. 2010;4(2):122-128. [CrossRef] [PubMed]
 
Danzig R. Catastrophic Bioterrorism—What Is To Be Done? Washington, DC: Center for Technology and National Security Policy, National Defense University; 2003.
 
DiCarlo AL, Maher C, Hick JL, et al. Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011;5(suppl 1):S32-S44. [CrossRef] [PubMed]
 
Hupert N, Wattson D, Cuomo J, Hollingsworth E, Neukermans K, Xiong W. Predicting hospital surge after a large-scale anthrax attack: a model-based analysis of CDC’s cities readiness initiative prophylaxis recommendations. Med Decis Making. 2009;29(4):424-437. [CrossRef] [PubMed]
 
Bartlett JG, Borio L. Healthcare epidemiology: the current status of planning for pandemic influenza and implications for health care planning in the United States. Clin Infect Dis. 2008;46(6):919-925. [CrossRef] [PubMed]
 
Manuell ME, Co MD, Ellison RT III. Pandemic influenza: implications for preparation and delivery of critical care services. J Intensive Care Med. 2011;26(6):347-367. [CrossRef] [PubMed]
 
Sobieraj JA, Reyes J, Dunemn KN, et al. Modeling hospital response to mild and severe influenza pandemic scenarios under normal and expanded capacities. Mil Med. 2007;172(5):486-490. [PubMed]
 
Ten Eyck RP. Ability of regional hospitals to meet projected avian flu pandemic surge capacity requirements. Prehosp Disaster Med. 2008;23(2):103-112. [PubMed]
 
Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press; 2009. [PubMed] [PubMed]
 
Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: The National Academies Press; 2012. [PubMed] [PubMed]
 
Institute of Medicine. Crisis standards of care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press; 2013. [PubMed] [PubMed]
 
Geiling J, Burkle FM Jr, Amundson D, et al. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e156S-e167S. [CrossRef] [PubMed]
 
Soremekun OA, Zane RD, Walls A, Allen MB, Seefeld KJ, Pallin DJ. Cancellation of scheduled procedures as a mechanism to generate hospital bed surge capacity-a pilot study. Prehosp Disaster Med. 2011;26(3):224-229. [CrossRef] [PubMed]
 
Meites E, Farias D, Raffo L, et al. Hospital capacity during an influenza pandemic-Buenos Aires, Argentina, 2009. Infect Control Hosp Epidemiol. 2011;32(1):87-90. [CrossRef] [PubMed]
 
Sprung CL, Cohen R, Adini B; European Society of Intensive Care Medicine’s Task Force for Intensive Care Unit Triage During an Influenza Epidemic or Mass Disaster. Chapter 1. Introduction. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(suppl 1):S4-S10. [CrossRef] [PubMed]
 
Kaji AH, Bair A, Okuda Y, Kobayashi L, Khare R, Vozenilek J. Defining systems expertise: effective simulation at the organizational level—implications for patient safety, disaster surge capacity, and facilitating the systems interface. Acad Emerg Med. 2008;15(11):1098-1103. [CrossRef] [PubMed]
 
Maldin-Morgenthau B, Toner E, Waldhorn R, et al. Roundtable: promoting partnerships for regional healthcare preparedness and response. Biosecur Bioterror. 2007;5(2):180-185. [CrossRef] [PubMed]
 
Courtney B, Toner E, Waldhorn R, et al. Healthcare coalitions: the new foundation for national healthcare preparedness and response for catastrophic health emergencies. Biosecur Bioterror. 2009;7(2):153-163. [CrossRef] [PubMed]
 
Joynt GM, Loo S, Taylor BL, et al; European Society of Intensive Care Medicine’s Task Force for Intensive Care Unit Triage During an Influenza Epidemic or Mass Disaster. Chapter 3. Coordination and collaboration with interface units. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(suppl 1):S21-S31. [CrossRef] [PubMed]
 
Carrier E, Yee T, Cross DA, Samuel DR. Emergency preparedness and community coalitions: opportunities and challenges. HSC Research Brief No. 24. Center for Studying Health System Change website. http://www.hschange.com/CONTENT/1323. Accessed August 12, 2014.
 
Dichter JR, Kanter RK, Dries D, et al. System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e87S-e102S. [CrossRef] [PubMed]
 
The CNA Corporation. (2004). Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies (No. IPR/11079). Alexandria, VA: The CNA Corporation; 2004. [PubMed] [PubMed]
 
Campbell C. The benefits of designing a stratification system for New York City pediatric intensive care units for use in regional surge capacity planning and management. J Community Health. 2010;35(4):337-347. [CrossRef] [PubMed]
 
DeLia D. Annual bed statistics give a misleading picture of hospital surge capacity. Ann Emerg Med. 2006;48(4):384-388. [CrossRef] [PubMed]
 
Schull MJ. Hospital surge capacity: if you can’t always get what you want, can you get what you need? Ann Emerg Med. 2006;48(4):389-390. [CrossRef] [PubMed]
 
Wu JT, Riley S, Fraser C, Leung GM. Reducing the impact of the next influenza pandemic using household-based public health interventions. PLoS Med. 2006;3(9):e361. [CrossRef] [PubMed]
 
Kellermann AL, Isakov AP, Parker R, Handrigan MT, Foldy S. Web-based self-triage of influenza-like illness during the 2009 H1N1 influenza pandemic. Ann Emerg Med. 2010;56(3):288-294. [CrossRef] [PubMed]
 
Spaulding AC, McCallum VA, Walker D, et al. How public health and prisons can partner for pandemic influenza preparedness: a report from Georgia. J Correct Health Care. 2009;15(2):118-128. [CrossRef] [PubMed]
 
Koonin LM, Hanfling D. Broadening access to medical care during a severe influenza pandemic: the CDC nurse triage line project. Biosecur Bioterror. 2013;11(1):75-80. [CrossRef] [PubMed]
 
Anhang Price R, Fagyubi D, Harris R, et al. Feasibility of web-based self-triage by parents of children with influenza-like illness: a cautionary tale. JAMA Pediatr. 2013;167(2):112-118. [CrossRef] [PubMed]
 
Edwards JC, Stapley J, Akins R, Silenas R, Williams JR. Lessons learned from a regional strategy for resource allocation. Biosecur Bioterror. 2005;3(2):113-118. [CrossRef] [PubMed]
 
Miska H. Emergency care centers—an efficient method for mitigation of consequences after a dirty bomb attack. Health Phys. 2012;103(2):200-203. [PubMed]
 
Pershad J, Waters TM. Use of tent for screening during H1N1 pandemic: impact on quality and cost of care. Pediatr Emerg Care. 2012;28(3):229-235. [CrossRef] [PubMed]
 
Rubin GJ, Dickmann P. How to reduce the impact of “low-risk patients” following a bioterrorist incident: lessons from SARS, anthrax, and pneumonic plague. Biosecur Bioterror. 2010;8(1):37-43. [CrossRef] [PubMed]
 
Sugerman D, Nadeau KH, Lafond K, et al. A survey of emergency department 2009 pandemic influenza A (H1N1) surge preparedness—Atlanta, Georgia, July-October 2009. Clin Infect Dis. 2011;52(suppl 1):S177-S182. [CrossRef] [PubMed]
 
Waseem M, McInerney JE, Perales O, Leber M. Impact of operational staging to improve patient throughput in an inner-city emergency department during the novel H1N1 influenza surge: a descriptive study. Pediatr Emerg Care. 2012;28(1):39-42. [CrossRef] [PubMed]
 
Scarfone RJ, Coffin S, Fieldston ES, Falkowski G, Cooney MG, Grenfell S. Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity. Ped Emerg Care. 2011;27:565-572. [CrossRef]
 
Smith PW, Smith AW, Meza JL. Influenza preparedness in Nebraska assisted living facilities. Biosecur Bioterror. 2009;7(4):429-432. [CrossRef] [PubMed]
 
Tomio J, Sato H, Mizumura H. Interruption of medication among outpatients with chronic conditions after a flood. Prehosp Disaster Med. 2010;25(1):42-50. [PubMed]
 
Einav S, Aharonson-Daniel L, Weissman C, Freund HR, Peleg K; Israel Trauma Group. In-hospital resource utilization during multiple casualty incidents. Ann Surg. 2006;243(4):533-540. [CrossRef] [PubMed]
 
Satterthwaite PS, Atkinson CJ. Using ‘reverse triage’ to create hospital surge capacity: Royal Darwin Hospital’s response to the Ashmore Reef disaster. Emerg Med J. 2012;29(2):160-162. [CrossRef] [PubMed]
 
Nap RE, Andriessen MP, Meessen NE, van der Werf TS. Pandemic influenza and hospital resources. Emerg Infect Dis. 2007;13(11):1714-1719. [CrossRef] [PubMed]
 
Rodriguez-Noriega E, Gonzalez-Diaz E, Morfin-Otero R, et al; Hospital Civil de Guadalajara, Fray Antonio Alcalde Emerging Respiratory Infections Response Team. Hospital triage system for adult patients using an influenza-like illness scoring system during the 2009 pandemic—Mexico. PLoS One. 2010;5(5):e10658. [CrossRef] [PubMed]
 
Hirshberg A, Scott BG, Granchi T, Wall MJ Jr, Mattox KL, Stein M. How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis. J Trauma. 2005;58(4):686-693. [CrossRef] [PubMed]
 
Roccaforte JD, Cushman JG. Disaster preparedness, triage, and surge capacity for hospital definitive care areas: optimizing outcomes when demands exceed resources. Anesthesiol Clin. 2007;25(1):161-177. [CrossRef] [PubMed]
 
Arrieta MI, Foreman RD, Crook ED, Icenogle ML. Insuring continuity of care for chronic disease patients after a disaster: key preparedness elements. Am J Med Sci. 2008;336(2):128-133. [CrossRef] [PubMed]
 
Laditka SB, Laditka JN, Xirasagar S, Cornman CB, Davis CB, Richter JV. Providing shelter to nursing home evacuees in disasters: lessons from Hurricane Katrina. Am J Public Health. 2008;98(7):1288-1293. [CrossRef] [PubMed]
 
Motoki E, Mori K, Kaji H, et al. Development of disaster pamphlets based on health needs of patients with chronic illnesses. Prehosp Disaster Med. 2010;25(4):354-360. [PubMed]
 
Klein KR, Rosenthal MS, Klausner HA. Blackout 2003: preparedness and lessons learned from the perspectives of four hospitals. Prehosp Disaster Med. 2005;20(5):343-349. [PubMed]
 
Prezant DJ, Clair J, Belyaev S, et al. Effects of the August 2003 blackout on the New York City healthcare delivery system: a lesson for disaster preparedness. Crit Care Med. 2005;33(1):S96-S101. [CrossRef] [PubMed]
 
Geiling J. Critical care of the morbidly obese in disaster. Crit Care Clin. 2010;26(4):703-714. [CrossRef] [PubMed]
 
Beigi R, Davis G, Hodges J, Akers A. Preparedness planning for pandemic influenza among large US maternity hospitals. Emerg Health Threats J. 2009;2:e2. [PubMed]
 
Broeze CL, Falder S, Rea S, Wood F. Burn disasters—an audit of the literature. Prehosp Disaster Med. 2010;25(6):555-559. [PubMed]
 
Kanter RK. The 2011 Tuscaloosa tornado: integration of pediatric disaster services into regional systems of care. J Pediatr. 2012;161(3):526-530. [CrossRef] [PubMed]
 
Kleinpeter MA. Disaster preparedness of dialysis patients for Hurricanes Gustav and Ike 2008. Adv Perit Dial. 2009;25:62-67. [PubMed]
 
Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning in New York City: updated recommendations for best practices. J Burn Care Res. 2012;33(5):587-594. [CrossRef] [PubMed]
 
Rebmann T. Preparing for pandemic influenza. J Perinat Neonatal Nurs. 2008;22(3):191-202. [CrossRef] [PubMed]
 
Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: executive summary. Pediatr Crit Care Med. 2011;12(6):S103-S108. [CrossRef] [PubMed]
 
Christian MD, Toltzis P, Kanter RK, Burkle FM Jr, Vernon DD, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6):S109-S119. [CrossRef] [PubMed]
 
Nap RE, Andriessen MP, Meessen NE, Albers MJ, van der Werf TS. Pandemic influenza and pediatric intensive care. Pediatr Crit Care Med. 2010;11(2):185-198. [CrossRef] [PubMed]
 
Barfield WD, Krug SE, Kanter RK, et al; Task Force for Pediatric Emergency Mass Critical Care. Neonatal and pediatric regionalized systems in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6):S128-S134. [CrossRef] [PubMed]
 
Burkle FM Jr, Williams A, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Pediatric emergency mass critical care: the role of community preparedness in conserving critical care resources. Pediatr Crit Care Med. 2011;12(6):S141-S151. [CrossRef] [PubMed]
 
Xiong W, Bair A, Sandrock C, Wang S, Siddiqui J, Hupert N. Implementing telemedicine in medical emergency response: concept of operation for a regional telemedicine hub. J Med Syst. 2012;36(3):1651-1660. [CrossRef] [PubMed]
 
Stiff D, Kumar A, Kissoon N, et al. Potential pediatric intensive care unit demand/capacity mismatch due to novel pH1N1 in Canada. Pediatr Crit Care Med. 2011;12(2):e51-e57. [CrossRef] [PubMed]
 
Potin M, Sénéchaud C, Carsin H, et al. Mass casualty incidents with multiple burn victims: rationale for a Swiss burn plan. Burns. 2010;36(6):741-750. [CrossRef] [PubMed]
 
Dries DJ, Reed MJ, Kissoon N, et al. Special populations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e75S-e86S. [CrossRef] [PubMed]
 
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e61S-e74S. [CrossRef] [PubMed]
 
Barbera JA, Macintyre AG. Medical and Health Incident Management (MaHIM) System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management. Washington, DC: Institute for Crisis, Disaster, and Risk Management, The George Washington University; 2002.
 
Christian MD, Lawless B, Trpkovski J, Dichter JR. Surge management for critical care leaders. Surge management for critical care leaders.. In:Flaatten H, Moreno RP, Putensen C, Rhodes A., eds. Organisation and Management of Intensive Care. Berlin, Germany: MWV; 2010:277-294.
 
US Dept. of Defense Common User Database. Defense Medical Material Program Office website. https://www.dmsb.mil/cud.asp. Accessed August 12, 2014.
 
Casagrande R, Wills N, Kramer E, et al. Using the Model of Resource and Time-based Triage (MORTT) to guide scarce resource allocation in the aftermath of a nuclear detonation. Disaster Med Public Health Prep. 2011;5(suppl 1):S98-S110. [CrossRef] [PubMed]
 
Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti - ethical dilemmas in early disaster response. NEJM. 2010;362:e38(1-3). [CrossRef]
 
Merin O, Blumberg N, Raveh D, Bar A, Nishizawa M, Cohen-Marom O. Global responsibility in mass casualty events: the Israeli experience in Japan. Am J Disaster Med. 2012;7(1):61-64. [CrossRef] [PubMed]
 
Lum ME, McMillan AJ, Brook CW, Lester R, Piers LS. Impact of pandemic (H1N1) 2009 influenza on critical care capacity in Victoria. Med J Aust. 2009;191(9):502-506. [PubMed]
 
Schellongowski P, Ullrich R, Hieber C, et al. A surge of flu-associated adult respiratory distress syndrome in an Austrian tertiary care hospital during the 2009/2010 Influenza A H1N1v pandemic. Wien Klin Wochenschr. 2011;123(7-8):209-214. [CrossRef] [PubMed]
 
Kissoon N, Bohn D. Use of extracorporeal technology during pandemics: ethical and staffing considerations. Pediatr Crit Care Med. 2010;11(6):757-758. [CrossRef] [PubMed]
 
Courtney B, Hodge JG Jr, Toner ES, et al. Legal preparedness: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e134S-e144S. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  A framework for critical care surge capacity planning, outlining the conventional, contingency, and crisis surge responses. PACU = postanesthesia care unit.Grahic Jump Location
Figure Jump LinkFigure 2 –  Various tiers of authority are involved in health-care surge response. Not all jurisdictions have Regional Health Authorities, in which cases, health-care coalitions work directly with the state or province. Hosp = hospital. (Adapted from the Medical Surge Capacity and Capability Handbook.49)Grahic Jump Location
Figure Jump LinkFigure 3 –  Matrix for deescalation planning.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Primary Target Audiences for Suggestions
Table Graphic Jump Location
TABLE 2 ]  Surge Continuum Taxonomy

Definitions from Hick et al.8

Table Graphic Jump Location
TABLE 3 ]  Challenges and Considerations Affecting Critical Care in Disasters
Table Graphic Jump Location
TABLE 4 ]  Situations Potentially Requiring a Crisis-Level Surge Response
Table Graphic Jump Location
TABLE 5 ]  Mitigating Factors on Critical Care Demand
Table Graphic Jump Location
TABLE 6 ]  Example Strategies for Addressing Resource Deficits and Usual Associated Response Categories
Table Graphic Jump Location
TABLE 7 ]  Key Considerations for Regional Plans
Table Graphic Jump Location
TABLE 8 ]  Key Components To Consider When Assessing Resource Commitments

(Adapted from US Dept. of Defense Common User Database.97)

Table Graphic Jump Location
TABLE 9 ]  Scenarios Where Deescalation of Critical Care Services May Be Considered

References

Einav S, Hick JL, Hanfling D, et al. Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e17S-e43S. [CrossRef] [PubMed]
 
Ornelas J, Dichter JR, Devereaux AV, Kissoon N, Livinski A, Christian MD. Methodology: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):35S-41S. [CrossRef] [PubMed]
 
Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A. The special injury pattern of terrorist bombings. J Am Coll Surg. 2004;199(6):875-879. [CrossRef] [PubMed]
 
The ANZIC Influenza Investigators. Critical care services and 2009 influenza H1N1 in Australia and New Zealand. N Engl J Med. 2009;361(20):1925-1934. [CrossRef] [PubMed]
 
Kanter RK. Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs. Crit Care Med. 2007;35(12):2837-2842. [CrossRef] [PubMed]
 
Kanter RK. Pediatric mass critical care in a pandemic. Pediatr Crit Care Med. 2012;13(1):e1-e4. [CrossRef] [PubMed]
 
Kanter RK, Moran JR. Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care. Pediatrics. 2007;119(1):94-100. [CrossRef] [PubMed]
 
Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3(suppl S1):S59-S67. [CrossRef] [PubMed]
 
Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—a functional impact approach: the PICE system. Acad Emerg Med. 1996;3(7):723-727. [CrossRef] [PubMed]
 
Barbisch DF, Koenig KL. Understanding surge capacity: essential elements. Acad Emerg Med. 2006;13(11):1098-1102. [CrossRef] [PubMed]
 
Hanfling D. Equipment, supplies, and pharmaceuticals: how much might it cost to achieve basic surge capacity? Acad Emerg Med. 2006;13(11):1232-1237. [CrossRef] [PubMed]
 
Mahoney EJ, Harrington DT, Biffl WL, Metzger J, Oka T, Cioffi WG. Lessons learned from a nightclub fire: institutional disaster preparedness. J Trauma. 2005;58(3):487-491. [CrossRef] [PubMed]
 
Shirley PJ. Critical care delivery: the experience of a civilian terrorist attack. J R Army Med Corps. 2006;152(1):17-21. [CrossRef] [PubMed]
 
Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219-2225. [CrossRef] [PubMed]
 
de Ceballos JP, Turégano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M, Martin-Llorente C, Guerrero-Sanz JE. 11 March 2004: The terrorist bomb explosions in Madrid, Spain—an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005;9(1):104-111. [CrossRef] [PubMed]
 
Auf der Heide E. Disaster Response: Principles of Preparation and Coordination. Ford Island, HI: Center for Excellence in Disaster Management and Humanitarian Assistance; 1989.
 
De Boer J. Order in chaos: modelling medical management in disasters. Eur J Emerg Med. 1999;6(2):141-148. [CrossRef] [PubMed]
 
Bayram JD, Zuabi S, Subbarao I. Disaster metrics: quantitative benchmarking of hospital surge capacity in trauma-related multiple casualty events. Disaster Med Public Health Prep. 2011;5(2):117-124. [CrossRef] [PubMed]
 
Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253-261. [CrossRef] [PubMed]
 
Peleg K, Kellermann AL. Enhancing hospital surge capacity for mass casualty events. JAMA. 2009;302(5):565-567. [CrossRef] [PubMed]
 
Tadmor B, McManus J, Koenig KL. The art and science of surge: experience from Israel and the U.S. military. Acad Emerg Med. 2006;13(11):1130-1134. [CrossRef] [PubMed]
 
Quarentelli EL. Delivery of Emergency Medical Care in Disasters: Assumptions and Realities. New York, NY: Irvington Publishers; 1983.
 
Bissell RA, Pinet L, Nelson M, Levy M. Evidence of the effectiveness of health sector preparedness in disaster response: the example of four earthquakes. Fam Community Health. 2004;27(3):193-203. [CrossRef] [PubMed]
 
Rivara FP, Nathens AB, Jurkovich GJ, Maier RV. Do trauma centers have the capacity to respond to disasters? J Trauma. 2006;61(4):949-953. [CrossRef] [PubMed]
 
Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477-1483. [CrossRef] [PubMed]
 
Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59(3):177-187. [CrossRef] [PubMed]
 
Aucoin RG. Hurricane Katrina—one hospital’s experience. Crit Care. 2006;10(1):109. [CrossRef] [PubMed]
 
Kirsch TD, Mitrani-Reiser J, Bissell R, et al. Impact on hospital functions following the 2010 Chilean earthquake. Disaster Med Public Health Prep. 2010;4(2):122-128. [CrossRef] [PubMed]
 
Danzig R. Catastrophic Bioterrorism—What Is To Be Done? Washington, DC: Center for Technology and National Security Policy, National Defense University; 2003.
 
DiCarlo AL, Maher C, Hick JL, et al. Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011;5(suppl 1):S32-S44. [CrossRef] [PubMed]
 
Hupert N, Wattson D, Cuomo J, Hollingsworth E, Neukermans K, Xiong W. Predicting hospital surge after a large-scale anthrax attack: a model-based analysis of CDC’s cities readiness initiative prophylaxis recommendations. Med Decis Making. 2009;29(4):424-437. [CrossRef] [PubMed]
 
Bartlett JG, Borio L. Healthcare epidemiology: the current status of planning for pandemic influenza and implications for health care planning in the United States. Clin Infect Dis. 2008;46(6):919-925. [CrossRef] [PubMed]
 
Manuell ME, Co MD, Ellison RT III. Pandemic influenza: implications for preparation and delivery of critical care services. J Intensive Care Med. 2011;26(6):347-367. [CrossRef] [PubMed]
 
Sobieraj JA, Reyes J, Dunemn KN, et al. Modeling hospital response to mild and severe influenza pandemic scenarios under normal and expanded capacities. Mil Med. 2007;172(5):486-490. [PubMed]
 
Ten Eyck RP. Ability of regional hospitals to meet projected avian flu pandemic surge capacity requirements. Prehosp Disaster Med. 2008;23(2):103-112. [PubMed]
 
Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press; 2009. [PubMed] [PubMed]
 
Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: The National Academies Press; 2012. [PubMed] [PubMed]
 
Institute of Medicine. Crisis standards of care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press; 2013. [PubMed] [PubMed]
 
Geiling J, Burkle FM Jr, Amundson D, et al. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e156S-e167S. [CrossRef] [PubMed]
 
Soremekun OA, Zane RD, Walls A, Allen MB, Seefeld KJ, Pallin DJ. Cancellation of scheduled procedures as a mechanism to generate hospital bed surge capacity-a pilot study. Prehosp Disaster Med. 2011;26(3):224-229. [CrossRef] [PubMed]
 
Meites E, Farias D, Raffo L, et al. Hospital capacity during an influenza pandemic-Buenos Aires, Argentina, 2009. Infect Control Hosp Epidemiol. 2011;32(1):87-90. [CrossRef] [PubMed]
 
Sprung CL, Cohen R, Adini B; European Society of Intensive Care Medicine’s Task Force for Intensive Care Unit Triage During an Influenza Epidemic or Mass Disaster. Chapter 1. Introduction. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(suppl 1):S4-S10. [CrossRef] [PubMed]
 
Kaji AH, Bair A, Okuda Y, Kobayashi L, Khare R, Vozenilek J. Defining systems expertise: effective simulation at the organizational level—implications for patient safety, disaster surge capacity, and facilitating the systems interface. Acad Emerg Med. 2008;15(11):1098-1103. [CrossRef] [PubMed]
 
Maldin-Morgenthau B, Toner E, Waldhorn R, et al. Roundtable: promoting partnerships for regional healthcare preparedness and response. Biosecur Bioterror. 2007;5(2):180-185. [CrossRef] [PubMed]
 
Courtney B, Toner E, Waldhorn R, et al. Healthcare coalitions: the new foundation for national healthcare preparedness and response for catastrophic health emergencies. Biosecur Bioterror. 2009;7(2):153-163. [CrossRef] [PubMed]
 
Joynt GM, Loo S, Taylor BL, et al; European Society of Intensive Care Medicine’s Task Force for Intensive Care Unit Triage During an Influenza Epidemic or Mass Disaster. Chapter 3. Coordination and collaboration with interface units. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(suppl 1):S21-S31. [CrossRef] [PubMed]
 
Carrier E, Yee T, Cross DA, Samuel DR. Emergency preparedness and community coalitions: opportunities and challenges. HSC Research Brief No. 24. Center for Studying Health System Change website. http://www.hschange.com/CONTENT/1323. Accessed August 12, 2014.
 
Dichter JR, Kanter RK, Dries D, et al. System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e87S-e102S. [CrossRef] [PubMed]
 
The CNA Corporation. (2004). Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies (No. IPR/11079). Alexandria, VA: The CNA Corporation; 2004. [PubMed] [PubMed]
 
Campbell C. The benefits of designing a stratification system for New York City pediatric intensive care units for use in regional surge capacity planning and management. J Community Health. 2010;35(4):337-347. [CrossRef] [PubMed]
 
DeLia D. Annual bed statistics give a misleading picture of hospital surge capacity. Ann Emerg Med. 2006;48(4):384-388. [CrossRef] [PubMed]
 
Schull MJ. Hospital surge capacity: if you can’t always get what you want, can you get what you need? Ann Emerg Med. 2006;48(4):389-390. [CrossRef] [PubMed]
 
Wu JT, Riley S, Fraser C, Leung GM. Reducing the impact of the next influenza pandemic using household-based public health interventions. PLoS Med. 2006;3(9):e361. [CrossRef] [PubMed]
 
Kellermann AL, Isakov AP, Parker R, Handrigan MT, Foldy S. Web-based self-triage of influenza-like illness during the 2009 H1N1 influenza pandemic. Ann Emerg Med. 2010;56(3):288-294. [CrossRef] [PubMed]
 
Spaulding AC, McCallum VA, Walker D, et al. How public health and prisons can partner for pandemic influenza preparedness: a report from Georgia. J Correct Health Care. 2009;15(2):118-128. [CrossRef] [PubMed]
 
Koonin LM, Hanfling D. Broadening access to medical care during a severe influenza pandemic: the CDC nurse triage line project. Biosecur Bioterror. 2013;11(1):75-80. [CrossRef] [PubMed]
 
Anhang Price R, Fagyubi D, Harris R, et al. Feasibility of web-based self-triage by parents of children with influenza-like illness: a cautionary tale. JAMA Pediatr. 2013;167(2):112-118. [CrossRef] [PubMed]
 
Edwards JC, Stapley J, Akins R, Silenas R, Williams JR. Lessons learned from a regional strategy for resource allocation. Biosecur Bioterror. 2005;3(2):113-118. [CrossRef] [PubMed]
 
Miska H. Emergency care centers—an efficient method for mitigation of consequences after a dirty bomb attack. Health Phys. 2012;103(2):200-203. [PubMed]
 
Pershad J, Waters TM. Use of tent for screening during H1N1 pandemic: impact on quality and cost of care. Pediatr Emerg Care. 2012;28(3):229-235. [CrossRef] [PubMed]
 
Rubin GJ, Dickmann P. How to reduce the impact of “low-risk patients” following a bioterrorist incident: lessons from SARS, anthrax, and pneumonic plague. Biosecur Bioterror. 2010;8(1):37-43. [CrossRef] [PubMed]
 
Sugerman D, Nadeau KH, Lafond K, et al. A survey of emergency department 2009 pandemic influenza A (H1N1) surge preparedness—Atlanta, Georgia, July-October 2009. Clin Infect Dis. 2011;52(suppl 1):S177-S182. [CrossRef] [PubMed]
 
Waseem M, McInerney JE, Perales O, Leber M. Impact of operational staging to improve patient throughput in an inner-city emergency department during the novel H1N1 influenza surge: a descriptive study. Pediatr Emerg Care. 2012;28(1):39-42. [CrossRef] [PubMed]
 
Scarfone RJ, Coffin S, Fieldston ES, Falkowski G, Cooney MG, Grenfell S. Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity. Ped Emerg Care. 2011;27:565-572. [CrossRef]
 
Smith PW, Smith AW, Meza JL. Influenza preparedness in Nebraska assisted living facilities. Biosecur Bioterror. 2009;7(4):429-432. [CrossRef] [PubMed]
 
Tomio J, Sato H, Mizumura H. Interruption of medication among outpatients with chronic conditions after a flood. Prehosp Disaster Med. 2010;25(1):42-50. [PubMed]
 
Einav S, Aharonson-Daniel L, Weissman C, Freund HR, Peleg K; Israel Trauma Group. In-hospital resource utilization during multiple casualty incidents. Ann Surg. 2006;243(4):533-540. [CrossRef] [PubMed]
 
Satterthwaite PS, Atkinson CJ. Using ‘reverse triage’ to create hospital surge capacity: Royal Darwin Hospital’s response to the Ashmore Reef disaster. Emerg Med J. 2012;29(2):160-162. [CrossRef] [PubMed]
 
Nap RE, Andriessen MP, Meessen NE, van der Werf TS. Pandemic influenza and hospital resources. Emerg Infect Dis. 2007;13(11):1714-1719. [CrossRef] [PubMed]
 
Rodriguez-Noriega E, Gonzalez-Diaz E, Morfin-Otero R, et al; Hospital Civil de Guadalajara, Fray Antonio Alcalde Emerging Respiratory Infections Response Team. Hospital triage system for adult patients using an influenza-like illness scoring system during the 2009 pandemic—Mexico. PLoS One. 2010;5(5):e10658. [CrossRef] [PubMed]
 
Hirshberg A, Scott BG, Granchi T, Wall MJ Jr, Mattox KL, Stein M. How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis. J Trauma. 2005;58(4):686-693. [CrossRef] [PubMed]
 
Roccaforte JD, Cushman JG. Disaster preparedness, triage, and surge capacity for hospital definitive care areas: optimizing outcomes when demands exceed resources. Anesthesiol Clin. 2007;25(1):161-177. [CrossRef] [PubMed]
 
Arrieta MI, Foreman RD, Crook ED, Icenogle ML. Insuring continuity of care for chronic disease patients after a disaster: key preparedness elements. Am J Med Sci. 2008;336(2):128-133. [CrossRef] [PubMed]
 
Laditka SB, Laditka JN, Xirasagar S, Cornman CB, Davis CB, Richter JV. Providing shelter to nursing home evacuees in disasters: lessons from Hurricane Katrina. Am J Public Health. 2008;98(7):1288-1293. [CrossRef] [PubMed]
 
Motoki E, Mori K, Kaji H, et al. Development of disaster pamphlets based on health needs of patients with chronic illnesses. Prehosp Disaster Med. 2010;25(4):354-360. [PubMed]
 
Klein KR, Rosenthal MS, Klausner HA. Blackout 2003: preparedness and lessons learned from the perspectives of four hospitals. Prehosp Disaster Med. 2005;20(5):343-349. [PubMed]
 
Prezant DJ, Clair J, Belyaev S, et al. Effects of the August 2003 blackout on the New York City healthcare delivery system: a lesson for disaster preparedness. Crit Care Med. 2005;33(1):S96-S101. [CrossRef] [PubMed]
 
Geiling J. Critical care of the morbidly obese in disaster. Crit Care Clin. 2010;26(4):703-714. [CrossRef] [PubMed]
 
Beigi R, Davis G, Hodges J, Akers A. Preparedness planning for pandemic influenza among large US maternity hospitals. Emerg Health Threats J. 2009;2:e2. [PubMed]
 
Broeze CL, Falder S, Rea S, Wood F. Burn disasters—an audit of the literature. Prehosp Disaster Med. 2010;25(6):555-559. [PubMed]
 
Kanter RK. The 2011 Tuscaloosa tornado: integration of pediatric disaster services into regional systems of care. J Pediatr. 2012;161(3):526-530. [CrossRef] [PubMed]
 
Kleinpeter MA. Disaster preparedness of dialysis patients for Hurricanes Gustav and Ike 2008. Adv Perit Dial. 2009;25:62-67. [PubMed]
 
Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning in New York City: updated recommendations for best practices. J Burn Care Res. 2012;33(5):587-594. [CrossRef] [PubMed]
 
Rebmann T. Preparing for pandemic influenza. J Perinat Neonatal Nurs. 2008;22(3):191-202. [CrossRef] [PubMed]
 
Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: executive summary. Pediatr Crit Care Med. 2011;12(6):S103-S108. [CrossRef] [PubMed]
 
Christian MD, Toltzis P, Kanter RK, Burkle FM Jr, Vernon DD, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Treatment and triage recommendations for pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6):S109-S119. [CrossRef] [PubMed]
 
Nap RE, Andriessen MP, Meessen NE, Albers MJ, van der Werf TS. Pandemic influenza and pediatric intensive care. Pediatr Crit Care Med. 2010;11(2):185-198. [CrossRef] [PubMed]
 
Barfield WD, Krug SE, Kanter RK, et al; Task Force for Pediatric Emergency Mass Critical Care. Neonatal and pediatric regionalized systems in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(6):S128-S134. [CrossRef] [PubMed]
 
Burkle FM Jr, Williams A, Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Pediatric emergency mass critical care: the role of community preparedness in conserving critical care resources. Pediatr Crit Care Med. 2011;12(6):S141-S151. [CrossRef] [PubMed]
 
Xiong W, Bair A, Sandrock C, Wang S, Siddiqui J, Hupert N. Implementing telemedicine in medical emergency response: concept of operation for a regional telemedicine hub. J Med Syst. 2012;36(3):1651-1660. [CrossRef] [PubMed]
 
Stiff D, Kumar A, Kissoon N, et al. Potential pediatric intensive care unit demand/capacity mismatch due to novel pH1N1 in Canada. Pediatr Crit Care Med. 2011;12(2):e51-e57. [CrossRef] [PubMed]
 
Potin M, Sénéchaud C, Carsin H, et al. Mass casualty incidents with multiple burn victims: rationale for a Swiss burn plan. Burns. 2010;36(6):741-750. [CrossRef] [PubMed]
 
Dries DJ, Reed MJ, Kissoon N, et al. Special populations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e75S-e86S. [CrossRef] [PubMed]
 
Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e61S-e74S. [CrossRef] [PubMed]
 
Barbera JA, Macintyre AG. Medical and Health Incident Management (MaHIM) System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management. Washington, DC: Institute for Crisis, Disaster, and Risk Management, The George Washington University; 2002.
 
Christian MD, Lawless B, Trpkovski J, Dichter JR. Surge management for critical care leaders. Surge management for critical care leaders.. In:Flaatten H, Moreno RP, Putensen C, Rhodes A., eds. Organisation and Management of Intensive Care. Berlin, Germany: MWV; 2010:277-294.
 
US Dept. of Defense Common User Database. Defense Medical Material Program Office website. https://www.dmsb.mil/cud.asp. Accessed August 12, 2014.
 
Casagrande R, Wills N, Kramer E, et al. Using the Model of Resource and Time-based Triage (MORTT) to guide scarce resource allocation in the aftermath of a nuclear detonation. Disaster Med Public Health Prep. 2011;5(suppl 1):S98-S110. [CrossRef] [PubMed]
 
Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti - ethical dilemmas in early disaster response. NEJM. 2010;362:e38(1-3). [CrossRef]
 
Merin O, Blumberg N, Raveh D, Bar A, Nishizawa M, Cohen-Marom O. Global responsibility in mass casualty events: the Israeli experience in Japan. Am J Disaster Med. 2012;7(1):61-64. [CrossRef] [PubMed]
 
Lum ME, McMillan AJ, Brook CW, Lester R, Piers LS. Impact of pandemic (H1N1) 2009 influenza on critical care capacity in Victoria. Med J Aust. 2009;191(9):502-506. [PubMed]
 
Schellongowski P, Ullrich R, Hieber C, et al. A surge of flu-associated adult respiratory distress syndrome in an Austrian tertiary care hospital during the 2009/2010 Influenza A H1N1v pandemic. Wien Klin Wochenschr. 2011;123(7-8):209-214. [CrossRef] [PubMed]
 
Kissoon N, Bohn D. Use of extracorporeal technology during pandemics: ethical and staffing considerations. Pediatr Crit Care Med. 2010;11(6):757-758. [CrossRef] [PubMed]
 
Courtney B, Hodge JG Jr, Toner ES, et al. Legal preparedness: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e134S-e144S. [CrossRef] [PubMed]
 
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