Planning for surge of disaster victims? Discharge the healthiest from every hospital, experts advise

December 06, 2006

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, M.D., head of emergency medicine at The Johns Hopkins Hospital 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.

There is consensus among health care officials that, whether dealing with a natural disaster like Hurricane Katrina, a possible terrorist attack like September 11, or epidemics like SARS or avian flu, affected hospitals have few means of making room for large numbers of incoming casualties, Kelen says.

In one common disaster response, medical centers would set up additional beds wherever they can (in hallways, cafeterias, etc.). 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," says Kelen. "So not only would the disaster victims not get adequate treatment, but neither would the patients who are already hospitalized."

The system 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 only be transferred to an acute-care facility and "very high-risk" patients could only be served 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 notes. It would also eliminate cumbersome bureaucracy, like the need in some hospitals to have the doctor who admitted the patient also sign the discharge paperwork. And, says Kelen, 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 the system could be implemented outside of a disaster situation as a tool "to manage even routine, everyday overloads of hospital resources."

Johns Hopkins Medicine

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