State of Disaster Science: A Review on Management of Large-Scale Patient Surge

Operational Coordination

Of the 28 articles, 11 (39.29%) contained content on the theme of “operational coordination,”^{5,10-13,15,16,26,27,34,36} which consisted of both challenges and recommendations. Adalja et al ¹² described the New York statewide response to Hurricane Sandy, in which the designated coordination center relied on calls from clinicians on the floor rather than connecting with the hospital incident command. This created barriers to situational awareness during the emergency response within hospitals and between hospitals and state authorities. Several articles describe NDMS’s past operations and note similar difficulties at the federal level.^5,13,14 Results from 3 NDMS-led tabletop exercises simulating response to an overseas military MCI revealed a lack of leadership, which led to communication failures, poor patient reception, and weak interoperability of critical civilian and military systems. ¹³ Additionally, a qualitative study assessing operational challenges with NDMS operations through semistructured discussions with key stakeholders found that partnering organizations felt a lack of understanding of NDMS’s role. ⁵ This finding was echoed in another publication outlining the lessons learned from the NDMS network response to Hurricane Gustav. ¹⁴ The lack of clarity around the roles and responsibilities of NDMS versus their affiliates led to breakdowns in joint planning and coordination during exercises and in actuality.^5,14

Methods for overcoming such operational challenges were offered in some of the articles’ discussions.^10,13,15,16 An article by Mandel-Ricci et al ¹⁰ captured the experiences of hospitals belonging to the Greater New York Hospital Association (GNYHA) during the COVID-19 pandemic. The authors identified lessons learned for overcoming operational obstacles, including enhanced awareness through intensive planning, data sharing systems, the creation of partnerships between private and public healthcare systems, and frequent meetings between GNYHA and the New York Health Department.

Information Sharing

In the context of hospital surge events, “information sharing” was discussed in 11 articles (39.29%).^{11-13,15,17-19,23,25,26,36} Authors detail experiences with different levels of communication and access to information during such events. Adalja et al ¹² emphasized that a lack of redundant communication systems and access to medical records created challenges for providers and slowed down patient transfers during the response to Hurricane Sandy. In this situation, failures in telecommunication systems and lack of access to a stable internet connection led to the need for printed forms as well as emergency communication devices. ¹² Fagbuyi et al ¹⁷ also found that, despite having regular access to their online records, preparing preprinted paper charts for use throughout the H1N1 pandemic increased provider efficiency during the acute emergency phase. However, charts needed to be scanned and entered in the hospital database following the surge, which proved manageable for a single facility, but may not be reproducible in larger systems, as noted in the article’s discussion of limitations.

In contrast, an article that captured the experiences of pharmacists at NYU Langone Health explained that the use of electronic messaging systems and collaborative rounding between physicians and pharmacists improved situational awareness and helped overcome the chaos and disjunction between departments during the height of the COVID-19 pandemic. ¹⁸ Other studies involving NDMS and other MCI responses also cited the need for electronic medical records, in these cases, to be shared between military and civilian systems and options for telecommunication.^13,15,17

Partnership and Public Information

Six articles (21.43%) contained the theme “partnerships and public information,”^{5,13-15,20,21} 5 of which discussed this in the context of NDMS.^{5,13,14,20,21} The other, a recent literature review on NDMS readiness highlighted a lack of published, up-to-date information. ²⁰ Additionally, there appears to be poor public perception of NDMS resulting from previous emergency responses. In several articles, NDMS partners shared issues with command, coordination, and communication during joint emergency responses. Partner hospitals were severely underprepared to receive patients and felt that their roles were not clear.^5,13 In a review of the NDMS by Franco et al, ²¹ the authors found that it cost approximately $1 million for a US hospital to invest in basic disaster preparedness equipment and resources, and “[i]f patients are admitted to NDMS participating hospitals during a crisis, there is reimbursement for care, but there is no funding provided to hospitals for NDMS enrollment and ongoing training.” However, according to documentation of the joint response of the state of Arkansas and NDMS to Hurricane Gustav in 2008, there were no financial incentives or sufficient reimbursement plans apparent to NDMS partners who participated. Arkansas hospitals felt abandoned by NDMS and forced to treat and cover the cost of patients without federal aid. ¹⁴

Franco et al ²¹ stressed that if NDMS established robust regional emergency healthcare partnerships, the resilience and efficacy of NDMS would greatly improve. In situations where disasters strain a region’s healthcare resources, it often becomes necessary to look to neighboring regions better positioned to provide additional medical support. The authors recommend that NDMS facilitate interregional cooperation with the aim of creating a nationwide network of functional healthcare regions characterized by transparent decisionmaking processes and strong ties between local healthcare providers, regional leaders, and the NDMS.

Planning and Personnel and Logistics

“Planning” was discussed in 17 out of 28 articles (60.71%)^{5,10,12-15,19-21,23,25-28,32,34,35} and “personnel and logistics” was discussed in 18 (64.29%).^{5,10,12,15-19,22-27,31,32,35,36} Many of the articles detailing experiences during surge events identified plans and strategies that deal with personnel and logistical challenges during the events. Processes that allowed for more efficient screening and managing of patients enabled limited staff to accommodate a greater patient influx. Fagbuyi et al ¹⁷ compared patient load during the 2009 H1N1 outbreak to the winter season before the start of that pandemic and described the need to develop a rapid screening method. This plan was developed by an urban, tertiary care US pediatric hospital and was associated with improved patient flow without having any negative impact on patient outcomes or requiring changes in staffing. During the statewide response to Hurricane Sandy in New York, to compensate for a lack of centralized command, a hospital stationed nurses in the loading area to relay information internally, which improved communication and allowed hospital staff to overcome challenges with situational awareness. ¹² Burns et al ²² discussed how surges were handled during the COVID-19 pandemic and how implementing a centralized transport destination officer was associated with improved load balancing and reduction in simultaneous patient arrivals. Several retrospective analyses from the COVID-19 pandemic emphasized the importance of creating nurse-led alternate care sites to reduce the strain on the emergency department (ED).^20,27 Similarly, Einav et al ¹⁶ highlighted how case management roles improved MCI response by enhancing situational awareness, patient safety, and staff psychological resilience within hospitals. Case managers provided assistance in patient management and triage, which helped reduce errors and improved continuity of care. Importantly, case management does not increase staff requirements and was recommended as a method to optimize existing human resources.

Drawing from the collective experiences of healthcare leaders in New York following the COVID-19 pandemic, a key recommendation emphasized by Mandel-Ricci et al ¹⁰ during the preparedness phase is the regular review and updating of comprehensive hospital system surge plans. Such plans should encompass strategies for repurposing existing beds and creating surge beds. The authors advised extending these facility-level plans into systemwide frameworks that address surge management, service line adjustments, and supervision of staff, equipment, and critical resources. ³ Other literature addressed planning and staffing needs, using supplemental staff sources, implementing rapid credentialing and training programs, and adding telecommunication options as strategies to accommodate staff shortages during emergencies.^17,21,22,29

Patient Movement

Ten articles (35.71%) provided information relevant to “patient movement” and many gave examples demonstrating strategies for enhancing surge capacity through patient transfer.^{10,12,13,15,19,21,28,29,31,35} Mandel-Ricci et al ¹⁰ noted that according to interviews with GNYHA, hospitals have shifted their focus from patient transfers to patient load balancing, which involves matching patients to available beds and resources across the healthcare system. This approach requires robust coordination and cultural shifts within hospitals to facilitate patient movement based on overall circumstances. In addition, formal partnerships between independent hospitals and health systems can facilitate technical assistance and patient placement. These partnerships are especially beneficial for hospitals less equipped to take on large numbers of patients simultaneously; during the COVID-19 pandemic, such connections enabled smaller facilities in New York to access resources and support from larger healthcare systems in their regions during times of increased demand.

Other helpful strategies include reverse triage, which involves assessing victims’ status and patients’ transfer hazards to prioritize care and maximize capacity utilization, as noted by Sheikhbardsiri et al. ²⁷ Training and educational workshops are essential to equip hospital staff with the necessary knowledge and skills for effective reverse triage. In some cases, the implementation of dedicated roles, such as nonclinical transfer coordinators in EDs, has proven effective in load balancing across hospital networks. These coordinators oversee patient transfers during surge events, ensuring efficient allocation of resources and patient distribution. ²⁹

However, despite many recommendations from recent surge experiences, many authors call for further work to determine ways to improve patient transfer. Questions remain for situations where patients require long-term care and when the distance between facilities becomes nonideal for ground transport.^10,17,29 Following hurricane and COVID-19 responses, providers were faced with questions such as what to do when patients with serious, long-term needs were admitted at sites lacking the care they required. These patients were often unable to return home, which stressed hospital resources and patient costs.^27,29 Lee et al ²⁸ suggests that the health of the patient must be considered when determining the “health of the system.” In addition, patients’ needs beyond just their medical status should be included when they are considered for transfer, such as social determinants (eg, how far away they live from the facility, if they have anyone available to support their recovery at home).

Policy development and Funding and Resources

The “policy development” theme was addressed by only Kirsch et al ⁵ who described their concern related to the “lack of sufficient authorities, policies, and procedures to adequately manage NDMS,” based on findings from discussions with key informants.

Five (18%) of the articles discussed content related to the “funding and resources” theme as defined for this review.^{5,12,14,25,27} All of the articles offered learnings from experiences with patients surges in hospitals from differing perspectives. Sheikhbardsiri et al ²⁷ found that the relationship between hospital surge capacity and bed occupancy rates is significant—surge capacity is limited with high occupancy rates and low unoccupied beds. Suggested methods for enhancing hospital capacity include optimizing physical space, such as through outpatient admissions management and utilizing nontreatment areas such as dining halls and auditoriums. Coordination and resource sharing between public and private entities, along with implementing emergency response programs, are also vital strategies for bolstering hospital capacity during crises. Drawing from lessons learned during the first wave of the COVID-19 pandemic, healthcare system leaders in New York also highlighted the importance of optimizing spaces for care and allocating resources. ¹⁰ They developed “just-in-time” solutions tailored to each facility within their network. These solutions included planning and preserving resources and space for both non-COVID-19 and COVID-19 patients, identifying supportive services and resources necessary for COVID-19 patients with adjusted quantities to accommodate anticipated surge levels, and ensuring the availability of staff for potential redeployment.

Two of the 5 articles specifically address funding and resources in relation to the NDMS response, and both emphasize the absence of incentives and reimbursement programs for partnering hospitals.^5,14 Without proper funding, hospitals are likely unable to adequately respond to combat medical surges, which has negative consequences not only for patients and hospital staff in the short term but also for the sustainability of NDMS partnerships. This shortfall underscores the need for supplemental aid in many instances.

Performance Improvement and Benchmarks

Within the total sample, 11 articles (39.29%) contained content relevant to the “performance improvement and benchmarks” theme.^{5,16,17,20,22,27,28,30,32-34} Some examples of metrics used to quantify surge capacity and management were provided. For example, France et al ³³ shared findings from an international exercise where participants executed 62 computer simulations of an ED response to a theoretical MCI. Results showed it was possible to use length of stay and patient volume metrics to measure ED surge capacity. ³³ In another study by Smith et al ²⁵ that retrospectively analyzed patient care reporting records during the COVID-19 pandemic of the Montgomery, Maryland County Fire and Rescue Service, the authors found that ambulance diversion and offload delay are 2 routinely collected metrics that could be used to evaluate emergency medical services response. Other examples of metrics that may be used to evaluate performance during surges and periods of overcrowding include ED boarding time and ED departure.^18,30

Operational Coordination

Challenges with communication and coordination at all levels—facility, local, state, and national—during surge responses were well documented.^{5,10-13,15,16,26,27,36} It is clear that a lack of situational awareness and strong relationships with partnering hospital systems resulted in the inadequacy of designated authorities to navigate the surge events. Operational coordination is critical for the NDMS Pilot Program as it fosters the establishment and maintenance of relationships among healthcare sector partners to further develop mutual trust, cooperation, and responsibility toward the achievement of the mission. NDMS leadership should consider establishing direct lines of communication between them and both hospital incident command and healthcare workers onsite during NDMS activations. Additionally, NDMS should anticipate the inclusion of other health facilities that extend beyond the definitive care network, as evidence suggests it is common practice for hospitals to reach out to their network for additional support during surges.

Information Sharing

Information sharing requires integrated solutions that track patients from points of entry into the definitive care system through discharge to home or to another facility, which promotes more efficient communication and coordination. The literature shows a connection between information-sharing systems and provider efficiency during patient surges, but a lack of consistency in implementation recommendations.^{12,13,15,17-19}

Overall, the experiences detailed in the literature highlight the need for centralized information and communication methods to improve system capacity. However, recommendations for how to do so remain unclear and inconsistent across the results and findings from these articles. NDMS Pilot Program leadership should consider prioritizing the development of a coordinated information system that can be used between pilot sites and monitored via a unified command center.

Partnership and Public Information

Articles that described interactions between civilian systems and NDMS cited challenges related to a lack of publicly available information regarding NDMS procedures and policies.^{5,13-15,20,21} For NDMS to be a reliable patient surge mechanism, it is critical that these partnerships are well defined and reestablished, not only through updated legal agreements and understanding but also through relationship building with the NDMS operators and healthcare facilities expected to handle surges during a wartime contingency scenario and beyond. NDMS needs to prioritize fostering relationships with all stakeholders and include them in the pilot program planning and evaluation. Actions such as establishing direct communication between a central command and providers onsite could improve situational awareness during surge events and could improve relationships with pilot sites.

Additionally, NDMS must consider the impact of a large wartime contingency scenario on the communities of the pilot sites. Communities are critical partners, as their willingness and cooperation in such an emergency are necessary for successful implementation of the pilot program and response for future NDMS activations. NDMS should prioritize continuous conversations with pilot sites and community representatives before, during, and after emergency response. This step can aid in the development of mutual trust and responsibility and ensure that NDMS plans minimize the negative impact such an event will have on the community.

Planning and Personnel and Logistics

Plans should enhance readiness for a medical surge to support healthcare infrastructure and incorporate local needs and leading practices. Articles highlight the importance of effective communication, streamlined decisionmaking processes, and efficient resource allocation during crises.^{5,10,12-28,31,32,34-36} Planning to increase surge capacity should involve assigning specific roles, such as case management, to optimize the utilization of existing human resources and minimize confusion and stress among staff members. This proactive approach not only improves patient care and safety but also enhances the overall resilience of healthcare systems in handling surges in patient volume during emergencies. The literature also calls for surge plans to be reviewed and updated regularly and for the establishment of systemwide plans that can enhance coordination and resource allocation across multiple facilities, thereby improving the overall response to surges and optimizing patient care delivery during times of crisis.

Surge planning is widely discussed in the manuscripts identified for this review, appearing in 17 out of the 28 total articles (82.14%). However, only 7 of these articles explicitly address planning at the national level in the United States.^{5,12,13,19-21,35} Evidence from the literature suggests that planning for increased patient loads is associated with improved surge management and increased efficiency of staffing and other resources. Planning at the local and state levels is also essential to national-level preparedness and capacity. Therefore, the NDMS pilot sites should discuss and identify which strategies are currently being used for increasing surge capacity at each site and whether there are additional strategies that could be applied and scaled at a regional or national level to manage personnel and logistical challenges during a surge event. Additionally, it should be investigated whether plans could be scalable across the pilot sites to minimize variations that may create barriers to collaboration.

Patient Movement

“Patient movement” considers whether resources are available to move patients from the patient reception site to the definitive care facilities. Ideally, these resources would be identified and included during the planning process at all levels so that sites are prepared for a medical surge. In the literature, authors identified cost and coordination challenges in transferring patients to and between facilities during surge events.^{10,12,13,15,19,21,28,29,31,35} These barriers were mostly the result of a breakdown within themes previously discussed, namely, planning, information sharing, and operational coordination. Consequently, they were often addressed by improving communication and planning within and between sites.

Addressing these gaps to patient movement is critical to the future of the NDMS pilot and the definitive care network. Of the 28 articles analyzed, only 5 explicitly mentioned patient outcomes in relation to surge capacity and response.^{12,15,28,29,35} Evidence suggests that ED crowding, prolonged boarding times, and simultaneous arrival of patients have been associated with poor health outcomes.^15,29 Patient transfer, especially load balancing between facilities, is a necessary action for handling surge events and can result in improved mortality; ²⁹ however, it is also possible that patient transfer can lead to situational and health complications as noted previously. Additionally, a rapid influx of patients at a pilot site in the scenario of a large-scale combat casualty will affect the surrounding communities’ ability to access medical care and transport services, and they must also be considered when discussing patient transport and outcomes.

Policy development and Funding and Resources

The themes “policy” and “funding and resources” were identified in the least number of articles. The policy theme is defined as the policies that exist at any level—local, state, and federal—to aid in society’s preparation for medical surge events, and it was addressed in only 1 article by Kirsch et al. ⁵ Five articles addressed the theme on funding and fesources,^{5,12,14,25,27} which encompassed information related to the availability of necessary capital and resources related to medical surge response and preparation, and whether stakeholders have an awareness and ability to leverage them. Experiences outlined in these articles also note the lack of funding allocated to medical surge response, despite the high cost of increasing hospital capacity in disaster situations. While these articles provided valuable insight into the policy and funding and resources themes, they consist of only a small percentage of the total articles analyzed. The gap in conversation around these themes in the evidence base highlights a critical lack of investment and buy-in for this federal healthcare infrastructure.

Performance Improvement and Benchmarks

Attempts to quantify the surge capacity of health facilities and to model future surge events to improve planning were outlined in approximately 40% of the articles analyzed, indicating that this is perhaps a topic of increasing significance, especially following the COVID-19 pandemic.^{5,16,17,20,22,27,28,30,32-34} The importance of developing metrics for evaluating surge capacity is evident, and the NDMS Pilot Program should use them to track progress and facility efficiency across sites. However, in this subsection of articles, all cite the need for further research and note the lack of widely recognized surge capacity evaluation metrics. NDMS stakeholders should invest in the development, validation, and adoption of appropriate evaluation metrics to ensure site capacity can be measured and maximized.