[ Evidence-Based Medicine ]

Surge Capacity Principles

Care of the Critically Ill and Injured During Pandemics and Disasters:
CHEST Consensus Statement
John L. Hick, MD; Sharon Einav, MD; Dan Hanfling, MD; Niranjan Kissoon, MBBS, FRCPC; Jeffrey R. Dichter, MD;
Asha V. Devereaux, MD, MPH, FCCP; and Michael D. Christian, MD, FRCPC, FCCP; on behalf of the Task Force for
Mass Critical Care

BACKGROUND: This article provides consensus suggestions for expanding critical care surge
capacity and extension of critical care service capabilities in disasters or pandemics. It focuses
on the principles and frameworks for expansion of intensive care services in hospitals in the
developed world. A companion article addresses surge logistics, those elements that provide the
capability to deliver mass critical care in disaster events. The suggestions in this article are
important for all who are involved in large-scale disasters or pandemics with injured or critically
ill multiple patients, including front-line clinicians, hospital administrators, and public health or
government officials.
METHODS: The Surge Capacity topic panel developed 23 key questions focused on the
following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and
informatics. Literature searches were conducted to identify evidence on which to base key
suggestions. Most reports were small scale, were observational, or used flawed modeling;
hence, the level of evidence on which to base recommendations was poor and did not permit
the development of evidence-based recommendations. Therefore, the panel developed expert
opinion-based suggestions using a modified Delphi process. Suggestions from the previous
task force were also included for validation by the expert panel.
RESULTS: This article presents 10 suggestions pertaining to the principles that should guide
surge capacity and capability planning for mass critical care, including the role of critical care
in disaster planning; the surge continuum; targets of surge response; situational awareness and
information sharing; mitigating the impact on critical care; planning for the care of special
populations; and service deescalation/cessation (also considered as engineered failure).
CONCLUSIONS: Future reports on critical care surge should emphasize population-based out-
comes as well as logistical details. Planning should be based on the projected number of criti-
cally ill or injured patients resulting from specific scenarios. This should include a consideration
of ICU patient care requirements over time and must factor in resource constraints that may
limit the ability to provide care. Standard ICU management forms and patient data forms to
assess ICU surge capacity impacts should be created and used in disaster events.
CHEST 2014; 146(4_Suppl):e1S-e16S

Revision accepted May 1, 2014; originally published Online First
August 21, 2014.
AFFILIATIONS: From Hennepin County Medical Center (Dr Hick),
University of Minnesota, Minneapolis, MN; Shaare Zedek Medical
Center (Dr Einav), Hebrew University Faculty of Medicine, Jerusalem,
Israel; Inova Health System (Dr Hanfling), Falls Church, VA; George
Washington University (Dr Hanfling), Washington, DC; BC Children’s
Hospital and Sunny Hill Health Centre (Dr Kissoon), University of
British Columbia, Vancouver, BC, Canada; Allina Health (Dr Dichter),
Minneapolis, MN; Aurora Healthcare (Dr Dichter), Milwaukee, WI;

journal.publications.chestnet.org e1S
Summary of Suggestions
Role of Critical Care in Disaster Planning
1. We suggest hospital and local/regional disaster
committees include a critical care expert to optimize
critical care surge capacity planning.
Surge Continuum: Conventional, Contingency,
and Crisis Care
2. We suggest utilization of the existing framework for
surge response that recognizes the shift in surge
response across thresholds that distinguish conven-
tional surge from contingency surge from crisis surge
and delivery of crisis care is important in ensuring
consistency in planning for critical care surge response.
Targets for Surge Response
3. We suggest in the presence of a slow-onset, impend-
ing disaster/threat, targets for surge capacity and
capability be focused, where possible, on projected
patient loads.
4a. We suggest hospital critical care resources be able
to expand immediately by at least 20% above the baseline
ICU maximal capacity for a conventional response.
4b. In a contingency response, we suggest hospital
critical care resources be able to expand rapidly by at
least 100% above the baseline ICU capacity to meet
patient demand using local and regional resources.
4c. We suggest hospital critical care resources be able
to expand by at least 200% above baseline ICU
capacity to meet patient demand in a crisis response
using any combination of local, regional, national,
and international resources.
5. We suggest more prolonged demands on critical
care compared with the demands placed on other
sections of the hospital (ie, days rather than hours) be
Sharp Hospital (Dr Devereaux), Coronado, CA; Royal Canadian Med-
ical Service (Dr Christian), Canadian Armed Forces and Mount Sinai
Hospital, Toronto, ON, Canada.
FUNDING/SUPPORT: This publication was supported by the Coopera-
tive Agreement Number 1U90TP00591-01 from the Centers of Disease
Control and Prevention, and through a research sub award agreement
through the Department of Health and Human Services [Grant 1 -
HFPEP070013-01-00] from the Office of Preparedness of Emergency
Operations. In addition, this publication was supported by a grant from
the University of California–Davis.
COI grids reflecting the conflicts of interest that were current as of the
date of the conference and voting are posted in the online supplementary
materials.
e2S Evidence-Based Medicine
taken into consideration when resuming routine
hospital activities that may require ICU support.
Situational Awareness and Information Sharing
6. We suggest facilities, coalitions, and other compo-
nents of the emergency response system, including
those related to government entities, study how
information about patients, events, and epidemi-
ology are shared on a routine basis and during a
major incident. Information technology should be
leveraged to provide better indicators, more rapid
alerting, and better patient data to facilitate
decision-making.
7. We suggest the ability to provide dynamic fore-
casting of the functioning and sustainability of the
supply chain be supported by hospitals.
Mitigating the Impact on Critical Care
8a. We suggest medically fragile patients be sup-
ported and protected by pre-event planning for
ongoing medical support in the community to
mitigate their reliance on hospital-based resources
during a disaster event.
8b. We suggest local and regional authorities be
responsible for integration of preventive community
medical support in the plans to treat medically fragile
patients during disasters.
8c. Given a situation where mitigation measures fail,
medically fragile patients and victims of a disaster or
pandemic should be given equal consideration for
access to ICU resources.
Planning of Surge Capacity for Unique
Populations
9a. We suggest regional planning include the expec-
tation that the hospital be able to provide initial
DISCLAIMER: American College of Chest Physicians guidelines and
consensus statements are intended for general information only, are not
medical advice, and do not replace professional care and physician
advice, which always should be sought for any medical condition. The
complete disclaimer for this consensus statement can be accessed at
http://dx.doi.org/10.1378/chest.1464S1.
CORRESPONDENCE TO: John L. Hick, MD, Hennepin County Medical
Center, 701 Park Ave S, Minneapolis, MN 55415; e-mail: John.hick@
hcmed.org
© 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.14-0733
[ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]
stabilization care to unique populations that they TABLE 1 ] Primary Target Audiences for Suggestions
may not normally serve such as pediatric, burn, and
Primary Target Audience
trauma patients.
Suggestion Hospital Public
9b. We suggest access to regional expertise for care of Number Clinicians Administrators Health/Government
all patients who require specialty critical care services, 1 9 9
including participation in the planning phase and 9 9
2 9
access to just-in-time consultation for care coordina-
3 9
tion during a response.
4a 9 9
4b 9 9
Service Deescalation and Engineered Failure 4c 9 9
10a. We suggest hospitals adopt a process of engi- 5 9
neered systems cessation when the staff and/or 6 9 9
material resources required for the ongoing critical 7 9 9
care of a small number of patients could be used to 8a 9 9
save a greater number of lives. 8b 9
10b. We suggest hospital cessation of the delivery of 8c 9 9
critical care services be considered if such endeavors 9a 9 9 9
are likely to entail significant personal risk to the 9b 9 9
treating team despite the availability of personal 10a 9
protective equipment and appropriate medical 10b 9
countermeasures. 10c 9 9 9
10c. We suggest a hospital’s decision to restrict or
expand the delivery of critical care be made as part
of a local/regional decision-making process, with
disasters. The suggestions in this article are important
consultation and input provided by hospital ICU
for all involved in a disaster or pandemic with
leadership.
multiple critically ill patients, including front-line
clinicians, hospital administrators, and public health
Introduction or government officials. Although it is important
This article focuses on key operational strategies and for all providers to be familiar with all aspects of
conceptual frameworks for the expansion of intensive surge response, Table 1 provides an overview of the
care services in hospitals that customarily provide suggestions most of interest to each group. A com-
such care in the developed world. This may include panion article in this guideline by Einav et al1 addresses
expanding critical care surge capacity and extending specific resources and tactics that describe the
critical care service capabilities or may require logistics required to support critical care surge
the limitation and scaling back of such services in capability.

Materials and Methods
The methods used by the task force in developing the suggestions in
this article were consistent with the policies of the American College
of Chest Physicians (CHEST) Guidelines Oversight Committee. The
Surge Capacity topic panel convened in June 2012 and first developed
23 key questions focused on the following domains: systems issues;
equipment, supplies, and pharmaceuticals; staffing; and informatics.
Literature searches were conducted to identify evidence on which
to base key suggestions. Searches were limited from January 1995
to October 2012; English-language articles were included, and non-
English language articles were excluded. A total of 1,444 articles
were identified. The results were reviewed for relevance to the topic
and the articles screened by two topic editors (J. L. H. and S. E.) for
inclusion. The lead topic editor (D. H.) was responsible for resolving
the results where initial consensus was not achieved. Seven hundred
twenty-seven articles were deemed relevant to the subject of surge
capacity planning and response. Most reports were small scale, were
observational, or used flawed modeling; hence, the level of evidence
on which to base recommendations was poor and did not permit
the development of evidence-based recommendations. Therefore,
the panel developed expert opinion-based suggestions using a modi-
fied Delphi process. (See the “Methodology” article by Ornelas et al2
in this consensus statement.) (e-Appendixes 1 and 2 provide lists of
key questions, key suggestions, and corresponding search terms and
results.)

journal.publications.chestnet.org e3S
Results
Role of Critical Care in Disaster Planning
1. We suggest hospital and local/regional disaster
committees include a critical care expert to optimize
critical care surge capacity planning.
Input from critical care physicians often is excluded
in preparations for and organization of hospital
disaster surge response plans because of an emphasis
on emergency and surgical services preparedness
activities. However, critical care services often are
significantly affected during disasters or pandemics.
For example, critically injured patients may comprise
26% of the patient load during terrorist bombings
(a nearly four-fold increase over conventional traumatic
injury),3 and pandemic influenza has accounted
for . 15 times the ICU admissions compared to
seasonal influenza.4 Critical care services are an
integral part of a continuum of care to decrease
mortality, and hence, early involvement of critical
care services in preparedness activities is necessary.
Critical care physician input into the planning process is
required from local and regional levels to ensure that
key considerations (eg, issues with staff transfer, specific
resources that may be required, transfer considerations
for ICU patients) are addressed, that valid assumptions
are being used in planning and policies, and that a
mechanism exists during an event for their expertise to
be incorporated into response actions. This may include
providing input on evacuation decisions and resource
distribution, sharing treatment information between
facilities, or developing common treatment or triage
policies. Modeling has shown that maximizing available
regional resources can have a significant impact on
the ability to cope with large volumes of pediatric ICU
patients.5-7
Surge Continuum: Conventional, Contingency,
and Crisis Care
2. We suggest utilization of the existing framework for
surge response that recognizes the shift in surge
response across thresholds that distinguish conven-
tional surge from contingency surge from crisis surge
and delivery of crisis care is important in ensuring
consistency in planning for critical care surge
response.
Disasters affect critical care in many ways, depending
on the onset, impact, and duration of the incident
(Table 28).9 The impact of the event will drive peak
demand at the facility, whereas the scope of the event
(local, regional, or national) will dictate available
options for supplies and patient transfers. Sudden-
impact disasters (Table 3) challenge facilities with the
immediate arrival of casualties and place demands on
space, staff, and supplies—the key logistical compo-
nents of surge capacity.10,11 Sudden-impact disasters
may affect ED services, which are of short duration,
but the impact of even sudden disasters on critical
care and surgical services may last days or even
weeks.12-15
Fortunately, mass casualty incidents involving . 40 victims
are rare, occurring only 10 to 15 times per year on
average in the United States.16 Mass causality mod-
eling17,18 and practical expectations19-21 (including
hospital requirements in Israel) both agree that a 20%
surge capacity will accommodate most acute incidents.
Thus, it is unusual for a typical mass casualty event to
exceed available community resources.22 However,
failure to plan for a larger incident will result in an
inadequate response because it is not possible to cope
with an event of unusual size with usual practices.
Effective hospital preparedness programs correlate

TABLE 2 ] Surge Continuum Taxonomy

Response Category Description

Conventional care The spaces, staff, and supplies used are consistent with daily practices within the institution.
These spaces and practices are used during a major mass casualty incident that triggers
activation of the facility emergency operations plan.
Contingency care The spaces, staff, and supplies used are not consistent with daily practices but maintain or have
minimal impact on usual patient care practices. These spaces or practices may be used
temporarily during a major mass casualty incident or on a more sustained basis during a
disaster (when the demands of the incident exceed community resources).
Crisis care Adaptive spaces, staff, and supplies are not consistent with usual standards of care but provide
sufficiency of care in the setting of a catastrophic disaster (ie, provide the best possible care to
patients given the circumstances and resources available).

Definitions from Hick et al.8

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TABLE 3 ] Challenges and Considerations Affecting Critical Care in Disasters
Onset Local Regional National

Acute Example: building collapse Example: earthquake Example: failure of national

Limited time frame Extended time frame,
including infrastructure
Limited peak or impact Extended peak (days)
Transfer options and resources Competition and access issues
available for transfers and resources
Slow Example: flood Example: extreme heat
Limited impact Extended impact, including
infrastructure (power)
Limited peak Extended peak (days)
Transfers and resources available Capacity may limit transfer options
power grid
Extended time frame
Extended, severe peak
Transfers are long distance,
competition for resources
significant, delivery of
resources delayed
Example: pandemic
Prolonged impact
Prolonged peak
Limited transfer options,
limited resources, severe
competition for resources
Potential for infrastructure
degradation

with lower rates of hospital mortality in major
disasters compared with lesser prepared facilities.23
Slow-onset, anticipated disasters (Table 3), such as
hurricanes or pandemics, offer the opportunity to
prepare, make proactive decisions, and mitigate
impact, but these pose unique challenges of maintain-
ing a sustained surge response over many days, often
with limited or no resources. In most mass casualty
incidents, demands are met by delivering conventional
care with occasional contingency measures.24 How-
ever, delivery of critical care in non-ICU environments
carries some risk to patients25 (Fig 1).
Although most disasters can be managed with conven-
tional or contingency care, in specific circumstances
(Table 4), a crisis response may be required. In these
cases, a crisis situation exists when a resource or
resources are in such shortfall that decision-making
moves from patient-centered to population-centered;
maximizing the use of available resources to save more
lives. This shift may necessitate resource triage. A
substantial number of publications since 2008 have
focused on crisis care applicable to critical care
planning.8,36-38
Targets for Surge Response
3. We suggest in the presence of a slow-onset, impend-
ing disaster/threat, targets for surge capacity and
capability be focused, where possible, on projected
patient loads.
4a. We suggest hospital critical care resources be able
to expand immediately by at least 20% above the
baseline ICU maximal capacity for a conventional
response.
4b. In a contingency response, we suggest hospital
critical care resources be able to expand rapidly by at
least 100% above the baseline ICU capacity to meet
patient demand using local and regional resources.
4c. We suggest hospital critical care resources be able
to expand by at least 200% above baseline ICU
capacity to meet patient demand in a crisis response
using any combination of local, regional, national,
and international resources.
5. We suggest more prolonged demands on critical
care compared with the demands placed on other
sections of the hospital (ie, days rather than hours) be
taken into consideration when resuming routine
hospital activities that may require ICU support.
Surge capacity and capability planning should be
conducted with specific and achievable targets for
increasing patient care services.39 Sudden-onset disaster
events are characterized by the need to triage (primary
and secondary triage), admit, and stabilize a high
volume of patients over a brief time frame (hours) in the
ED. Patients admitted to the ICU are fewer than those
treated in the ED but occupy ICU beds 10 to 100 times
longer (days to weeks) than the time they spent in the
ED.12-15 In the presence of a slow-onset, impending
disaster or pandemic, targets for surge capacity and

journal.publications.chestnet.org e5S
Figure 1 – A framework for critical care surge capacity planning, outlining the conventional, contingency, and crisis surge responses. PACU 5 postanes-
thesia care unit.

capability should be focused, where possible, on
projected patient loads.
The targets for conventional care (at least 20% beyond
usual capacity) are generally achieved using resources
immediately available within the facility (vacant beds,
discharge of patients to lower-intensity care units,
cancellation of procedures)40 and should be achieved
within a 2-h period. Depending on the role of the
hospital in community response (eg, the only level I
trauma center or pediatric facility in the area) and the
hazards identified in the community (eg, risk for
earthquake, terrorism), it may be prudent to plan for
additional conventional capacity. Contingency care
(100% beyond usual capacity or two times the usual
ICU beds) typically requires care to be provided in
nontraditional areas (postanethesia care unit, operating
rooms) using community or regional resources and
should be achieved with adequate preplanning of

TABLE 4 ] Situations Potentially Requiring a Crisis-Level Surge Response

Situation Rationale

Significant damage to infrastructure Damage to community resources can have tremendous implications for critical
care. Roadways, communications, utilities, and other health-care facilities
may be damaged, significantly limiting options for patient transfer, staff
reporting for duty, and arrival of supplemental resources. Facility impact
may range from negligible to catastrophic (eg, direct impact by tornado or
hurricane); thus, capacity and capabilities can be severely limited in the
context of damage to facility or community infrastructure.26-28
Massive local impact Improvised nuclear device detonation and large-scale anthrax attacks are
examples of situations in which the resources to provide care exist, but the
local pressure of casualties will overwhelm the best-prepared system and
severely strain initial resources. Resources are available and transfers
possible, but the relief valves for the system do not provide significant
decompression until after the peak of casualty arrivals.29,30
Pandemic In a severe pandemic, competing demands on resources, long-duration impact,
and potential staff illness contribute to very limited options for importing
resources or transferring patients. Most models of severe pandemics predict
that current and surge capacities for critical care would be exceeded.31-35

e6S Evidence-Based Medicine [ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]

supplemental equipment (monitors, beds, and ventila-
tors) within 12 h of the event. A key factor that may
limit achieving this goal is the availability of ventilators,
requiring anesthesia machines and regional stockpiles to
be used.41 Crisis care (200% beyond usual capacity or
three times the usual ICU beds) will most likely require
access to outside resources, such as strategic national
stockpiles, and will likely require 48 to 72 h to achieve.
The facility should identify what spaces would be used
and what supplemental supplies (monitors, beds, and
ventilators) would be required to minimize delays if
occasion warrants.42
With current practices of just-in-time staffing and
supplies, few facilities have a large number of readily
available resources for critical care in disaster situations.43
This makes participation in regional coalitions impera-
tive to leverage regional resources when local resources
are insufficient.44-47 Further discussion of the importance
of coalitions and regional response may be found in the
article “System Level Planning, Coordination, and
Communication” by Dichter et al48 in this guideline.
Hospitals that are affected by a disaster and have
moved to contingency or crisis care response mode
are expected to engage community partners to Figure 2 – Various tiers of authority are involved in health-care surge
response. Not all jurisdictions have Regional Health Authorities, in
request resources or transfer patients to facilities which cases, health-care coalitions work directly with the state or
with available resources. However, during the 2009 province. Hosp 5 hospital. (Adapted from the Medical Surge Capacity
influenza A(H1N1) pandemic, certain health-care and Capability Handbook.49)

facilities were considering triage of extracorporeal

membrane oxygenation and mechanical ventilation
without being aware that these resources were available
at other local facilities (N. Lurie, MD, MSPH, Assis-
tant Secretary for Preparedness and Response, US
Department of Health and Human Services, personal
communication, January 2013).
Prior to an event, critical care physicians should
understand how their hospital participates in the
response process and how their response tiers represent
geographically layered entities that range from the local
hospital and health-care coalitions and regional author-
ities, to regions, state/province, interstate/province, and
national authorities (Fig 2). Understanding the resources
available at each level and how they are accessed is
necessary to exchange information and obtain resources
quickly during an event. These mechanisms, including
exercises with a critical care component or focus, should
be tested a priori.
Situational Awareness and Information Sharing
6. We suggest facilities, coalitions, and other compo-
nents of the emergency response system, including
those related to government entities, study how
information about patients, events, and epidemi-
ology are shared on a routine basis and during a
major incident. Information technology should be
leveraged to provide better indicators, more rapid
alerting, and better patient data to facilitate
decision-making.
7. We suggest the ability to provide dynamic fore-
casting of the functioning and sustainability of the
supply chain be supported by hospitals.
Timely and ongoing provision of incident updates to
hospitals allows the facility to tailor its response to the
demands of the incident. Awareness of other critical
care resources in the area allows the facility to balance
demand by either providing or requesting assets,
depending on the impact at their facility and other
facilities. Decisions regarding the implementation of
mass critical care and the levels and types of care
anticipated will rely on the timely exchange of infor-
mation that facilitates situational awareness and the
specific needs for critical care services as the event
unfolds.

journal.publications.chestnet.org e7S
The ability to provide such situational awareness relies
on well-established systems of both hardware (eg, radio,
Internet-based information exchange) and software
(ie, the systems and policies that define the process and
scope of information exchange between facilities and
agencies). A mechanism must also be in place for
hospitals to obtain validated information from public
safety sources and a process (hospital coalition staff,
other resources) to filter what is relevant (eg, street
closures that will have an impact on staff response)
and provide timely, accurate, and useful updates to
facilities.
Alerting hospitals about an event should occur by
predetermined, redundant methods to ensure receipt of
the information. How notification is triggered and the
response engendered at the hospital should be part of
a structured process. The hospitals should consider
available indicators (disease incidence, reports of events
in the community, etc) and define appropriate trigger
thresholds for hospital notification and activation of its
disaster plan as well as for engaging regional hospital
coalition partners. A thorough discussion of indicators
and triggers published by the Institute of Medicine38
may be a valuable resource for communities to define or
reevaluate the indicators they use and the actions they
take in response.
Monitoring of indicators and resources, such as available
ICU beds, should be standard daily practice so that in
the event of a disaster, incident managers are aware of
their facility’s capacity and when they should call for
assistance. Available, staffed beds are important but
serve as only one indicator of capacity once a disaster
plan is activated. Hence, updates from facilities are
important to define the actual capacity of the system and
balance this against the demands of an evolving
incident.
What additional information is tracked (ventilators,
medications, and staffing) depends on local policies,
processes, and the specifics of the event. For instance,
more-frequent discussion and information sharing
must occur if facilities are operating in crisis mode or
if the event is prolonged. Definitions and categoriza-
tion of the information collected should be under-
stood and accurate to be of use during an event;
otherwise, the information collected will be inconsis-
tent or misleading.50-52 These efforts at the coalition
level must be closely integrated with the incident
management processes of the jurisdiction to ensure
coordination of efforts and congruency of priorities,
e8S Evidence-Based Medicine
including participation of the coalition in a Joint
Information System.
Mitigating the Impact on Critical Care
8a. We suggest medically fragile patients be supported
and protected by pre-event planning for ongoing
medical support in the community to mitigate their
reliance on hospital-based resources during a disaster
event.
8b. We suggest local and regional authorities be
responsible for integration of preventive community
medical support in the plans to treat medically fragile
patients during disasters.
8c. Given a situation where mitigation measures fail,
medically fragile patients and victims of a disaster or
pandemic should be given equal consideration for
access to ICU resources.
Critical care resources are finite, and there will always
be situations in which hospital resources will be insuffi-
cient to meet demands. To avert or delay this situation,
prevention of excessive patient loading and advocacy
for prevention and early treatment of illness and
injury to forestall progression of illness are important
(Table 5).
Medically fragile patients (home-bound patients reliant
on critical care equipment or specialized care or
treatment and long-term-care facility residents) are
likely to deteriorate during disasters due to decreased
access to medications and medical support in the
community.73,74 Preventable increases in use of hospital-
based resources by medically fragile patients can blunt
the surge response. Therefore, every effort should be
made to encourage patient and caregiver preparedness
and enhance the ability of shelters and long-term-care
facilities to provide care during and after an event.75
Critical care physicians should ensure that patients on
home oxygen or ventilation (including noninvasive
ventilation) have contingency plans for loss of power
and that community shelters can provide care because
these patients can place severe demands on hospital
resources following blackouts and natural disasters.76,77
However, when such patients present to acute care
facilities during disasters, they should be triaged
and treated similarly to any other patient presenting
for care.
When mitigation of impact is not successful in pre-
serving adequate resources, we suggest the common
strategies of conserve, substitute, adapt, reuse, and
reallocate from the 2008 series continue to be used
[ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]
journal.publications.chestnet.org

TABLE 5 ] Mitigating Factors on Critical Care Demand

Category Sample Actions Critical Care Physician Role

Prevention Vaccination Advocate for vaccination of professionals and public53

Screening and early treatment
Special medical needs planning
Triage
Risk communication
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Social distancing, quarantine
Personal protective equipment use
Hand hygiene
Telephone or web-based assessment and
prescribing for those with early symptoms54-57
Screening and assessment centers and augmented
outpatient screening and care58-64
Planning for shelters to accommodate those with
dependency on medical technologies
Home disaster planning emphasized for those
with special medical needs
Adequate planning by long-term-care facilities to
accommodate power failures and evacuations
without reliance on hospitals for back-up65
Experienced providers provide the most accurate
assessments and triage
Triage of patients out of the ICU may open
significant capacity
In larger events, triage becomes more critical to
ensure that resources are used well71,72
Public should have accurate information on when to
seek care, where, and what the resource situation
is in the area
Emphasize compliance with infection control precautions
Ensure that institution is providing accurate, timely information to staff
Champion appropriate infection control practices in the workplace and at home
Emphasize the need to provide as many options as possible for early
treatment and increased capacity to prevent elopements, thus avoiding
additional cases that may progress
Ensure that consistent, up-to-date treatment information and protocols
are available for clinical staff
Emphasize planning for patients in pulmonary and other clinics on home
oxygen and ventilators for disasters and power failures to prevent
presentation to hospitals during catastrophic events
Emphasize home planning for those with medical conditions requiring daily
management (eg, dialysis, diabetes) to prevent serious short-term
complications due to interruptions in treatment
Emphasize access to ongoing medications needed to prevent potentially
severe complications66
Critical care leadership (charge [supervising] nurse and physician) should
understand the process by which patients in the ICU can be rapidly assessed
for movement to lower levels of care during a disaster, which may be
facilitated by use of daily bump lists or structured assessments in addition
to clinical expertise (suggestion 3a)67,68
Ensure that triage staff have experience with critical care and the assessment
and treatment of respiratory and multiorgan failure to ensure the best
possible stewardship of resources69,70
Experienced providers facilitate optimal resource use through accurate triage
(suggestion 3b)14
Ensure that hospital is working with public health to provide information on
appropriate location for people to seek care to avoid overwhelming hospital
EDs and potentially contributing to delays in treatment
Ensure that hospital is providing updates to public health on the resource
situation; public may elect to self-refer to facilities with more resources
outside the immediate area, easing the burden on affected facilities
to proactively and fairly preserve or extend the avail-
ability of resources (Table 6). Before instituting
resource-sparing strategies, hospitals should exhaust all
avenues to obtain supplies from partners in their
health-care coalition or other neighboring health-care
facilities.
Planning of Surge Capacity for Unique
Populations
prepared to receive, stabilize, and treat these popula-
tions for the first 48 h.79-85 This involves basic supply
preparedness as well as ensuring that staff members
have basic training and some quick-reference resources
available to care for these patients. An overview of
key considerations for regional plans is outlined in
Table 7 and an in-depth discussion of critical care
surge planning for special populations is presented
elsewhere in this supplement.93

9a. We suggest regional planning include the expecta-
tion that the hospital be able to provide initial
stabilization care to unique populations that they may
not normally serve, such as pediatric, burn, and
trauma patients.
9b. We suggest access to regional expertise for care of
all patients who require specialty critical care services,
including participation in the planning phase and
access to just-in-time consultation for care coordina-
tion during a response.
Specialty regional plans, such as for burns, trauma,
and pediatrics, should be organized similarly to general
systems, with similar regional coordinating entities,
thresholds, activation plans, use of subject matter
experts, and planning and training resources. This
common framework helps to promote familiarity
of roles and expectations and may improve event
performance.
Service Deescalation and Engineered Failure

Certain patient groups may require specialized
equipment (eg, those with morbid obesity78), and some
may require both equipment and expertise (usually
provided at specialty centers). Although most hospitals
that provide critical care do not serve specialty
patients, such as burn, trauma, maternity, or pediatric
patients, during a disaster, all hospitals should be
10a. We suggest hospitals adopt a process of engi-
neered systems cessation when the staff and/or
material resources required for the ongoing critical
care of a small number of patients could be used to
save a greater number of lives.
10b. We suggest hospital cessation of the delivery of
critical care services be considered if such endeavors

TABLE 6 ] Example Strategies for Addressing Resource Deficits and Usual Associated Response Categories
Definition Conventional Contingency Crisis

Prepare Cache materials, maintain adequate par levels 9 9 9

Conserve Restricting use to maintain supply may play a significant 9 9 9
role at all stages of response, for example, conserving
oxygen to maintain saturations . 90% in contingency or
only using antivirals for selected high-risk patients in
contingency or crisis (depending on the risk of a poor
outcome without the therapy) or medication dose titration
where applicable
Substitute Using one resource instead of another for the same function; 9 9 9
class/class substitutions of benzodiazepines would be a
conventional example, and antibiotic substitutions of
varying efficacy could span the spectrum to crisis
Adapt Repurposing supplies or equipment; for example, using the 9 9
heart rate alarms on oxygen saturation monitors to detect
tachydysrhythmias and bradydysrhythmias or using
anesthesia machines for mechanical ventilation
Reuse Reuse in contingency would present minimal risk (supplies 9 9
requiring disinfection, eg, cervical collars, nasogastric
tubes); reuse of sterile supplies would enter into crisis care
Reallocate Taking treatments from one patient to give to another; this is 9
restricted to crisis care and usually applied to mechanical
ventilation and other life-preserving, binary treatments
(that cannot be titrated)

e10S Evidence-Based Medicine [ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]

TABLE 7 ] Key Considerations for Regional Plans
Key Consideration Detailed Description

Triage and transfer criteria for
specialty patients
Regional expectations for preparedness
of nonspecialty hospitals
Regional coordination process
Resource request and evacuation
coordination
Subject matter expertise
For example, children aged , 5 y or those with congenital medical conditions
may be transferred preferentially to a children’s hospital.86-88
These should be set in relation to the available resources in the community;
if there is only one burn center in the region or only one children’s hospital
in a community in a seismic zone, this will affect the expectations for
surrounding hospitals relative to expected capabilities.
A regional health authority, hospital coalition, or other responsible entity
should be able to gather and vet information about the patients and their
conditions and work with subject matter experts (eg, burn surgeons) to
ensure that appropriate transfers are arranged and appropriate support
(resources and expertise) is provided to hospitals that are temporarily
admitting specialty patients.89 Use of a regional triage officer to provide
specialized oversight for patients requiring specialized care (burn, trauma,
pediatrics, etc) should be considered. This may be combined with the
use of telemedicine to provide immediate patient care capability.90 Some
evidence indicates that regional load balancing can accommodate
significantly larger patient volumes than would be predicted, although a
massive pandemic would overwhelm even the most robust system.7,91
This entity should also be responsible in conjunction with transportation
coordinators for determining whether patients require forward movement
to other areas, the time frame, the resources the patients require, and
whether regional or national support is required to assist local care and
evacuation of patients to other areas.92 Matching of patients to appropriate
transportation resources and destinations is a key factor in achieving
successful outcomes.
In many cases, the local experts will be too engaged in patient care to
provide telephone or other support to hospitals that are boarding specialty
patients. Regional plans should account for the ability to contact specialty
institutions that can provide telephone, telemedicine, and other support to
the local hospitals.

are likely to entail significant personal risk to the
treating team despite the availability of personal
protective equipment and appropriate medical
countermeasures.
10c. We suggest a hospital’s decision to restrict or expand
the delivery of critical care be made as part of a
local/regional decision-making process, with consul-
tation and input provided by hospital ICU leadership.
In certain settings, the resources required to provide critical
care may represent such a disproportionate investment of
time and available resources that providing full intensive
care support is judged inappropriate. This is different
from situations in which a select resource is unavailable,
as discussed in the “Triage” article by Christian et al94
in this guideline, or a situation in which critical care is
chronically constrained, such as a in a developing nation
experiencing a disaster, which is discussed in the
“Resource-Poor Settings: Infrastructure and Capacity
Building” article by Geiling et al39 in this guideline.
Hospital services, including critical care, should not
continue per usual or cease completely in a binary
fashion. Rather, engineered failure should occur, with
restriction of certain services that consume the most
time and resources first followed by others as the
situation worsens.95,96 The process may be thought of as
akin to shutting down certain high-demand circuits to
preserve an electrical system.
Orderly deescalation of services preserves the ability to
provide essential services by preventing catastrophic
failure of the system and redirects resources for the
response. In some acute disasters that directly affect
the facility, planned deescalation may not be possible.
General considerations when assessing resource
commitments are presented in Table 8.97 Use of these
categories of resource commitment has also been
used in prior nuclear incident modeling.98 Overall
approaches to decrease demand entail two components:
(1) decreasing existing demands on the system, thereby
freeing capacity for surge response, and (2) diverting
new demands for services away from the system, thus
preventing the consumption of that resource. Often,
there is a reflex response to cancel all elective surgeries

journal.publications.chestnet.org e11S
TABLE 8 ] Key Components To Consider When
Assessing Resource Commitments
Component Details
Treater The amount of staff expertise required to
provide critical care
Time The amount of staff time required to
manage the patients
Treatment The amount of resources required to
manage the patients
Threat Any risks to the provider or patient
generated by the situation due to
infrastructure damage, imminent
dangers to providers and patients, or
a high risk of disease transmission
without appropriate personal protective
equipment available
(Adapted from US Dept. of Defense Common User Database.97)
and close all outpatient clinics. This is easier to opera-
tionalize in a sudden isolated surge event but much
more complex in a prolonged surge situation.
Specifically, decisions about which services can or will
be provided and which cannot or will not be provided
should be based on a consideration of (1) the conse-
quence to patients of suspending or delaying the service,
(2) the resource requirements of that service, and (3) the
ability to provide the resources in the context of altered
standards of care99 (Fig 3). Health-care coalitions or
regional health authorities should have a central com-
mittee imbued with adequate situational awareness that
will inform (or make, depending on authority) decisions
regarding the deescalation and reestablishment of services.
Ideally, these activities should be supported at a national
level, when possible, by professional societies developing
classifications for prioritizing patients.
e12S Evidence-Based Medicine
In certain scenarios (Table 9100), it is not prudent to
expend significant staff time, expertise, and resources
on a few patients (eg, those receiving extracorporeal
membrane oxygenation33,101-103) when many other
patients are in need of and could benefit from stabiliza-
tion care to prevent multiorgan failure. A process to
determine which therapies will continue to be offered
and which require restriction to allow critical care
resources to be redeployed should be in place. The
decision to limit critical care services should always be
made jointly between the hospital incident commander
and the critical care services leadership in coordination
with the health-care coalition or regional health authority.
Some events are so overwhelming and immediate that the
clinician has no choice but to deescalate care (eg, a bomb
or natural disaster destroys a significant portion of the
facility, posing an imminent threat); however, in all other
situations, decisions to deescalate should be made in
concert with other elements of the emergency response
system and not by individuals or clinical teams alone (see
the “Legal Preparedness” article by Courtney et al104 in
this consensus statement).
When such a situation arises, it should be communi-
cated to the regional hospital coalition and ideally to
public health and other jurisdictional agencies. Importa-
tion of resources and transfer of patients to other areas
should be exhausted as options before restrictions on
care are made. Restrictions generally should be the least
restrictive to meet the incident demands and should be
lifted as soon as resources allow.
Areas for Research
Most of the suggestions regarding surge preparation
and response would benefit significantly from rigorous
Figure 3 – Matrix for deescalation
planning.
[ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]
TABLE 9 ] Scenarios Where Deescalation of Critical Care Services May Be Considered
Scenario Reason for Deescalation

Inability to provide resource-intense therapies
Staff illness
Infrastructure damage
Extreme, overwhelming mass casualty events
Pandemics or other situations during which critical care is stressed
to the point where provision of extremely intensive support
(eg, extracorporeal membrane oxygenation, hand-bagging) cannot
be sustained because of the degree to which critical care staff and
resources are stretched to provide care to patients with a better
chance of a good outcome.
Pandemics during which so many critical care nursing and physician
staff are ill (and no replacements are available) that it becomes
unsafe to provide critical care to such a large number of patients.
Disasters in which the infrastructure of the facility and community
is so damaged that appropriate and/or safe critical care cannot be
provided and usual medical care may have to be adapted or
restricted.100
Disasters in which the hospital is so overwhelmed by an event
despite emergency mass critical care that it is judged that the
ICU staff and resources are better applied to saving many lives
in other parts of the facility and community than continuing to
provide resource-intensive care for a small number of patients.
This could occur in the setting of an improvised nuclear device
detonation or a massive natural disaster or terrorist event,
potentially in combination with infrastructure damage.

scientific research to build a base of evidence to guide
effective surge capacity development. Formal study of
the role of critical care physicians in disaster leadership
would enhance their involvement and effectiveness
in these situations. In addition, most of the suggestions
regarding the capacity required to respond to specific
situations are purely theoretical and would benefit from
verification of realistic targets for surge capacity using
mathematical modeling. Simulation research informed
by modeling can be used to determine a hospital’s ability
to achieve targets and how best to implement strategies
most effectively. In virtually every disaster, communica-
tion and information exchange is a challenge. There is a
significant need for psychology, sociology, and informa-
tion technology researchers to collaboratively develop
and test tools to improve communication and informa-
tion exchange during disasters. The importance of
critical care is increasingly recognized and integrated
into disaster management systems, presenting an
opportunity to develop novel approaches to other areas
of disaster management. Similarly, situational aware-
ness of critical care resources is a key component of
mounting an effective response during a disaster or
pandemic. Research is required to develop useful tools
for real-time tracking and dissemination of critical
care resources. Furthermore, in the event of an over-
whelming disaster or pandemic requiring critical care
services to be scaled back, good evidence is lacking
about the best manner in which to implement
engineered failure to minimize harm overall and most
effectively preserve the remaining functions within the
system.
Conclusions
Critical care services should accommodate a spec-
trum of incident impacts and provide conventional,
contingency, and crisis care. As a hospital moves to
contingency and crisis care, health-care coalition and
jurisdictional entities become partners in maximizing
capacity and capabilities and provide regional consis-
tency of care. Appropriate incident notification and
ongoing situational awareness, resource tracking and
management, and transfer management are roles
coalitions or regional governments play to achieve
the greatest good for the greatest number of people.
Reducing the impact on hospital and critical care
services is a key factor in preserving capacity. All
hospitals should be prepared to care for trauma, burn,
and pediatric patients in case an event overwhelms or
incapacitates a key specialty center. In certain situa-
tions, the resources required to provide critical care
may be better applied to other patients or victims, and
critical care may be limited to free up these resources.
This should be a joint institutional and regional
decision and, thus, relies on strong facility and
regional command, control, and communication
systems to consider and implement these shifts in
care.

journal.publications.chestnet.org e13S
Acknowledgments
Author contributions: J. L. H. had full access to all of the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis. J. L. H., S. E., D. H., N. K., J. R. D.,
A. V. D., and M. D. C. contributed to the development of PICO (popula-
tion, intervention, comparison, and outcome) questions, expert opinion
suggestions, study concept and design, and data acquisition, analysis,
and interpretation based on the Delphi process; J. L. H., S. E., and D. H.
contributed to the literature review and drafting of the manuscript;
And N. K., J. R. D., A. V. D., and M. D. C. contributed to the critical
revision of the manuscript for important intellectual content.
Financial/nonfinancial disclosures: The authors have reported to
CHEST the following conflicts of interest: Dr Hanfling is a consultant
on anthrax management for GlaxoSmithKline plc. Dr Einav has
received grant funding unrelated to this consensus statement. Drs
Hick, Kissoon, Dichter, Devereaux, and Christian have reported that
no potential conflicts of interest exist with any companies/organiza-
tions whose products or services may be discussed in this article.
Role of sponsors: The American College of Chest Physicians was
solely responsible for the development of these guidelines. The
remaining supporters played no role in the development process.
External supporting organizations cannot recommend panelists or
topics, nor are they allowed prepublication access to the manuscripts
and recommendations. Further details on the Conflict of Interest
Policy are available online at http://chestnet.org.
Endorsements: This consensus statement is endorsed by the American
Association of Critical-Care Nurses, American Association for Respira-
tory Care, American College of Surgeons Committee on Trauma,
International Society of Nephrology, Society for Academic Emergency
Medicine, Society of Critical Care Medicine, Society of Hospital Medicine,
World Federation of Pediatric Intensive and Critical Care Societies,
World Federation of Societies of Intensive and Critical Care Medicine.
Other contributions: The opinions expressed within this manuscript
are solely those of the author (M. D. C.) and do not represent the
official position or policy of the Royal Canadian Medical Service,
Canadian Armed Forces, or the Department of National Defence.
Additional information: The e-Appendixes can be found in the
Supplemental Materials section of the online article.
Collaborators: Executive Committee: Michael D. Christian,
MD, FRCPC, FCCP; Asha V. Devereaux, MD, MPH, FCCP, co-chair;
Jeffrey R. Dichter, MD, co-chair; Niranjan Kissoon, MBBS, FRCPC;
Lewis Rubinson, MD, PhD; Panelists: Dennis Amundson, DO, FCCP;
Michael R. Anderson, MD; Robert Balk, MD, FCCP; Wanda D. Barfield,
MD, MPH; Martha Bartz, MSN, RN, CCRN; Josh Benditt, MD; William
Beninati, MD; Kenneth A. Berkowitz, MD, FCCP; Lee Daugherty
Biddison, MD, MPH; Dana Braner, MD; Richard D Branson, MSc, RRT;
Frederick M. Burkle Jr, MD, MPH, DTM; Bruce A. Cairns, MD;
Brendan G. Carr, MD; Brooke Courtney, JD, MPH; Lisa D. DeDecker,
RN, MS; COL Marla J. De Jong, PhD, RN [USAF]; Guillermo
Dominguez-Cherit, MD; David Dries, MD; Sharon Einav, MD; Brian
L. Erstad, PharmD; Mill Etienne, MD; Daniel B. Fagbuyi, MD; Ray
Fang, MD; Henry Feldman, MD; Hernando Garzon, MD; James Geiling,
MD, MPH, FCCP; Charles D. Gomersall, MBBS; Colin K. Grissom,
MD, FCCP; Dan Hanfling, MD; John L. Hick, MD; James G. Hodge Jr,
JD, LLM; Nathaniel Hupert, MD; David Ingbar, MD, FCCP; Robert K.
Kanter, MD; Mary A. King, MD, MPH, FCCP; Robert N. Kuhnley, RRT;
James Lawler, MD; Sharon Leung, MD; Deborah A. Levy, PhD, MPH;
Matthew L. Lim, MD; Alicia Livinski, MA, MPH; Valerie Luyckx, MD;
David Marcozzi, MD; Justine Medina, RN, MS; David A. Miramontes, MD;
Ryan Mutter, PhD; Alexander S. Niven, MD, FCCP; Matthew S. Penn,
JD, MLIS; Paul E. Pepe, MD, MPH; Tia Powell, MD; David Prezant,
MD, FCCP; Mary Jane Reed, MD, FCCP; Preston Rich, MD; Dario
Rodriquez, Jr, MSc, RRT; Beth E. Roxland, JD, MBioethics; Babak
Sarani, MD; Umair A. Shah, MD, MPH; Peter Skippen, MBBS;
Charles L. Sprung, MD; Italo Subbarao, DO, MBA; Daniel Talmor, MD;
Eric S. Toner, MD; Pritish K. Tosh, MD; Jeffrey S. Upperman, MD;
Timothy M. Uyeki, MD, MPH, MPP; Leonard J. Weireter Jr, MD; T. Eoin
West, MD, MPH, FCCP; John Wilgis, RRT, MBA; ACCP Staff: Joe
Ornelas, MS; Deborah McBride; David Reid; Content Experts: Amado
Baez, MD; Marie Baldisseri, MD; James S. Blumenstock, MA; Art
e14S Evidence-Based Medicine
Cooper, MD; Tim Ellender, MD; Clare Helminiak, MD, MPH; Edgar
Jimenez, MD; Steve Krug, MD; Joe Lamana, MD; Henry Masur, MD;
L. Rudo Mathivha, MBChB; Michael T. Osterholm, PhD, MPH; H.
Neal Reynolds, MD; Christian Sandrock, MD, FCCP; Armand
Sprecher, MD, MPH; Andrew Tillyard, MD; Douglas White, MD;
Robert Wise, MD; Kevin Yeskey, MD.
References
1. Einav S, Hick JL, Hanfling D, et al. Surge capacity logistics: care of
the critically ill and injured during pandemics and disasters:
CHEST consensus statement. Chest. 2014;146(4_suppl):
e17S-e43S.
2. Ornelas J, Dichter JR, Devereaux AV, Kissoon N, Livinski A,
Christian MD. Methodology: care of the critically ill and injured
during pandemics and disasters: CHEST consensus statement.
Chest. 2014;146(4_suppl):35S-41S.
3. Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A. The special injury
pattern of terrorist bombings. J Am Coll Surg. 2004;199(6):875-879.
4. The ANZIC Influenza Investigators. Critical care services and 2009
influenza H1N1 in Australia and New Zealand. N Engl J Med.
2009;361(20):1925-1934.
5. Kanter RK. Strategies to improve pediatric disaster surge response:
potential mortality reduction and tradeoffs. Crit Care Med.
2007;35(12):2837-2842.
6. Kanter RK. Pediatric mass critical care in a pandemic. Pediatr Crit
Care Med. 2012;13(1):e1-e4.
7. Kanter RK, Moran JR. Pediatric hospital and intensive care unit
capacity in regional disasters: expanding capacity by altering
standards of care. Pediatrics. 2007;119(1):94-100.
8. Hick JL, Barbera JA, Kelen GD. Refining surge capacity:
conventional, contingency, and crisis capacity. Disaster Med Public
Health Prep. 2009;3(suppl S1):S59-S67.
9. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—a
functional impact approach: the PICE system. Acad Emerg Med.
1996;3(7):723-727.
10. Barbisch DF, Koenig KL. Understanding surge capacity: essential
elements. Acad Emerg Med. 2006;13(11):1098-1102.
11. Hanfling D. Equipment, supplies, and pharmaceuticals: how much
might it cost to achieve basic surge capacity? Acad Emerg Med.
2006;13(11):1232-1237.
12. Mahoney EJ, Harrington DT, Biffl WL, Metzger J, Oka T, Cioffi
WG. Lessons learned from a nightclub fire: institutional disaster
preparedness. J Trauma. 2005;58(3):487-491.
13. Shirley PJ. Critical care delivery: the experience of a civilian
terrorist attack. J R Army Med Corps. 2006;152(1):17-21.
14. Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical
mortality in urban mass casualty incidents: analysis of triage, surge,
and resource use after the London bombings on July 7, 2005.
Lancet. 2006;368(9554):2219-2225.
15. de Ceballos JP, Turégano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M,
Martin-Llorente C, Guerrero-Sanz JE. 11 March 2004: The terrorist
bomb explosions in Madrid, Spain—an analysis of the logistics,
injuries sustained and clinical management of casualties treated at
the closest hospital. Crit Care. 2005;9(1):104-111.
16. Auf der Heide E. Disaster Response: Principles of Preparation and
Coordination. Ford Island, HI: Center for Excellence in Disaster
Management and Humanitarian Assistance; 1989.
17. De Boer J. Order in chaos: modelling medical management in
disasters. Eur J Emerg Med. 1999;6(2):141-148.
18. Bayram JD, Zuabi S, Subbarao I. Disaster metrics: quantitative
benchmarking of hospital surge capacity in trauma-related multiple
casualty events. Disaster Med Public Health Prep. 2011;5(2):117-124.
19. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and
community strategies for patient care surge capacity. Ann Emerg
Med. 2004;44(3):253-261.
20. Peleg K, Kellermann AL. Enhancing hospital surge capacity for
mass casualty events. JAMA. 2009;302(5):565-567.
21. Tadmor B, McManus J, Koenig KL. The art and science of surge:
experience from Israel and the U.S. military. Acad Emerg Med.
2006;13(11):1130-1134.
[ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]
22. Quarentelli EL. Delivery of Emergency Medical Care in Disasters:
Assumptions and Realities. New York, NY: Irvington Publishers; 1983.
23. Bissell RA, Pinet L, Nelson M, Levy M. Evidence of the effective-
ness of health sector preparedness in disaster response: the
example of four earthquakes. Fam Community Health. 2004;27(3):
193-203.
24. Rivara FP, Nathens AB, Jurkovich GJ, Maier RV. Do trauma centers
have the capacity to respond to disasters? J Trauma. 2006;61(4):
949-953.
25. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP;
DELAY-ED Study Group. Impact of delayed transfer of critically ill
patients from the emergency department to the intensive care unit.
Crit Care Med. 2007;35(6):1477-1483.
26. Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in
disasters: emergency department principles. Ann Emerg Med.
2012;59(3):177-187.
27. Aucoin RG. Hurricane Katrina—one hospital’s experience. Crit
Care. 2006;10(1):109
28. Kirsch TD, Mitrani-Reiser J, Bissell R, et al. Impact on hospital
functions following the 2010 Chilean earthquake. Disaster Med
Public Health Prep. 2010;4(2):122-128.
29. Danzig R. Catastrophic Bioterrorism—What Is To Be Done?
Washington, DC: Center for Technology and National Security
Policy, National Defense University ; 2003.
30. DiCarlo AL, Maher C, Hick JL, et al. Radiation injury after a nuclear
detonation: medical consequences and the need for scarce resources
allocation. Disaster Med Public Health Prep. 2011;5(suppl 1):
S32-S44.
31. Hupert N, Wattson D, Cuomo J, Hollingsworth E, Neukermans K,
Xiong W. Predicting hospital surge after a large-scale anthrax
attack: a model-based analysis of CDC’s cities readiness initiative
prophylaxis recommendations. Med Decis Making. 2009;29(4):
424-437.
32. Bartlett JG, Borio L. Healthcare epidemiology: the current status
of planning for pandemic influenza and implications for health
care planning in the United States. Clin Infect Dis. 2008;46(6):
919-925.
33. Manuell ME, Co MD, Ellison RT III. Pandemic influenza:
implications for preparation and delivery of critical care services.
J Intensive Care Med. 2011;26(6):347-367.
34. Sobieraj JA, Reyes J, Dunemn KN, et al. Modeling hospital response
to mild and severe influenza pandemic scenarios under normal
and expanded capacities. Mil Med. 2007;172(5):486-490.
35. Ten Eyck RP. Ability of regional hospitals to meet projected avian
flu pandemic surge capacity requirements. Prehosp Disaster Med.
2008;23(2):103-112.
36. Institute of Medicine. Guidance for Establishing Crisis Standards of
Care for Use in Disaster Situations: A Letter Report. Washington, DC:
The National Academies Press; 2009.
37. Institute of Medicine. Crisis Standards of Care: A Systems
Framework for Catastrophic Disaster Response. Washington, DC:
The National Academies Press; 2012.
38. Institute of Medicine. Crisis standards of care: A Toolkit for Indicators
and Triggers. Washington, DC: The National Academies Press; 2013.
39. Geiling J, Burkle FM Jr, Amundson D, et al. Resource-poor settings:
infrastructure and capacity building: care of the critically ill and
injured during pandemics and disasters: CHEST consensus
statement. Chest. 2014;146(4_suppl):e156S-e167S.
40. Soremekun OA, Zane RD, Walls A, Allen MB, Seefeld KJ, Pallin DJ.
Cancellation of scheduled procedures as a mechanism to generate
hospital bed surge capacity-a pilot study. Prehosp Disaster Med.
2011;26(3):224-229.
41. Meites E, Farias D, Raffo L, et al. Hospital capacity during an
influenza pandemic-Buenos Aires, Argentina, 2009. Infect Control
Hosp Epidemiol. 2011;32(1):87-90.
42. Sprung CL, Cohen R, Adini B; European Society of Intensive Care
Medicine’s Task Force for Intensive Care Unit Triage During an
Influenza Epidemic or Mass Disaster. Chapter 1. Introduction.
Recommendations and standard operating procedures for intensive
care unit and hospital preparations for an influenza epidemic or
mass disaster. Intensive Care Med. 2010;36(suppl 1):S4-S10.
journal.publications.chestnet.org
43. Kaji AH, Bair A, Okuda Y, Kobayashi L, Khare R, Vozenilek J.
Defining systems expertise: effective simulation at the
organizational level—implications for patient safety, disaster surge
capacity, and facilitating the systems interface. Acad Emerg Med.
2008;15(11):1098-1103.
44. Maldin-Morgenthau B, Toner E, Waldhorn R, et al. Roundtable:
promoting partnerships for regional healthcare preparedness and
response. Biosecur Bioterror. 2007;5(2):180-185.
45. Courtney B, Toner E, Waldhorn R, et al. Healthcare coalitions:
the new foundation for national healthcare preparedness and
response for catastrophic health emergencies. Biosecur Bioterror.
2009;7(2):153-163.
46. Joynt GM, Loo S, Taylor BL, et al; European Society of Intensive
Care Medicine’s Task Force for Intensive Care Unit Triage During
an Influenza Epidemic or Mass Disaster. Chapter 3. Coordination
and collaboration with interface units. Recommendations and
standard operating procedures for intensive care unit and hospital
preparations for an influenza epidemic or mass disaster. Intensive
Care Med. 2010;36(suppl 1):S21-S31.
47. Carrier E, Yee T, Cross DA, Samuel DR. Emergency preparedness
and community coalitions: opportunities and challenges. HSC
Research Brief No. 24. Center for Studying Health System Change
website. http://www.hschange.com/CONTENT/1323. Accessed
August 12, 2014.
48. Dichter JR, Kanter RK, Dries D, et al. System-level planning,
coordination, and communication: care of the critically ill and
injured during pandemics and disasters: CHEST consensus
statement. Chest. 2014;146(4_suppl):e87S-e102S.
49. The CNA Corporation. (2004). Medical Surge Capacity and
Capability: A Management System for Integrating Medical and
Health Resources During Large-Scale Emergencies (No. IPR/11079).
Alexandria, VA: The CNA Corporation; 2004.
50. Campbell C. The benefits of designing a stratification system for
New York City pediatric intensive care units for use in regional
surge capacity planning and management. J Community Health.
2010;35(4):337-347.
51. DeLia D. Annual bed statistics give a misleading picture of hospital
surge capacity. Ann Emerg Med. 2006;48(4):384-388.
52. Schull MJ. Hospital surge capacity: if you can’t always get what you
want, can you get what you need? Ann Emerg Med. 2006;48(4):
389-390.
53. Wu JT, Riley S, Fraser C, Leung GM. Reducing the impact of the
next influenza pandemic using household-based public health
interventions. PLoS Med. 2006;3(9):e361.
54. Kellermann AL, Isakov AP, Parker R, Handrigan MT, Foldy S.
Web-based self-triage of influenza-like illness during the 2009
H1N1 influenza pandemic. Ann Emerg Med. 2010;56(3):288-294.
55. Spaulding AC, McCallum VA, Walker D, et al. How public health
and prisons can partner for pandemic influenza preparedness: a
report from Georgia. J Correct Health Care. 2009;15(2):118-128.
56. Koonin LM, Hanfling D. Broadening access to medical care during
a severe influenza pandemic: the CDC nurse triage line project.
Biosecur Bioterror. 2013;11(1):75-80.
57. Anhang Price R, Fagyubi D, Harris R, et al. Feasibility of web-based
self-triage by parents of children with influenza-like illness: a
cautionary tale. JAMA Pediatr. 2013;167(2):112-118.
58. Edwards JC, Stapley J, Akins R, Silenas R, Williams JR. Lessons
learned from a regional strategy for resource allocation. Biosecur
Bioterror. 2005;3(2):113-118.
59. Miska H. Emergency care centers—an efficient method for
mitigation of consequences after a dirty bomb attack. Health Phys.
2012;103(2):200-203.
60. Pershad J, Waters TM. Use of tent for screening during H1N1
pandemic: impact on quality and cost of care. Pediatr Emerg Care.
2012;28(3):229-235.
61. Rubin GJ, Dickmann P. How to reduce the impact of “low-risk
patients” following a bioterrorist incident: lessons from SARS,
anthrax, and pneumonic plague. Biosecur Bioterror. 2010;8(1):37-43.
62. Sugerman D, Nadeau KH, Lafond K, et al. A survey of
emergency department 2009 pandemic influenza A (H1N1) surge
preparedness—Atlanta, Georgia, July-October 2009. Clin Infect Dis.
2011;52(suppl 1):S177-S182.
e15S
63. Waseem M, McInerney JE, Perales O, Leber M. Impact of
operational staging to improve patient throughput in an inner-city
emergency department during the novel H1N1 influenza surge: a
descriptive study. Pediatr Emerg Care. 2012;28(1):39-42.
64. Scarfone RJ, Coffin S, Fieldston ES, Falkowski G, Cooney MG,
Grenfell S. Hospital-based pandemic influenza preparedness and
response: strategies to increase surge capacity. Ped Emerg Care.
2011;27:565-572.
65. Smith PW, Smith AW, Meza JL. Influenza preparedness in Nebraska
assisted living facilities. Biosecur Bioterror. 2009;7(4):429-432.
66. Tomio J, Sato H, Mizumura H. Interruption of medication among
outpatients with chronic conditions after a flood. Prehosp Disaster
Med. 2010;25(1):42-50.
67. Einav S, Aharonson-Daniel L, Weissman C, Freund HR , Peleg K;
Israel Trauma Group. In-hospital resource utilization during
multiple casualty incidents. Ann Surg. 2006;243(4):533-540.
68. Satterthwaite PS, Atkinson CJ. Using ‘reverse triage’ to create
hospital surge capacity: Royal Darwin Hospital’s response to the
Ashmore Reef disaster. Emerg Med J. 2012;29(2):160-162.
69. Nap RE, Andriessen MP, Meessen NE, van der Werf TS. Pandemic
influenza and hospital resources. Emerg Infect Dis. 2007;13(11):
1714-1719.
70. Rodriguez-Noriega E, Gonzalez-Diaz E, Morfin-Otero R, et al;
Hospital Civil de Guadalajara, Fray Antonio Alcalde Emerging
Respiratory Infections Response Team. Hospital triage system for
adult patients using an influenza-like illness scoring system during
the 2009 pandemic—Mexico. PLoS One. 2010;5(5):e10658.
71. Hirshberg A, Scott BG, Granchi T, Wall MJ Jr, Mattox KL,
Stein M. How does casualty load affect trauma care in urban
bombing incidents? A quantitative analysis. J Trauma. 2005;58(4):
686-693.
72. Roccaforte JD, Cushman JG. Disaster preparedness, triage, and
surge capacity for hospital definitive care areas: optimizing
outcomes when demands exceed resources. Anesthesiol Clin.
2007;25(1):161-177.
73. Arrieta MI, Foreman RD, Crook ED, Icenogle ML. Insuring
continuity of care for chronic disease patients after a disaster: key
preparedness elements. Am J Med Sci. 2008;336(2):128-133.
74. Laditka SB, Laditka JN, Xirasagar S, Cornman CB, Davis CB, Richter
JV. Providing shelter to nursing home evacuees in disasters: lessons
from Hurricane Katrina. Am J Public Health. 2008;98(7):1288-1293.
75. Motoki E, Mori K, Kaji H, et al. Development of disaster pamphlets
based on health needs of patients with chronic illnesses. Prehosp
Disaster Med. 2010;25(4):354-360.
76. Klein KR, Rosenthal MS, Klausner HA. Blackout 2003:
preparedness and lessons learned from the perspectives of four
hospitals. Prehosp Disaster Med. 2005;20(5):343-349.
77. Prezant DJ, Clair J, Belyaev S, et al. Effects of the August 2003
blackout on the New York City healthcare delivery system: a lesson
for disaster preparedness. Crit Care Med. 2005;33(1):S96-S101.
78. Geiling J. Critical care of the morbidly obese in disaster. Crit Care
Clin. 2010;26(4):703-714.
79. Beigi R, Davis G, Hodges J, Akers A. Preparedness planning for
pandemic influenza among large US maternity hospitals. Emerg
Health Threats J. 2009;2:e2.
80. Broeze CL, Falder S, Rea S, Wood F. Burn disasters—an audit of the
literature. Prehosp Disaster Med. 2010;25(6):555-559.
81. Kanter RK. The 2011 Tuscaloosa tornado: integration of pediatric
disaster services into regional systems of care. J Pediatr. 2012;161(3):
526-530.
82. Kleinpeter MA. Disaster preparedness of dialysis patients for
Hurricanes Gustav and Ike 2008. Adv Perit Dial. 2009;25:62-67.
83. Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning
in New York City: updated recommendations for best practices.
J Burn Care Res. 2012;33(5):587-594.
84. Rebmann T. Preparing for pandemic influenza. J Perinat Neonatal
Nurs. 2008;22(3):191-202.
85. Kissoon N; Task Force for Pediatric Emergency Mass Critical Care.
Deliberations and recommendations of the Pediatric Emergency
e16S Evidence-Based Medicine
Mass Critical Care Task Force: executive summary. Pediatr Crit
Care Med. 2011;12(6):S103-S108.
86. Christian MD, Toltzis P, Kanter RK, Burkle FM Jr, Vernon DD,
Kissoon N; Task Force for Pediatric Emergency Mass Critical Care.
Treatment and triage recommendations for pediatric emergency
mass critical care. Pediatr Crit Care Med. 2011;12(6):S109-S119.
87. Nap RE, Andriessen MP, Meessen NE, Albers MJ, van der Werf TS.
Pandemic influenza and pediatric intensive care. Pediatr Crit Care
Med. 2010;11(2):185-198.
88. Barfield WD, Krug SE, Kanter RK, et al; Task Force for Pediatric
Emergency Mass Critical Care. Neonatal and pediatric regionalized
systems in pediatric emergency mass critical care. Pediatr Crit Care
Med. 2011;12(6):S128-S134.
89. Burkle FM Jr, Williams A, Kissoon N; Task Force for Pediatric
Emergency Mass Critical Care. Pediatric emergency mass critical
care: the role of community preparedness in conserving critical
care resources. Pediatr Crit Care Med. 2011;12(6):S141-S151.
90. Xiong W, Bair A, Sandrock C, Wang S, Siddiqui J, Hupert N.
Implementing telemedicine in medical emergency response:
concept of operation for a regional telemedicine hub. J Med Syst.
2012;36(3):1651-1660.
91. Stiff D, Kumar A, Kissoon N, et al. Potential pediatric intensive care
unit demand/capacity mismatch due to novel pH1N1 in Canada.
Pediatr Crit Care Med. 2011;12(2):e51-e57.
92. Potin M, Sénéchaud C, Carsin H, et al. Mass casualty incidents with
multiple burn victims: rationale for a Swiss burn plan. Burns.
2010;36(6):741-750.
93. Dries DJ, Reed MJ, Kissoon N, et al. Special populations: care of the
critically ill and injured during pandemics and disasters: CHEST
consensus statement. Chest. 2014;146(4_suppl):e75S-e86S.
94. Christian MD, Sprung CL, King MA, et al. Triage: care of the
critically ill and injured during pandemics and disasters: CHEST
consensus statement. Chest. 2014;146(4_suppl):e61S-e74S.
95. Barbera JA, Macintyre AG. Medical and Health Incident
Management (MaHIM) System: A Comprehensive Functional System
Description for Mass Casualty Medical and Health Incident
Management. Washington, DC: Institute for Crisis, Disaster, and
Risk Management, The George Washington University ; 2002.
96. Christian MD, Lawless B, Trpkovski J, Dichter JR. Surge
management for critical care leaders. Surge management for critical
care leaders. In: Flaatten H, Moreno RP, Putensen C, Rhodes A,
eds. Organisation and Management of Intensive Care. Berlin,
Germany : MWV; 2010:277-294.
97. US Dept. of Defense Common User Database. Defense Medical
Material Program Office website. https://www.dmsb.mil/cud.asp.
Accessed August 12, 2014.
98. Casagrande R, Wills N, Kramer E, et al. Using the Model of
Resource and Time-based Triage (MORTT) to guide scarce
resource allocation in the aftermath of a nuclear detonation.
Disaster Med Public Health Prep. 2011;5(suppl 1):S98-S110.
99. Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field
hospital in Haiti - ethical dilemmas in early disaster response.
NEJM. 2010;362:e38(1-3).
100. Merin O, Blumberg N, Raveh D, Bar A, Nishizawa M, Cohen-
Marom O. Global responsibility in mass casualty events: the Israeli
experience in Japan. Am J Disaster Med. 2012;7(1):61-64.
101. Lum ME, McMillan AJ, Brook CW, Lester R, Piers LS. Impact of
pandemic (H1N1) 2009 influenza on critical care capacity in
Victoria. Med J Aust. 2009;191(9):502-506.
102. Schellongowski P, Ullrich R, Hieber C, et al. A surge of flu-
associated adult respiratory distress syndrome in an Austrian
tertiary care hospital during the 2009/2010 Influenza A H1N1v
pandemic. Wien Klin Wochenschr. 2011;123(7-8):209-214.
103. Kissoon N, Bohn D. Use of extracorporeal technology during
pandemics: ethical and staffing considerations. Pediatr Crit Care
Med. 2010;11(6):757-758.
104. Courtney B, Hodge JG Jr, Toner ES, et al. Legal preparedness: care
of the critically ill and injured during pandemics and disasters:
CHEST consensus statement. Chest. 2014;146(4_suppl):
e134S-e144S.
[ 146#4 CHEST OCTOBER 2014 SUPPLEMENT ]