Public Health Emergency Preparedness

Executive Summary

Greater Boston and Massachusetts were used as prototypes to evaluate the feasibility of, and requirements for, reopening a shuttered hospital to expand surge capacity during an urban mass casualty event. Massachusetts health planners previously identified the need for 150-250 additional beds for a surge event; this is the scale of operation explored in this project.  Other communities may be considering this option as well. Our objective was to develop tools to help planners determine whether this option is feasible in their local communities and to carry out the advance planning and preparation that would be required.

After considering several candidate facilities, conducting careful walk-throughs and assessments of two candidate facilities, and discussing options with the owners of several others in the greater Boston area, we concluded that the following factors would help emergency planners evaluate candidate shuttered hospitals and determine the most likely candidates for surge capacity expansion:

• A completely abandoned hospital that has been vacant for many years would likely have been stripped of anything saleable and will no longer have working utilities, fire and life safety systems, or even possibly water and sanitation fixtures. Thus a totally shuttered facility cannot safely be converted to inpatient care in a timely manner.
• Location and the relative local value of the real estate involved may indicate the likelihood that a facility will remain empty and available or be converted to other purposes such as condominiums or assisted living.
• Similarly, a shuttered hospital may have an uncertain ownership status, may be owned by a city or a developer, or may be part of a bankruptcy proceeding. Uncertain or changing ownership may mean that no one is legally able to negotiate for the use of the facility in an emergency.  A partially-shuttered hospital that maintains some sort of affiliation with a tertiary hospital (e.g. urgent care center, walk-in clinic) may be a more likely candidate for surge capacity since organizational/contractual arrangements already exist that can be used to advantage in an emergency.
• A larger shuttered hospital may have more to offer than a very small one for surge capacity purposes.
• A surge facility located fairly close to the major tertiary medical centers may be advisable to minimize patient transportation time and issues.
• A facility that maintains a cafeteria and food preparation area, certified life safety systems, a phone switch, and similar basic functionality would be better than one that is entirely vacant and unused.

Planners could rank potential surge facilities using a list such as this, as a first step in identifying the best candidate facilities. The resulting list of candidate facilities should be reassessed periodically, as the status of facilities can change over time.

Timing

All urban hospitals in Boston have plans in place to cope with dramatically increased capacity for up to 72 hours; the surge facility would therefore need to open within 3 to 7 days of a mass casualty event. The surge facility would need to operate for a range of 2 to 8 weeks, depending on the nature of the disaster and the needs of mass casualty victims, although, theoretically, there is no limit to how long the facility could remain open.

Rapid reopening would only be possible with considerable advance planning and preparation, requiring at a minimum a couple of months. It is not possible to reopen a partially-shuttered hospital in the days after a mass casualty event without this advance preparatory work.

Scenarios

There are two general scenarios we believe are appropriate in considering reopening a partially-shuttered hospital as a surge facility: 

Scenario 1

Generic mass casualty event (conventional terrorism or war, weapon of mass destruction, or natural disaster) in which hundreds of ambulatory medical/surgical (med/surg) patients need to be transferred from 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 also conceivable that there would be a domino pattern in a larger metropolitan area experiencing a mass casualty event, in which patients from tertiary care settings would be transferred to community hospitals and then less acutely ill patients in community hospitals would be transferred to the surge facility.¹ 

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. 

Special considerations for a surge facility under an isolation scenario such as this include: willingness of facility owners to allow this use at their facility, prophylaxis of staff working at the surge facility, security and perimeter control, infectious waste removal and treatment, negative pressure rooms or wards, laundering of contaminated linens, and (possibly) body disposal. 

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, and home health and 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 be 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 responders would continue to send patients to the tertiary medical centers' emergency departments and physicians at 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. Based on the facilities we assessed, it would not be possible to establish an intensive care unit (ICU) or an operating room (OR) or suite in a shuttered or partially-shuttered hospital within 3 to7 days.  We assume that no emergency department would be created at a former hospital being reopened to meet surge demands. In addition, because of a lack of ICU and OR services, it would 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 a surge facility, as the patients' chemotherapy, radiation therapy, and other care needs are too sophisticated. 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 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 partially-shuttered hospital would not be appropriate as a surge facility in the following circumstances:

• A bioterrorism (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 because a shuttered or partially-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.
• 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 die almost immediately, need 24 hours of ICU care, or walk away with minimal treatment.  There would be little need for a large-scale inpatient hospice.

Recommendations

In addition to a variety of recommendations appearing throughout this report, the following overarching recommendations are offered:

Any community considering a shuttered hospital for surge expansion or as an isolation facility, must thoroughly assess candidate facilities and plan in advance to make this option ready should the need arise. Waiting until a mass casualty event has occurred will eliminate the options altogether—a shuttered hospital simply cannot be reopened in the days after a disaster without advance planning. (We would argue that no surge facility, whether at a shuttered hospital, a school, or a hotel, can be opened without advance planning.)

The most efficient and comprehensive approach might be for an existing tertiary medical center to take on the responsibility of making the surge facility its 'satellite.' Existing contracts and vendor agreements could be extended to the 'satellite' facility, and medical, security, materials management, and other staff could lend their expertise. Patient charts could remain unified and pharmacy/lab services could be extended to the satellite. While some cities may not have a tertiary medical center or an enterprise willing and able to fill this role, and this approach is certainly not the only one that would work, it is a logistically reasonable and efficient approach for planners to consider.

Federal and State regulations pose barriers to the rapid conversion/reopening of a shuttered hospital (e.g., the Emergency Medical Treatment and Active Labor Act [EMTALA], Medicare Conditions of Participation, the Health Insurance Portability and Accountability Act [HIPAA]).² These issues should be considered well in advance of a mass casualty event necessitating surge capacity expansion. Provision for waivers could be set in place in advance, for example, to permit surge capacity expansion. Perhaps the Federal Government could offer 'model' waiver legislation and/or regulations as a starting point for States.

There remain unanswered policy questions that planners need to consider, including:

• Who will have responsibility for operating the facility? Options include a local tertiary care hospital or hospital system, or a city or State health department. Will this entity bear legal/liability responsibility as well?
• Who will have responsibility at Federal and State levels to review/revise regulations and establish contingencies for waiving specific regulatory requirements in an emergency?
• How will the surge facility and its staff, equipment, and supplies be paid for?  Can this be determined in advance, or only after a major emergency? Will third party insurers be asked to reimburse for care provided in the surge facility, and will the facility therefore need a sophisticated billing system (not dealt with here)?

Return to Contents
Proceed to Next Section