A nationwide blue-ribbon panel of health care experts
recommends that hospital plans for a surge of disaster
victims should begin with a strategy to empty their beds of
relatively healthier patients.
Preliminary data suggest that such a strategy could
safely empty 70 percent of a hospital's inpatient
population within 72 hours.
So-called "surge capacity" is tight in the nation's
hospitals, shriveled by years of decreases in patient
capacity, cost controls, managed care, regulation and
nursing shortages.
Led by Gabor Kelen, head of
emergency medicine at The Johns Hopkins Hospital and
School of Medicine and director of the Johns Hopkins
Office of Critical
Event Preparedness and Response, the panel concluded
that all hospitalized patients at any given time should be
routinely ranked according to how sick they are and
assigned a constantly updated "score" based on their vital
signs, present condition and prognosis. That number would
put them at a moment's notice into risk groups that would
rapidly inform decisions to discharge them or send them to
another facility should a major disaster occur.
Kelen says that there is consensus among health care
officials that, whether dealing with a natural disaster
like Hurricane Katrina, a possible terrorist attack like
Sept. 11 or epidemics like SARS or avian flu, affected
hospitals have few means of making room for large numbers
of incoming casualties.
In one common disaster response, medical centers would
set up additional beds wherever they can, such as in
hallways and cafeterias, but concerned that staffing levels
could not expand to care for so many new patients, the
authors of the study, in the latest issue of the journal
Lancet, say "disposition classification" is a must.
"Without this sort of system in place, the worry is
that a hospital's resources would be quickly overwhelmed in
a major crisis," Kelen said. "So not only would the
disaster victims not get adequate treatment but neither
would the patients who are already hospitalized."
The system that Kelen and the other panelists envision
puts patients in one of five categories, based on their
considered risk of a life-threatening or life-impairing
medical problem within 72 hours of hospital discharge.
Patients classified as "minimum" risk could go home upon
being discharged. Those in the "low-risk" group could also
be transferred home, depending on the severity and scope of
the disaster. Those in the "moderate" category could not go
home but could be transferred to a facility offering basic
medical resources. "High-risk" patients could be
transferred only to an acute-care facility, and "very
high-risk" patients could be served only in a critical care
facility.
Only a score card system can "take the emotion" out of
the decision-making process in the midst of a major
disaster, Kelen noted. It also would eliminate cumbersome
bureaucracy, such as the need in some hospitals to have the
admitting physician also sign the patient's discharge
paperwork. And, Kelen said, such a disaster plan would
create an "ethical framework" through which patients could
be discharged and admitted based on the level of care they
require.
In a follow-up study, being planned now, a panel will
score 4,000 real patients and, by closely examining their
progress post-discharge, determine whether or not the
classification system would have actually worked in
disaster conditions.
The authors note that the logistics behind
transferring such a large number of patients to other
facilities were not examined in this particular exercise
but are hardly trivial. Kelen also said that the system
could be implemented outside of a disaster situation as a
tool "to manage even routine, everyday overloads of
hospital resources."