Public Health Emergency Preparedness

Chapter 1. Background and Introduction

1.1 Hospital Surge Capacity

America's health-care system, in both urban and rural areas, is at or near capacity with little ability to expand to respond to an unusually large mass casualty or surge event. The economics of hospital finance have largely driven excess capacity out of the system. Hospitals in many cities not only are at virtually 100% capacity but also must frequently close their emergency departments to new patients.³ Likewise, there is little excess capacity in the nursing home, home health, or other health-care sectors.⁴  Patients cannot readily be moved out of hospitals to make room for large numbers of trauma victims or infectious patients, because there is nowhere to move them.

Jeffrey Rubin, in Recurring Pitfalls in Hospital Preparedness and Response, notes that despite requirements, standards, and best intentions, the combination of staff and equipment shortages, lack of surge capacity, and minimal funding have remained significant obstacles.⁵ Although there have been (and likely will continue to be) substantial improvements, most hospitals are still unprepared to effectively manage the results of a major mass casualty incident requiring rapid expansion of hospital capacity for any sustained period beyond the initial incident.

In a presentation for the National Defense Industrial Association, Hospital and Healthcare Systems—Surge Capacity Donna Barbisch discussed options for expanding hospital surge capacity, which she termed expanding through a "planned degradation of care." She suggested:

• Converting existing buildings to temporary hospitals.
• Building temporary facilities.
• Developing protocols addressing emergency standard of care procedures.⁶

At a presentation before the Secretary's Council for Public Health Preparedness in 2002, Lyman van Nostrand of the Health Resources and Services Administration (HRSA) noted several strategies for increasing capacity, including:

• Converting short stay (outpatient procedure) beds into inpatient beds.
• Using hallways or creating alternative patient treatment areas.
• Partnering... to create emergency inpatient and outpatient capacity outside the hospital.

HRSA funds emergency preparedness in all States and requires that a surge plan be in place by August, 2005. This project uses Massachusetts as a case study to explore issues surrounding use of a shuttered hospital for surge capacity expansion. In Massachusetts, a Statewide system is in place to help regions allocate 'surge capacity' beds—that is, hospitals throughout the State contribute data to a system that will allow regional coordinators to identify empty beds and distribute patients among existing hospitals.⁷ At best, however, this sort of planning and coordination can redistribute several dozens of patients or perhaps a couple of hundred and, to date, has not been tested or drilled in any real-time scenario. In a hospital system as close to capacity as that of greater Boston, this relocation of patients would be inadequate to meet the surge requirements of many hundreds or thousands of simultaneous trauma or infectious disease patients and has no sustainability beyond the few days following an event, nor is sustainability part of the plan. Regional planning councils are considering other surge capacity expansion possibilities.

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1.2 Use of Shuttered Facilities to Expand Surge Capacity

Recognizing that reallocating patients among existing hospital beds will not be adequate for a truly large-scale disaster or even moderate patient surge, the Massachusetts Department of Public Health (DPH) Surge Capacity Workgroup in late 2003 convened a subcommittee to explore the use of shuttered facilities. Minutes from the first meeting indicate the purpose of the group:

"Use of shuttered facilities to create Surge Capacity: DPH presented the topic of exploring the use of shuttered hospital sites for use to meet surge capacity needs in a disaster. The workgroup agreed that it would be appropriate to work on identifying shuttered sites, mechanisms to salvage or preserve them, and to present to the workgroup recommended next steps. DPH agreed to convene a 'Shuttered Sites' subgroup to convene and report to the workgroup."⁸

What sort of facilities could best serve as medical surge facilities and provide the needed 125 beds? Many communities around the country have experienced hospital closures and conversions in recent years and have former hospitals that have not yet been converted to other purposes. Former hospitals might be the best alternative for surge facilities—better than churches, schools, or hotels—because they are plumbed, wired, and in other ways appropriate for inpatient care, since they were originally designed and operated as inpatient hospitals. 

Although not every community has such shuttered facilities, many do.  For example, during the decade from 1990-1999, bed capacity in the city of Boston declined nearly 28%.⁹ In the Boston area, several community hospitals were converted to outpatient services only, generally leaving large empty floors of former inpatient rooms. Boston is not alone: hospital capacity in other cities has also declined during the past decade. According to the Washington D.C. Hospital Association, for example, there were 4,741 acute care hospital beds in service in 1994; by late 2003, that number had dropped almost 42 percent to 2,767.¹⁰ The former D.C. General Hospital was a Level 1 trauma center with nearly 850 acute care beds and has now has been reduced to an Urgent Care and Outpatient Center in its former emergency department.¹¹

We focused on the greater Boston area as a test setting for several reasons. First, Boston's Longwood Medical Area (LMA) is an example of geographically concentrated trauma/emergency medical services that would bear the burden of responding to a mass casualty incident. Boston serves as the trauma "capital" for much of eastern New England. Many other cities are similarly organized with a geographic concentration of specialty and trauma care serving a much larger region. Second, there have been a significant number of community hospital closures around Boston in recent years. Unfortunately this also is true of many other major urban areas. Thus, we believe that Boston illustrates a very common situation for large urban areas (areas that may also be at increased risk of a major terrorist event).  Third, this option is consistent with State priorities. The Massachusetts Department of Health has been discussing the concept of surge capacity expansion and has appointed a committee to consider the option of using shuttered hospitals for this purpose. 

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1.3 How Much Additional Capacity Is Needed?

In a report filed in 2003, Massachusetts divided emergency preparedness planning into six regions for purposes of addressing patient surge and other needs. DPH further indicated that it would develop plans for hospitals in each region to collectively handle a surge of up to 500 patients beyond the licensed bed capacity of the hospitals. The planning would be for a total of 3000 surge patients Statewide. In other words, the surge planning task was to locate an additional 3000 hospital beds in the Commonwealth.

In a 2004 update to the 2003 report, DPH increased the number of required hospital surge beds to 3214 and identified two possible sources of the required beds:

1. Approximately 1880 beds that are licensed, but not staffed, located in existing hospitals. 
2. Approximately 1,200 licensed hospital beds that could be opened up through early discharge and transfer of patients to other settings, postponement of nonemergent procedures, etc. The plan for early discharge and surgery postponement, however, is not sustainable as patients who are discharged earlier than typical often require a return to an inpatient or emergency setting at a higher rate than others, and postponed nonemergency surgeries become more urgent or emergent as time passes.

This 2004 estimate leaves approximately 124 beds that do not currently exist and must be further identified.

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1.4 Facility Selection

The Massachusetts Hospital Association Web site contains a list of hospitals that have been closed over the past two decades, whether they were converted to other purposes (and to which purposes), and the current ownership status (Table 1). From this list we identified 6-7 facilities close to Boston that appear to be good candidates for the proposed project and we contacted several of them. There is probably no ideal or perfect facility for this exploratory work and given that we have several local options, we used the following criteria, in descending order, to select two candidate facilities:

• The hospital has not physically deteriorated to the point at which patient safety would be jeopardized.
• The hospital has some ongoing medical or quasi-medical mission (but not inpatient) and maintains its life safety/emergency systems.
• The hospital could be made available and ready for surge capacity within 3 to 7 days of a mass casualty event (Boston hospitals drill/plan to function at extreme excess capacity for up to 72 hours but cannot sustain this level of operations).
• Current owners were willing to participate in this project and were able to commit the cooperation of the facility managers.
• Facilities are close enough to Boston to permit rapid patient transport (i.e., inside the route 128 beltway).

Using the criteria above, we explored the candidate facilities.¹² Our search and negotiation efforts with several area real estate and health-care organizations resulted in selection of two hospitals to be used as examples for purposes of this project, which we will call Hospital 1 and Hospital 2.¹³ Both hospitals meet all the above criteria.¹⁴

Hospital 1 is located in an inner suburb of Boston. This hospital was formerly licensed for 350 beds, although the typical average maximum census was closer to 200 beds, and is sited on 12.8 acres. The building was constructed in the 1930s with the most recent addition in 1985.  The hospital was closed as an inpatient facility in 2001, with portions of the building currently used for administrative offices, a small walk-in clinic, a few doctor's offices, a dialysis unit, a sleep clinic, biomedical tenants, and an elder day care center. 

Hospital 2 is also located in an inner suburb of Boston. This hospital was formerly licensed for 161 beds, and is sited on 18.1 acres. The building was constructed in 1917, with the most recent addition in 1984. The hospital was closed as an inpatient facility in 2000 with portions currently used for outpatient services and physician offices (including pediatrics, internal medicine, and oncology).

We conducted inspection tours of these two hospitals aided by the current building engineers. Our inspection team consisted of experts in disaster medicine, emergency medicine, pre-hospital care and patient transport, anesthesiology and critical care medicine, nursing, emergency management, building engineering, materials management, patient transportation, and other relevant fields (all from the Brigham and Women's Hospital and Massachusetts General Hospital) and project staff from Abt Associates. Working from predeveloped checklists, the team itemized detailed information about the current status of the closed hospitals, from utilities to food preparation to patient care, while planning for the eventual goal of being able to care for inpatients within 3 to 7 days of initial activation. 

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1.5 Assumptions for Reopening a Shuttered Hospital as a Surge Facility

This section outlines the assumptions for this project that were developed by project staff from Abt Associates and experts from Massachusetts General Hospital and Brigham and Women's Hospital.

Timing

Since area hospitals have plans in place to cope with dramatically increased capacity for up to 72 hours, we assumed that the surge facility would need to open within 3-7 days after a mass casualty event. We anticipate that the surge facility would need to operate for a range of 2-8 weeks, depending on the nature of the disaster and the needs of mass casualty victims, although there is no maximum operational period.

This rapid reopening will only be possible with considerable advance planning and preparation—which probably will require at least a few months. Reopening a partially-shuttered hospital after a mass casualty event without this advance preparatory work would not be possible.

Recommendation: A partially-shuttered hospital should be ready to open as a surge facility 3-7 days after a mass casualty event.

Scenarios

Two general scenarios are appropriate in considering whether to reopen a partially-shuttered hospital as a surge facility. 

Scenario 1

Generic mass casualty event (conventional terrorism or war, weapon of mass destruction, natural disaster) in which hundreds of ambulatory med/surg patients need to be transferred out of the tertiary care hospitals to make capacity for mass casualty victims. In this scenario, every possible patient at the major tertiary hospitals would be transferred to other settings of care and all elective and non-urgent admissions and procedures would be delayed; if this still did not reduce demand sufficiently, the surge facility would be opened. The most critically ill patients would remain in the tertiary care facilities, and the most medically stable patients would be relocated to the surge facility. It is conceivable that there would also be a domino effect in which patients from a tertiary care setting would be transferred to a community hospital and then those less acutely ill patients from the community setting would be transferred to the surge facility. 

Scenario 2

An infectious BT agent or communicable disease epidemic (e.g., smallpox, flu, SARS) that requires the creation of an infectious-disease/isolation or quarantine hospital as the surge facility.

Most of the factors necessary for an isolation surge facility are the same for Scenarios 1 and 2, above, and include:

• Basic human needs (shelter, heat, food, water).
• Basic medical care (beds, medical staff, medical equipment and supplies, medications, electricity).
• Maintenance of sanitary conditions and management of wastes (plumbing, sanitizable surfaces, linens, means of waste disposal).
• Ancillary patient needs (social services, family waiting areas).
• Communications, safety, and security (fixed and portable communications devices, life safety systems, site and building access control devices, security staff).

Special considerations for a surge facility operated under Scenario 2 include the following:

• Willingness of owners to permit isolation/infectious disease containment use. The current facility owner will need to give permission for its use, which may be harder to obtain if the facility is to be used as an infectious disease/isolation hospital. The fact that partially shuttered hospitals have limited current uses and are likely to be demolished or converted in the future might minimize this problem, especially in comparison with other surge capacity options such as schools, hotels, or churches serving as isolation facilities in which the facility must be returned to its previous function when the epidemic is over. 
• Staff Prophylaxis. If there is an effective vaccine or prophylactic medication for a biological agent causing a community epidemic, this will need to be administered to all staff prior to the facility opening. 
• Security. In addition to the site and facility access control devices for any surge use, an increase in security staff may be needed under the isolation scenario.  The immediate neighbors may be against the opening of an infectious disease/isolation facility near their homes and may try to prevent its opening. Lockdown and exterior crowd control security protocols need to be developed in advance as part of the overall surge facility planning effort.
• Media. An isolation surge facility will likely draw significant media attention during a highly-publicized epidemic or bioterrorism attack. A media contact person should be designated to handle media information requests and ensure that a single, clear, and consistent set of information is provided to the media.
• Infectious Wastes. Infectious wastes will likely be managed off-site as most hospitals no longer operate on-site incinerators, and shuttered hospitals are even less likely to have functioning incinerators. There are existing procedures for wastes from an isolation patient in regular hospitals (i.e. red bag waste procedures), which would be broadly used at an isolation surge facility. Biohazardous waste transporters and medical waste processors will be available in most major cities.
• Isolation Air Handling. The air isolation mechanism at shuttered hospitals prevents air in the isolation space from seeping out of the area into other building airspaces, or from recirculating into other building areas via the mechanical ventilation. These mechanisms do not filter or otherwise contain air contaminants from exiting via the exhaust to the outside. High Energy Particulate Air (HEPA) filtration is an additional containment measure that could be considered for air exhausted from isolation rooms or wards.
• Infectious Laundry. Laundry at the surge facility will likely be outsourced, as is the case with many major hospitals. Potentially biohazardous laundry is generated under even a typical hospital's operations, and there are procedures in place to handle this laundry, for example (e.g. red bag procedures and elimination of laundry sorting prior to laundering). Additional measures should not be necessary with the exception of an incident of smallpox, in which autoclaving of linens is also recommended prior to laundering.  Commercial laundries servicing hospitals may or may not have autoclave capability. As a precautionary alternative, disposable linens may be used.
• Isolation Anterooms. An anteroom space is required outside of specific patient isolation areas to prevent cross-contamination of patients. Shuttered hospitals should have anterooms outside of areas previously used for isolation purposes. Also, general design of most former hospitals includes patient units or wards with nursing stations, and this physical lay-out may be amenable to the temporary creation of anterooms serving entire units or sections of a floor.
• Body Disposal. As indicated in the Medical Examiners, Coroners, and Biologic Terrorism guidance prepared by the Centers for Disease Control, the majority of biologic terrorism agents are not likely to be transmitted through nonautopsy handling of corpses. Such transmission can occur, however, with smallpox, hemorrhagic fever virus, and anthrax. With these agents, cremation without embalming should be employed. For all agents, surface decontamination of the corpse-containing body bags is also recommended.

Recommendation: An isolation facility will have special requirements for the facility, staff, waste handling, ventilation, etc.

Patient Care Assumptions

During a mass casualty event, tertiary medical centers would discharge patients, delay admissions, relocate patients to rehabilitation and nursing facilities, and almost immediately clear 25% of their beds for emergency use. These activities would mean that surrounding community hospitals, nursing homes, rehab facilities, home health and all other service providers would rapidly reach capacity, leaving nowhere else to relocate patients. The surge facility is intended as a relocation facility for the most ambulatory patients who can most safely be moved out of tertiary medical centers, to clear space for disaster victims. This facility would not be the initial intake point for patients straight from the disaster scene, since it will not have an emergency room. It would not be a 'diversion' destination for ambulances; emergency planners would continue to send patients to the tertiary medical centers' emergency departments and those hospitals would decide which existing and new patients could be safely relocated to the surge facility.

Inappropriate Services/Patients

Since the goal of the surge facility is to maintain community standards of care as nearly as possible, it would be inappropriate to relocate certain types of patients. Under either scenario, it would not be possible to reconstitute an Intensive Care Unit (ICU) in a shuttered hospital, or an operating room (OR) or suite. We assume that no emergency department would be created at a shuttered hospital being reopened to meet surge demands. In addition, because of a lack of ICU and OR services, it would probably not be possible to create a large inpatient acute burn or trauma unit in such a hospital. Under certain circumstances, however, trauma or burn patients in the later stages of convalescence might be appropriately relocated to the surge facility. Medical experts advise that it would be inappropriate to relocate acutely ill oncology patients to such the surge facility, as the patients' chemotherapy, radiation therapy, and other care needs are too sophisticated for such a place. It would not be appropriate to relocate psychiatric inpatients, since most psychiatric patients in acute care hospitals are immediate suicide risks and the entire relocation procedure would further exacerbate their very tenuous stability.  Pediatric patients would probably not be relocated either, since their needs (and their parents' needs) could not be met as completely in a surge facility as in a dedicated children's hospital.

We further determined that a shuttered hospital would probably not be appropriate as a surge facility in the following circumstances: 

• To receive victims of a BT agent that is airborne and infectious and has no vaccine (e.g., Ebola) therefore posing a significant immediate risk to health-care providers. This was ruled out as a viable option because a shuttered hospital would be unlikely to have an adequate airflow system to handle these patients although there might not be an adequate airflow system at any functional hospital either.
• As a hospice for patients needing pain and supportive care while dying from chemical or radiation terrorism events. This was ruled out because victims of chemical terrorism would either probably die almost immediately, need 24 hours of ICU care, or walk away with minimal treatment. There would probably be no need for a large-scale inpatient hospice. 

Recommendation: A surge facility could not safely offer surgery, ICU, or emergency services; these services should remain at tertiary hospitals while the surge facility is used for stable medical and post-surgical patients (clearing space in the tertiary hospitals).

Patient Population Assumptions

Patients would continue to be cared for in the surge facility for at least 30 days (and perhaps as many as 60 days or longer), and we further assume that all the patients would not arrive on Day 1 of the event; their arrival would most likely be spread out between days 3 and 11 following a mass casualty event, or spread out even more in the case of an evolving epidemic. For Scenario 1 we assume an average patient stay of 2 to 3 days; for Scenario 2 the length of stay is more difficult to predict but could be 2-3 weeks. Patients would be discharged slowly, over the course of several days or weeks, until the surge facility is no longer needed.

Ideally, the required amount of supplies held in inventory at the surge facility should be adequate to last at least 3 days per patient, regardless of the patient population.

For the purposes of estimating equipment and supply needs, we assume the surge facility will be operating at 100% capacity (a maximum of 300 patients at Hospital 1) beginning 3-7 days after an emergency is declared, and will continue for at least 30 days. For our calculations, at day 30, the surge facility would continue to be operating at capacity. This is an artificial endpoint. Under Scenario 1, we could safely assume that a surge facility could end peak operation before day 30, while under Scenario 2, peak operation could continue for up to 60 days. At day 30, any remaining patients might be directed back into one of the tertiary or community hospitals under Scenario 1, and the same would probably be true by day 60 for Scenario 2 (personnel, equipment, and supplies would need to be increased if the epidemic during Scenario 2 is protracted). 

Technology Assumptions

The two hospitals we inspected had some vestiges of information technology remaining (data ports, phone switches, etc.), but little was in working order; we expect the same to be true for other shuttered hospitals. We assume that no significant investment would be made at a shuttered hospital prior to an emergency and therefore assume that any information technology the surge facility needs must be brought in during the 3-7 days that the facility is being prepared. While the lack of information technology might be an annoyance, hospitals can function with either very low-tech substitutions (paper records) or with very high tech solutions (wireless communications). For the majority of this report, we have assumed very basic voice communications and suggest less automated work-arounds in other circumstances in which information technology is normally readily available. More sophisticated approaches can be used if feasible, but we did not want to let technology become an obstacle during the critical 3-7 day window.

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1.6 Planning Phases

There are several identifiable phases to be considered, including: preplanning, ramp-up after a disaster, opening day, ongoing operations, and close-out.

1.6.1 Preplanning

A substantial amount of advance preparation must take place before a disaster arises that necessitates the opening of a shuttered hospital as a surge facility. A thorough facility assessment should be conducted early to select the facility to be used and identify what is in working order and what is not. Most importantly, authorities must decide who will be responsible for the facility and for getting it up and running. Options include operating the reopened facility as a satellite of a local major tertiary hospital; having county or State government take responsibility; or possibly a combination of these two approaches. We used Massachusetts as our case study and note that Massachusetts is unique in not having county health departments.  In Massachusetts, more authority may be retained at the State level, while in other States more responsibility may devolve to county authorities. 

Recommendation: Substantial preplanning is required to prepare a surge facility; waiting until after a disaster occurs will essentially eliminate this option.

This report does not address issues of financing, but planners may wish to determine the costs of reopening a shuttered facility and how these costs will be recovered.

In order to decide which items or services will be contracted for or outsourced, and which will not, planners should examine the potential for borrowing from other hospitals in the metropolitan area, and also consider goods and services that may be available under a disaster declaration from State and Federal authorities, including the Strategic National Stockpile. Once the facility assessment has been completed, the planning team should undertake a detailed analysis of available services in their area. 

The complexity and scope of hospital procurement has created an industry of vendor middlemen to simplify the process. National equipment and supply vendors provide a host of services (see equipment and supplies chapter below). Regional vendors may be more specialized and only provide one or two necessary services. Some contracting arrangements can be made in advance on a 'contingency' basis so that contracts can be implemented rapidly when an emergency occurs. In the preplanning stage, it is possible to develop contracts, purchase orders, vendor relationships, and inventory reallocation plans for the 200-bed facility. Not everything needs to be contracted for in advance, however, as many vendors report being able to meet the new demand at virtually any time. If the entire equipment and supply process is to be arranged under a comprehensive service contract, the facility assessment itself could perhaps include someone from the selected contractor who will be responsible for so much of the time-sensitive ramp-up during the week prior to opening. Using an existing contract at a major medical center as the contractual 'vehicle' would promote even faster procurement.

Recommendation: An existing tertiary medical center could be responsible for operating the surge facility as a satellite, extending contracts, expertise, medical records, lab services, and pharmacy to the surge facility.

During discussions with one of the largest national equipment and supply vendors, representatives stated that they have never before proactively entered into an arrangement to provide surge capacity to a facility with whom they do not have a preexisting nonemergency contract.¹⁵ The company did note that while they could theoretically provide equipment and materials to a surge facility, it would be impossible to provide the staff necessary to support the operation. Their staff is deployed at existing hospitals and they do not have specialists on-call for emergency deployment. Even the largest hospital service contractors do not maintain on-call environmental services, food service, or materials logistic management staff. Thus, although large hospital contractors can probably supply a large share of the required equipment and supplies, staff may need to be obtained in other ways.

Contractor and Vendor Arrangements

In addition to routine operating contracts and vendor arrangements, every hospital has strategies to deal with emergency evacuation and patient relocation. These include contingency plans for equipment and supplies at other locations, contingency plans for restructuring staff shifts, and many other emergency strategies. Hospitals also have existing relationships with suppliers and vendors to make very quick adjustments to inventory in order to avoid inventory depletions caused by spikes in the patient population/demand. 

For example, in June of 2001, Tropical Storm Allison dumped nearly 80% of Houston's annual rainfall in 2 days. The resulting flood destroyed more than 180,000 square feet of hospital space at the Methodist Hospital.¹⁶ The hospital had a major national a nonclinical hospital support service company that provided facilities management, supply management, and dietary food service for the Methodist Hospital, provide additional emergency services to the facility during the flood emergency. After the hospital shut down, almost 200,000 square feet of space and many patients were transferred to other local hospitals. The support service company sent many of their Methodist Hospital staff to these other local hospitals, following the patients transferred from Methodist Hospital. The company honored their existing relationship with Methodist and continued serving Methodist patients after they were transferred to other hospitals. At the same time, the company was unable to provide support services, supplies, or equipment to affected hospitals with which they did not have existing contracts, and would have been unable to begin a new contractual arrangement with a surge facility in the midst of the flood.

The scenarios for reopening a partially-shuttered hospital as a surge facility are quite different from the emergency and contingency plans set in place for events such as the Houston flood. While actual hospital capacity in Houston decreased during and after the floods, our scenarios envision the need to increase metropolitan area hospital bed capacity by at least 200 beds. The surge facility will probably only open when all other hospitals are operating well beyond 100% capacity.

Personnel responsible at large Boston area hospitals indicated that there is only limited excess capacity either in their staff or equipment systems that could be allocated to a surge facility, even on a short-term basis. Given the tight margins at U.S. hospitals today (e.g. "just in time" inventory systems, nursing shortages), it is unlikely that many could part with enough fixed inventory or staff to stock and operate a 200-bed facility. Unless excess capital inventory and staff exist at local hospitals, a diverse array of vendors will be needed to provide the surge facility with the capital goods, materials and supplies, and staff necessary to operate the facility. 

A recent case study of an outsourcing experiment at medical facilities in the United Kingdom had somewhat mixed results, and offers the following lessons:¹⁷

• Maintain core service staff. The experience at Leicester Hospital suggests that successful use of facility service contractors requires that the hospital employ a core staff. If a planning team determines that complete outsourcing is a possibility, they should examine their needs for other core services staff based on comfort level, the facility, and existing experience with the service vendor.
• Clear communication channels should be established and chains of command outlined. The case study and anecdotal conversations suggest this may be the most important aspect of successful service outsourcing. The planning team may elect to hold proactive collaboration sessions or mock drills before any surge need to establish relationships and informal communication channels that are essential to any operation.
• Include the contractors in learning and planning tasks. Contractors should be considered part of the team, not an external organization—and therefore be included in planning sessions and conferences. The UK case studies detail this recommendation as, "Make the contractor part of the family."
• The operational entity is still legally responsible for service. The organization that leads the surge facility operation, despite the fact that they are contracting out services, still maintains overall responsibility for service provisioning of critical services.
• Recognize the contractor's need for a reasonable profit. Under a surge situation, some organizations may donate materials, equipment, and supplies, but most will need to be paid for in the commercial market. (This report does not address cost or financing issues.)

A-La-Carte Services

While vendors and service providers are capable of providing all or many core and support services under a unified contract, such services are also available (from the same firms or others) a la carte. The processes, pitfalls and considerations are similar to those discussed for the comprehensive outsourced services, and thus similar planning processes should be undertaken to employ the services of various vendors for the surge facility.

Advantages and Disadvantages of Vendor Contracting

In an emergency situation in which most specialized staffing resources are needed at other existing hospitals, large service providers are a one-stop-shop for many of the needs associated with operating a medical care facility and can alleviate pressure on surge facility planners during the ramp-up period leading to the opening of the surge facility. 

Proponents of outsourcing are particularly enthusiastic about outsourcing nonmedical services. They suggest that it saves money while increasing service quality because the practice allows the hospital to focus on its core competency of providing medical care. Food service, physical plant maintenance, materials management, pharmacy services, facility management, patient transport, IT, and other similar services are important, but ancillary to this core mission. Food services, for example, could be contracted out to a firm that specializes in food preparation, dietary planning, and food service for hospitals.

Detractors of outsourcing cite cost and quality as reasons to keep services in-house. Other general complaints about outsourcing include reduced collaboration and communication, interrupted chains of command between contractor staff and hospital management, and conflicting hospital/contractor organizational goals. Some of these complaints may relate to the general concern that using contractors reduces overall control of the service provision process. Each planning team will need to complete a thorough analysis before deciding whether to outsource services. And planners should develop an organizational chart with clearly delineated responsibilities both for the week prior to reopening of the facility and for ongoing operations.

1.6.2 Ramp-Up During the 3-7 Days After the Emergency Is Declared and Before the Facility Opens

Upon declaration of a major mass casualty event and a decision to reopen a partially-shuttered hospital, the lead person responsible for each activity below will need to devote full time to preparing the facility. We suggest the following assignments (at a minimum), which mirror sections in this report:

• Facility Readiness (Structure, Systems, Repairs, Removal of Debris/Furniture, Testing, Cleaning, etc.).
• Equipment and Supplies (Including Pharmacy, Laundry, and Food Service).
• Staffing.
• Security.
• Patient Transportation.

• Patient Information Systems (Medical Records).

It will be each team leader's responsibility to ensure that their area of control is adequately prepared for 200 patients within 3 to 7 days of the emergency event. Since these teams must work concurrently rather than consecutively, responsibility must be distributed for both decision-making and spending. Most critically, communication between the teams must be clear and frequent during the ramp-up.

1.6.3 Day 1

Three to 7 days after the emergency event occurs, the surge facility must be ready to receive patients. Much will need to happen on Day 1, particularly in terms of staff at the facility and patient transport. We assume that staff will have been assembled (together or in shifts) in the day or 2 prior to opening so that they will have met each other and be somewhat familiar with the physical layout of the facility. Security staff will also have been introduced to the facility in the days prior to opening, and their shifts will be established for opening day. Supplies and equipment will be in place, as well as a functional pharmacy, dietary services, housekeeping, and other ancillary services. 

A major effort on Day 1 will be patient discharge from their tertiary hospitals, transport to the surge facility, and intake at the surge facility. This movement will be facilitated by an abbreviated patient transport record (see sections below on patient transport and patient information) listing each patient's monitoring, medication, and other needs that must be met during and after transport. 

We expect that extra staff will be in place on Day 1 to handle unforeseen difficulties on this unusual day, and staff shift rotations might need considerable overlap so that the hand off from one shift to another is smooth. 

1.6.4 Ongoing Operations

Once the facility has opened, team members will be responsible for continued operations, taking on roles similar to their customary responsibilities in routine hospital operations. We assume that most of the leadership team will have the necessary experience in their areas of expertise. For example, the senior members of the security team will have backgrounds in hospital security, and those running the pharmacy will have worked at hospital pharmacies. Team members would continue providing services such as overseeing service contracts, managing staff, ensuring quality of service, maintaining appropriate inventory levels, and mitigating problems within their areas of influence and responsibility. 

Teams may face different problems or issues if the surge facility remains open more than a few weeks. Temporary fixes may not hold for 3 months, and supplies that are available immediately to open the facility may need to be replenished. Staffing that can be handled in the short-term with Public Health Service clinicians and other Federal or State assets, may not be available longer term, and their lodging needs cannot be considered temporary indefinitely. If the facility must remain open for more than a few weeks, adjustments will be needed by many teams.

1.6.5 Facility Closure

As the emergency subsides, the surge facility will begin to reduce staff, services, and supply re-order volume. For example, the materials management team leader must manage this decline toward closure, maintaining levels of service and supply appropriate for the decreasing intensity of operations, while beginning to plan for return of leased equipment, etc. When the facility is fully closed, the materials management leader will be responsible for ending contracts and determining how the remaining supplies and equipment will be allocated within the local health system.

1.6.6 Review and Replan

After the surge facility closes, we recommend that team leaders assemble and review the experience—what went well and what did not. This review can be used to revise plans so that if the surge facility is needed again, operations will have improved based on lessons learned from the first experience.

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1.7 Report Organization

This report deals with Scenarios 1 and 2 described above. In each section of this report, all general information provided is applicable to both scenarios. Any additional, special requirements for the infectious disease/isolation situation (Scenario 2) are noted.

This report contains our findings from visiting Hospital 1 and Hospital 2, our conclusions regarding what one can expect to find at any partially-shuttered hospital, conclusions about features that probably vary between one shuttered hospital and another, the many resources that are not available at any partially-shuttered hospital and would need to be brought to the facility before it could be reopened to meet surge demands, and how these needs can best be met. The sections of the report are presented in the following areas:

2.0 Facility Structure and Status
3.0 Equipment and Supplies
4.0 Staffing
5.0 Patient Transportation
6.0 Security
7.0 Patient Information

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