The 2022-2023 Pediatric Respiratory Illness Surge: Survey of Acute and Critical Care Resource Use.

OBJECTIVE: A surge of pediatric respiratory illnesses beset the United States in late 2022 and early 2023. This study evaluated within-surge hospital acute and critical care resource availability and utilization. The study aimed to determine pediatric hospital acute and critical care resource use during a respiratory illness surge. METHODS: Between January and February 2023, an online survey was sent to the sections of hospital medicine and critical care of the American Academy of Pediatrics, community discussion forums of the Children's Hospital Association, and PedSCCM-a pediatric critical care website. Data were summarized with median values and interquartile range. RESULTS: Across 35 hospitals with pediatric intensive care units (PICU), increase in critical care resource use was significant. In the month preceding the survey, 26 (74%) hospitals diverted patients away from their emergency department (ED) to other hospitals, with 46% diverting 1-5 patients, 23% diverting 6-10 patients, and 31% diverting more than 10 patients. One in 5 hospitals reported moving patients on mechanical ventilation from the PICU to other settings, including the ED (n = 2), intermediate care unit (n = 2), cardiac ICU (n = 1), ward converted to an ICU (n = 1), and a ward (n = 1). Utilization of human critical care resources was high, with PICU faculty, nurses, and respiratory therapists working at 100% capacity. CONCLUSIONS: The respiratory illness surge triggered significant hospital resource use and diversion of patients away from hospitals. Pediatric public health emergency-preparedness should innovate around resource capacity.

The impact of surge capacity enhancement training for nursing managers on hospital disaster preparedness and response: an action research study.

INTRODUCTION: Hospitals as the main providers of healthcare services play an essential role in the management of disasters and emergencies. Nurses are one of the important and influential elements in increasing the surge capacity of hospitals. Accordingly, the present study aimed to assess the effect of surge capacity enhancement training for nursing managers on hospital disaster preparedness and response. METHODS: All nursing managers employed at Motahari Hospital in Tehran took part in this interventional pre- and post-test action research study. Ultimately, a total of 20 nursing managers were chosen through a census method and underwent training in hospital capacity fluctuations. The Iranian version of the "Hospital Emergency Response Checklist" was used to measure hospital disaster preparedness and response before and after the intervention. RESULTS: The overall hospital disaster preparedness and response score was 184 (medium level) before the intervention and 216 (high level) after the intervention. The intervention was effective in improving the dimensions of hospital disaster preparedness, including "command and control", "triage", "human resources", "communication", "surge capacity", "logistics and supply", "safety and security", and "recovery", but had not much impact on the "continuity of essential services" component. CONCLUSION: The research demonstrated that enhancing the disaster preparedness of hospitals can be achieved by training nursing managers using an action research approach. Encouraging their active participation in identifying deficiencies, problems, and weaknesses related to surge capacity, and promoting the adoption and implementation of suitable strategies, can enhance overall hospital disaster preparedness.

COVID-19 healthcare success or failure? Crisis management explained by dynamic capabilities.

INTRODUCTION: This paper presents a structured review of the use of crisis management, specifically examining the frameworks of surge capacity, resilience, and dynamic capabilities in healthcare organizations. Thereafter, a novel deductive method based on the framework of dynamic capabilities is developed and applied to investigate crisis management in two hospital cases during the COVID-19 pandemic. BACKGROUND: The COVID-19 pandemic distinguishes itself from many other disasters due to its global spread, uncertainty, and prolonged duration. While crisis management in healthcare has often been explained using the surge capacity framework, the need for adaptability in an unfamiliar setting and different information flow makes the dynamic capabilities framework more useful. METHODS: The dynamic capabilities framework's microfoundations as categories is utilized in this paper for a deductive analysis of crisis management during the COVID-19 pandemic in a multiple case study involving two Swedish public hospitals. A novel method, incorporating both dynamic and static capabilities across multiple organizational levels, is developed and explored. RESULTS: The case study results reveal the utilization of all dynamic capabilities with an increased emphasis at lower organizational levels and a higher prevalence of static capabilities at the regional level. In Case A, lower-level managers perceived the hospital manager as brave, supporting sensing, seizing, and transformation at the department level. However, due to information gaps, sensing did not reach regional crisis management, reducing their power. In Case B, with contingency plans not initiated, the hospital faced a lack of management and formed a department manager group for patient care. Seizing was robust at the department level, but regional levels struggled with decisions on crisis versus normal management. The novel method effectively visualizes differences between organizational levels and cases, shedding light on the extent of cooperation or lack thereof within the organization. CONCLUSION: The researchers conclude that crisis management in a pandemic, benefits from distributed management, attributed to higher dynamic capabilities at lower organizational levels. A pandemic contingency plan should differ from a plan for accidents, supporting the development of routines for the new situation and continuous improvement. The Dynamic Capabilities framework proved successful for exploration in this context.

Children's Hospital Resource Utilization During the 2022 Viral Respiratory Surge.

OBJECTIVES: Multiple viral respiratory epidemics occurred concurrently in 2022 but their true extent is unclear. To aid future surge planning efforts, we compared epidemiology and resource utilization with prepandemic viral respiratory seasons in 38 US children's hospitals. METHODS: We performed a serial cross-sectional study from October 2017 to March 2023. We counted daily emergency department (ED), inpatient, and ICU volumes; daily surgeries; viral tests performed; the proportion of ED visits resulting in revisit within 3 days; and proportion of hospitalizations with a 30-day readmission. We evaluated seasonal resource utilization peaks using hierarchical Poisson models. RESULTS: Peak volumes in the 2022 season were 4% lower (95% confidence interval [CI] -6 to -2) in the ED, not significantly different in the inpatient unit (-1%, 95% CI -4 to 2), and 8% lower in the ICU (95% CI -14 to -3) compared with each hospital's previous peak season. However, for 18 of 38 hospitals, their highest ED and inpatient volumes occurred in 2022. The 2022 season was longer in duration than previous seasons (P < .02). Peak daily surgeries decreased by 15% (95% CI -20 to -9) in 2022 compared with previous peaks. Viral tests increased 75% (95% CI 69-82) in 2022 from previous peaks. Revisits and readmissions were lowest in 2022. CONCLUSIONS: Peak ED, inpatient, and ICU volumes were not significantly different in the 2022 viral respiratory season compared with earlier seasons, but half of hospitals reached their highest volumes. Research on how surges impact boarding, transfer refusals, and patient outcomes is needed as regionalization reduces pediatric capacity.

Understanding Pediatric Surge in the United States.

The concepts of pediatric surge in the United States continue to evolve from a theoretic framework to practical implementation. As disasters become more frequent, ranging from natural to human-caused, children remain a vulnerable population. The coronavirus disease 2019 pandemic and the 2022 to 2023 tripledemic respiratory surge revealed advances and continued challenges in our ability to care for a large influx of pediatric patients. Understanding pediatric surge through the framework of the 4 S's (space, staff, stuff, and systems/structures) can identify gaps at multiple levels.

What If Nice Terrorist Attack Would Have Happened in Milan? Drawing a Disaster Plan for Mass Casualty Incidents Involving the Pediatric Population.

Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.

Rapid Nurse Training to Meet Surge Capacity: An Integrative Review.

BACKGROUND: The COVID-19 pandemic resulted in unprecedented health care challenges and transformation of nursing practice. A significant challenge faced by health care systems was the rapid identification and training of nurses in various specialties, including critical care, to care for a large influx of critically ill patients. OBJECTIVE: To identify common themes and modalities that support best practices for the rapid training of registered nurses in team-based critical care nursing. METHODS: With the Whittemore and Knafl integrative review methodology as a framework, a literature review was conducted using a priori search terms. RESULTS: The integrative review included 11 articles and revealed 3 common themes: communication challenges, team dynamics, and the methodological approach to implementing training. DISCUSSION: This integrative review highlighted 3 main implications for future practice and policy in the event of another pandemic. Clear and frequent communication, multidisciplinary huddles, and open communication are paramount for mitigating role confusion and enhancing team dynamics. A multimodal approach to training appears to be feasible and effective for rapidly training support registered nurses to care for critically ill patients. However, the optimal training duration remains unidentified. CONCLUSIONS: Rapidly training registered nurses to care for critically ill patients in a team-based dynamic is a safe and effective course of action to mitigate staff shortages if another pandemic occurs.

Disaster management - preparation and planning for acute care facilities.

PURPOSE OF REVIEW: Both human-derived and naturally-occurring disasters stress the surge capacity of health systems and acute care facilities. In this article, we review recent literature related to having a disaster plan, facility planning principles, institutional and team preparedness, the concept of surge capacity, simulation exercises and advantages and disadvantages of each. RECENT FINDINGS: Evidence suggests that every institution should have a disaster plan and a dedicated team responsible for updating this plan. The disaster plan must be people-oriented and incorporate different perspectives and opinions so that all stakeholders feel included and can contribute to a joint response. Simulation exercises are fundamental for preparation so that the team functions seamlessly in uncommon times when disaster management transitions from a theoretical plan to one that is executed in real time. Notably, however, there are significantly different realities related to disaster management between countries and even within the same country or region. Unfortunately, key stakeholders such as hospital administration, board of directors and investors often do not believe they have any responsibility related to disaster management planning or response. Additionally, while a disaster plan often exists within an institution, it is frequently not well known or understood by many stakeholders. Communication, simple plans and well defined roles are some of the most important characteristics of a successful response. In extreme circumstances, adapting civilian facilities to manage high-volume warfare-related injuries may be adopted, but the consequences of this approach for routine healthcare within a system can be devastating. SUMMARY: Disaster management requires careful planning with input from multiple stakeholders and a plan that is frequently updated with repeated preparation to ensure the team is ready when a disaster occurs. Close communication as well as clearly defined roles are critical to success when transitioning from preparation to activation and execution of a disaster response.

Measures and Impact of Caseload Surge During the COVID-19 Pandemic: A Systematic Review.

OBJECTIVES: COVID-19 pandemic surges strained hospitals globally. We performed a systematic review to examine measures of pandemic caseload surge and its impact on mortality of hospitalized patients. DATA SOURCES: PubMed, Embase, and Web of Science. STUDY SELECTION: English-language studies published between December 1, 2019, and November 22, 2023, which reported the association between pandemic "surge"-related measures and mortality in hospitalized patients. DATA EXTRACTION: Three authors independently screened studies, extracted data, and assessed individual study risk of bias. We assessed measures of surge qualitatively across included studies. Given multidomain heterogeneity, we semiquantitatively aggregated surge-mortality associations. DATA SYNTHESIS: Of 17,831 citations, we included 39 studies, 17 of which specifically described surge effects in ICU settings. The majority of studies were from high-income countries ( n = 35 studies) and included patients with COVID-19 ( n = 31). There were 37 different surge metrics which were mapped into four broad themes, incorporating caseloads either directly as unadjusted counts ( n = 11), nested in occupancy ( n = 14), including additional factors (e.g., resource needs, speed of occupancy; n = 10), or using indirect proxies (e.g., altered staffing ratios, alternative care settings; n = 4). Notwithstanding metric heterogeneity, 32 of 39 studies (82%) reported detrimental adjusted odds/hazard ratio for caseload surge-mortality outcomes, reporting point estimates of up to four-fold increased risk of mortality. This signal persisted among study subgroups categorized by publication year, patient types, clinical settings, and country income status. CONCLUSIONS: Pandemic caseload surge was associated with lower survival across most studies regardless of jurisdiction, timing, and population. Markedly variable surge strain measures precluded meta-analysis and findings have uncertain generalizability to lower-middle-income countries (LMICs). These findings underscore the need for establishing a consensus surge metric that is sensitive to capturing harms in everyday fluctuations and future pandemics and is scalable to LMICs.

The 4 S's of Disaster Management Framework: A Case Study of the 2022 Pediatric Tripledemic Response in a Community Hospital.

Most children in the United States present to community hospitals for emergency department (ED) care. Those who are acutely ill and require critical care are stabilized and transferred to a tertiary pediatric hospital with intensive care capabilities. During the fall of 2022 "tripledemic," with a marked increase in viral burden, there was a nationwide surge in pediatric ED patient volume. This caused ED crowding and decreased availability of pediatric hospital intensive care beds across the United States. As a result, there was an inability to transfer patients who were critically ill out, and the need for prolonged management increased at the community hospital level. We describe the experience of a Massachusetts community ED during this surge, including the large influx in pediatric patients, the increase in those requiring critical care, and the total number of critical care hours as compared with the same time period (September to December) in 2021. To combat these challenges, the pediatric ED leadership applied a disaster management framework based on the 4 S's of space, staff, stuff, and structure. We worked collaboratively with general emergency medicine leadership, nursing, respiratory therapy, pharmacy, local clinicians, our regional health care coalition, and emergency medical services (EMS) to create and implement the pediatric surge strategy. Here, we present the disaster framework strategy, the interventions employed, and the barriers and facilitators for implementation in our community hospital setting, which could be applied to other community hospital facing similar challenges.

Managing Surges in Demand: A Grounded Conceptual Framework of Surge Management Capability.

Surge management is important to hospital operations, yet surge literature has mostly focused on the addition of resources (e.g., 25% more beds) during events like pandemics. Such views are limiting, as meeting surge demands requires hospitals to engage in practices tailored to a surge's unique contingencies. We argue that a dynamic view of surge management should include surge management capability, which refers to how resources are deployed to respond to surge contingencies. To understand this capability, we qualitatively studied five hospital systems experiencing multiple surges due to COVID-19 between April 2020 and March 2022. We develop a framework showing that managing surges involves preserving capacity, expanding capacity, smoothing capacity demand, and enabling surge management. We contribute to surge literature by identifying practices hospitals can adopt to address surges and offering a better understanding of surge conditions (e.g., degree of novelty) that make some surge management practices more appropriate than others.

The Impact of Exposure to Previous Disasters on Hospital Disaster Surge Capacity Preparedness in Finland: Hospital disaster surge capacity preparedness.

OBJECTIVE: As disasters are rare and high-impact events, it is important that the learnings from disasters are maximized. The aim of this study was to explore the effect of exposure to a past disaster or mass casualty incident (MCI) on local hospital surge capacity planning. METHODS: The current hospital preparedness plans of hospitals receiving surgical emergency patients in Finland were collected (n = 28) and analyzed using the World Health Organization (WHO) hospital emergency checklist tool. The surge capacity score was compared between the hospitals that had been exposed to a disaster or MCI with those who had not. RESULTS: The overall median score of all key components on the WHO checklist was 76% (range 24%). The median surge capacity score was 65% (range 39%). There was no statistical difference between the surge capacity score of the hospitals with history of a disaster or MCI compared to those without (65% for both, P = 0.735). CONCLUSION: Exposure to a past disaster or MCI did not appear to be associated with an increased local hospital disaster surge capacity score. The study suggests that disaster planning should include structured post-action processes for enabling meaningful improvement after an experienced disaster or MCI.

The Minnesota Medical Operations Coordination Center: A COVID-19 Statewide Response to Ensure Access to Critical Care and Medical-Surgical Beds.

BACKGROUND: COVID-19 led to unprecedented inpatient capacity challenges, particularly in ICUs, which spurred development of statewide or regional placement centers for coordinating transfer (load-balancing) of adult patients needing intensive care to hospitals with remaining capacity. RESEARCH QUESTION: Do Medical Operations Coordination Centers (MOCC) augment patient placement during times of severe capacity challenges? STUDY DESIGN AND METHODS: The Minnesota MOCC was established with a focus on transfer of adult ICU and medical-surgical patients; trauma, cardiac, stroke, burn, and extracorporeal membrane oxygenation cases were excluded. The center operated within one health care system's bed management center, using a dedicated 24/7 telephone number. Major health care systems statewide and two tertiary centers in a neighboring state participated, sharing information on system status, challenges, and strategies. Patient volumes and transfer data were tracked; client satisfaction was evaluated through an anonymous survey. RESULTS: From August 1, 2020, through March 31, 2022, a total of 5,307 requests were made, 2,008 beds identified, 1,316 requests canceled, and 1,981 requests were unable to be fulfilled. A total of 1,715 patients had COVID-19 (32.3%), and 2,473 were negative or low risk for COVID-19 (46.6%). COVID-19 status was unknown in 1,119 (21.1%). Overall, 760 were patients on ventilators (49.1% COVID-19 positive). The Minnesota Critical Care Coordination Center placed most patients during the fall 2020 surge with the Minnesota Governor's stay-at-home order during the peak. However, during the fall 2021 surge, only 30% of ICU patients and 39% of medical-surgical patients were placed. Indicators characterizing severe surge include the number of Critical Care Coordination Center requests, decreasing placements, longer placement times, and time series analysis showing significant request-acceptance differences. INTERPRETATION: Implementation of a large-scale Minnesota MOCC program was effective at placing patients during the first COVID-19 pandemic fall 2020 surge and was well regarded by hospitals and health systems. However, under worsening duress of limited resources during the fall 2021 surge, placement of ICU and medical-surgical patients was greatly decreased.

Preparing your emergency department for disaster: Optimizing surge capacity during mass casualty events.

Mass casualty events can cause patient surges within healthcare facilities. These surges can be limited to hours or continue for days or weeks. As emergency departments are the front doors to the healthcare system, it is critical that they are prepared to accept patient surges. Focusing plans on optimizing space, staff, and supplies is critical to a successful response. Boarded or non-emergent patients must be diverted, discharged, and decanted from the emergency department to expand resuscitation space. If inadequate, non-clinical space may be required for patient care. Staff call-in lists should be maintained, and in-house berthing for staff during prolonged responses may be necessary. Further, identifying the spectrum of care, from conventional to crisis, is necessary to thrive during a disaster response: staff must understand that business as usual will not be compatible with austere disaster response before levels of care begin to decline.

Use of Information Technology Systems for Regional Health Care Information-Sharing and Coordination During Large-Scale Medical Surge Events.

Medical surge events require effective coordination between multiple partners. Unfortunately, the information technology (IT) systems currently used for information-sharing by emergency responders and managers in the United States are insufficient to coordinate with health care providers, particularly during large-scale regional incidents. The numerous innovations adopted for the COVID-19 response and continuing advances in IT systems for emergency management and health care information-sharing suggest a more promising future. This article describes: (1) several IT systems and data platforms currently used for information-sharing, operational coordination, patient tracking, and resource-sharing between emergency management and health care providers at the regional level in the US; and (2) barriers and opportunities for using these systems and platforms to improve regional health care information-sharing and coordination during a large-scale medical surge event. The article concludes with a statement about the need for a comprehensive landscape analysis of the component systems in this IT ecosystem.

Determining surgical surge capacity with a hybrid simulation exercise.

Background: To help test and improve surgical surge capacity, mass casualty incident (MCI) exercises generate valuable information. Both large scale table-top exercises (TTX) and full-scale exercises (FSX) have limitations if you want to test an organisation's capability and structure. A hybrid exercise incorporating the advantages of TTX and FSX is a possible way forward, but is no standardised exercise method, yet. This study aims at evaluating the exercise results to determine the feasibility of a hybrid TTX/FSX exercise for an organization's capability and structure. Methods: A hybrid MCI simulation using moulaged figurants and simulation cards was designed, where the emergency department of a level 1 trauma centre receives 103 casualties over 4 h. After registration and triage, all casualties are expected to be resuscitated in real time and are transferred for further treatment inside the hospital (radiology, operating theatres, intensive care unit (ICU)/postop and wards). When reaching operation theatre, ICU or ward, figurants are replaced by simulation cards. Observers ensured that those procedures performed were adequate and adhered to realistic times. Use of resources (materials, drugs etc.) were registered. Primary endpoint was average time spent in the emergency department, from time of arrival, to transfer out. Secondary endpoints were related to patient flow and avoidable fatalities. Results: The hospital managed to deal with the flow of patients without collapse of existing systems. Operating theatres as well as ICU and ward beds were available at the end of the exercise. Several details in the hospital response were observed that had not been noticed during previous TTX. Conclusion: FSX have a valuable role in training, equipping, exercising, and evaluating MCI management. Hybrid simulations combining both FSX and TTX may optimise resource utilisation and allow more frequent exercises with similar organisational benefit.

Hospital surge capacity preparedness in disasters and emergencies: a systematic review.

BACKGROUND: Adequate and effective emergency preparedness for hospital surge capacity is a prerequisite to ensuring standard healthcare services for disaster victims. This study aimed to identify, review, and synthesize the preparedness activities for and the barriers to hospital surge capacity in disasters and emergencies. METHODS: We systematically searched seven databases (PubMed, MEDLINE, CINAHL, Scopus, Embase, Ovid, and PsycINFO). We included all English peer-reviewed studies published in January 2016 and July 2022 on surge capacity preparedness in hospital settings. Two independent researchers screened titles and abstracts, reviewed the full texts, and conducted data extractions using CADIMA software. We assessed the rigor of the included studies using the NIH quality assessment tools for quantitative studies, the Noyes et al. guidelines for qualitative studies, and the MMAT tool for mixed methods studies and summarized findings using the narrative synthesis method. We also used PRISMA reporting guidelines. RESULTS: From the 2560 studies identified, we finally include 13 peer-reviewed studies: 10 quantitative, one qualitative, and two mixed methods. Five studies were done in the USA, three in Iran (n = 3), and the remaining in Australia, Pakistan, Sweden, Taiwan, and Tanzania. The study identified various ways to increase hospital surge capacity preparedness in all four domains (staff, stuff, space, and system); among them, the use of the Hospital Medical Surge Preparedness Index and the Surge Simulation Tool for surge planning was noteworthy. Moreover, nine studies (69%) recognized several barriers to hospital surge capacity preparedness. CONCLUSION: The review provides synthesized evidence of contemporary literature on strategies for and barriers to hospital surge capacity preparedness. Despite the risk of selection bias due to the omission of gray literature, the study findings could help hospital authorities, public health workers, and policymakers to develop effective plans and programs for improving hospital surge capacity preparedness with actions, such as enhancing coordination, new or adapted flows of patients, disaster planning implementation, or the development of specific tools for surge capacity. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022360332.

The impact of the three-level collaboration exercise on collaboration and leadership during scenario-based hospital evacuation exercises using flexible surge capacity concept: a mixed method cross-sectional study.

BACKGROUND: Hospitals play a crucial role in responding to disasters and public health emergencies. However, they are also vulnerable to threats such as fire or flooding and can fail to respond or evacuate adequately due to unpreparedness and lack of evacuation measures. The United Nations Office for Disaster Risk Reduction has emphasised the importance of partnerships and capacity building in disaster response. One effective way to improve and develop disaster response is through exercises that focus on collaboration and leadership. This study aimed to examine the effectiveness of using the 3-level collaboration (3LC) exercise in developing collaboration and leadership in districts in Thailand, using the concept of flexible surge capacity (FSC) and its collaborative tool during a hospital evacuation simulation. METHODS: A mixed-method cross-sectional study was conducted with 40 participants recruited from disaster-response organisations and communities. The data from several scenario-based simulations were collected according to the collaborative elements (Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport), in the disaster response education, "Major Incident Medical Management and Support" using self-evaluation survey pre- and post-exercises, and direct observation. RESULTS: The 3LC exercise effectively facilitated participants to gain a mutual understanding of collaboration, leadership, and individual and organisational flexibility. The exercise also identified gaps in communication and the utilisation of available resources. Additionally, the importance of early community engagement was highlighted to build up a flexible surge capacity during hospital evacuation preparedness. CONCLUSIONS: the 3LC exercise is valuable for improving leadership skills and multiagency collaboration by incorporating the collaborative factors of Flexible Surge Capacity concept in hospital evacuation preparedness.