Emergency department pre-planning for the surge of thunderstorm asthma

patients: A narrative review

Word count: 3.298

(Draft – 1 by Raja Yasmin Khalilah Fahmizal / 1219314)

Introduction
Thunderstorm asthma (TSA) is the occurrence of bronchospasm or asthma exacerbation
observed following a thunderstorm in the surrounding area (1). TSA's proposed pathogenesis
is a complex interaction of individual susceptibility, environmental factors, and
meteorological conditions (2). Epidemic Thunderstorm Asthma (ETSA) can occur when TSA
appears in many individuals at once in an area and for a short period and is characterized by a
sudden patient increase for asthma to the local hospital Emergency Departments (EDs) or
general practitioners following a thunderstorm, which can cause fatalities and overwhelm
healthcare workers (1,3,4).

Since TSA first appeared in the 1980s, its episodes have been detected more than 20 times in
several areas of the world, including United Kingdom, Australia, Europe, North America, and
the Middle East, with varying numbers of people affected. Australia has the highest number
of episodes, where 10 of the world's TSA episodes occur in Australia. The 2016 TSA episode
in Australia is known as the worst TSA, responsible for approximately 4000 people with
respiratory problems and nine deaths. (2)

The sudden increase in caseloads in hospitals due to thunderstorm asthma events in several
countries in recent years expects health care providers to be anticipated and prepared (1). The
hospital’s ability to cope with this sudden influx of large numbers of patients is called ‘surge
capacity’ (5). Increasing surge capacity is often achieved by managing existing resources,
which can be added, reduced, or reused and requires a systemic approach that comes from
various levels of public health service providers, starting from primary care providers,
community and private organizations, and other healthcare establishments such as hospitals
and their departments (5,6). This review focuses on surge capacity that optimizes hospital-
based care, particularly in the hospital EDs during ETSA.

It is estimated that ETSA will occur more frequently and severely in the future and may
affect previously unaffected areas, where climate change and increasing levels of air
pollution are considered the main contributors (7–9). Consequently, future ETSA is predicted
to have a larger number of patients presenting to the EDs, resulting in more stress and other
consequences requiring the EDs to increase their surge capacity (3).

Surge capacity is a critical element of the hospital's disaster management plan. However,
preparedness gaps due to communication and integration defects have made the surge event a
significant challenge for healthcare workers and triggered the need for a comprehensive surge
capacity protocol that can be implemented in an emergency (10). Strengthening the surge
capacity of EDs is a vital strategy to overcome ETSA. In this narrative review, we hope to
contribute to future practice, policy and research by analysing what is available in the current
literature on surge capacity planning and strategy.

Methods

Search Strategy

We looked for information in the most recent literature on efforts to provide surge capacity in
disaster response planning and activities, focusing on hospital and EDs level response
planning and the institutional experience of ETSA. In March 2021, we searched for articles
using the following terms; ‘thunderstorm asthma or thunderstorm-related asthma or
thunderstorm-associated asthma’ and ‘surge capacity or emergency surge’ through Ovid
(Embase) and PubMed (Medline). Additional articles, including grey literature, were
obtained through further analysis of references of relevant articles.

Inclusion and Exclusion Criteria

Inclusion criteria included publications in the last 20 years which discuss and describe TSA
event and management of surge in the hospital EDs. In addition, all types of publications
were eligible, including theses, systematic reviews, books, and reports. Publications that were
published in languages other than English were excluded along with publications without
available full text.

Article selection

The process began with selecting relevant articles by two reviewers by examining the titles
and abstracts obtained from the initial screening. By examining titles and abstracts, articles
that could meet the inclusion criteria were taken and further analysed their references to find
whether articles or grey literature could become additional articles for this review. Articles
that were deemed eligible and relevant underwent full-text screening to assess and confirm
their eligibility and relevance. Disagreements and doubts about the eligibility and relevance
of the articles were resolved by discussion with the third reviewer.

Results

Article selection

A flow diagram in Figure 1 shows the process of article selection for this review. The
electronic literature search yielded 3089 records from two databases. Abstracts and titles
examination left 80 potential eligible and relevant articles. 132 articles were added from the
reference screening resulting in 212 articles for full-text screening. Full-text screening
identified 12 eligible and relevant articles to be included in this review. Table 1 shows a
summary of the included articles.

The included articles comprise a variety of publications, study designs and findings. Four
articles reviewed general principles of surge capacity in disaster management, three papers
discussed how different countries managed ETSA, while the other five focused on the
innovations in the optimization of surge capacity applicable in the hospital EDs during
ETSA.

General Principles of Surge Capacity in Disaster Management

All four articles recognized essential elements in surge capacity augmentation planning
during a disaster. Apart from one article that focuses on Chemical, Biological, Radiological,
Nuclear, and Explosive Events (CBRNe), which suggests organization, technology, and
individual as the essential elements (11), other three articles that discuss disaster in general
proposed similar essential elements: staff/personnel, stuff/supplies/resources, structure/space,
and system/mechanism (12–14). The articles agree that the optimum utilization of these
elements could increase surge capacity during a disaster (12–14). Additionally, one of these
three articles even managed to provide a precision strategy to augment surge capacity during
a disaster (14).

Management of ETSA by Different Countries

The first article is a report by Victoria State Government which provides a review of response
to the 2016 ETSA occurred in Melbourne, Australia. This report revealed that the initial
response taken by healthcare establishments of Victoria at the beginning of the event was
additional staff arrangement, early-discharging patients, rapid transfer from waiting room to
ward, providing additional spaces, triage, asthma assessment, and management clinics (15).

The second article is an overview of 2013 ETSA that occurred in Ahvaz, Iran. Unlike the
previous article, this article does not provide the initial steps taken by local healthcare
establishments to overcome surges due to ETSA, but this article provides information on
what medications are most often given in EDs to treat affected patients. This overview
revealed that oxygen was given to 83.1% of patients, the most frequently administered drugs
in the emergency department were short-acting β2-agonists, and the administration of a drug
that is not the first-line treatment of bronchospasm (aminophylline) was found in 50% of
patients. (16)

The last article reported on the ETSA that occurred in China. It provides recommendations on
what to do with patients affected by ETSA but specifically for children who were shown to
be possible to be affected. The recommendations contained in this article are to be prepared
to provide standard treatment for allergic rhinitis, make a proper diagnosis of potential
asthma, and prescribe preventative medication (17).

Innovations in the Optimization of Surge Capacity for Future ETSA

Three articles suggest innovation in the form of technology (18–20). One article provides a
review on the importance of using telemedicine in a disaster situation (18). This article
highlights that telemedicine can improve the quality of communication between healthcare
establishments, including paramedics, to provide quality services (18). This article also
introduces the concept of Tele-ICU monitoring, where paramedics can apply distant-care
while treating the most critical patients (18).

Like the previous article, the second article also highlights the importance of using
technology in the event of a disaster (19). However, this article specifically discussed the
circumstances during the 2016 ETSA surge in Melbourne, Australia (19). This article
highlights the importance of technology related to electronic prescribing and clinical
documentation and introduces Thunderstorm Asthma Packs, an additional solution created by
the local hospital, Austin Hospital, for future ETSA (19). The packs will be prepared before
ETSA usually takes place in Melbourne, Australia and will contain medicines for asthma
patients that can be used in ED and at home and patient information sheets about TSA (19).
The third technology article is an experimental study of a mobile technology for patient
processing, management, and triage during Mass Casualty Incident (MCI), namely the
Emergency Department Informatics Computational Tool (EDICT) (20). The experiment
succeeded in concluding that EDICT can reduce the burden on hospitals in using resources
and allow nurses while still on the go to provide triage to patients through the connection they
have with the EDICT system that can help them make reliable decisions and
recommendations (20).

Unlike the previous three articles, the last two articles discuss the triage mechanism that can
increase surge capacity, reverse triage (21,22). The first article found that reverse triage
increased by an average of 20% of hospital capacity (21). The second article introduces a
guideline that can be applied during reverse triage to determine which patients are suitable for
early discharge (22). This guideline is in the form of a checklist containing 25 items called
the Early Discharge Assessment Checklist (EDAC) (22). This article found that the number
of patients deemed dischargeable by the EDAC assessment was one third of patients in the
study, which is similar as the number of dischargeable patients after the 48-hour follow-up
assessment indicating that EDAC can be a reliable tool for providing data on early patient
discharge during a disaster (22).

Discussion

The purpose of this narrative review was to gain a better understanding of surge capacity
planning and strategy that optimizes hospital-based care, particularly in the hospital EDs
during ETSA. The findings of the present review are outlined into three categories. First is
the general principle of surge capacity in disaster management, second is management of
ETSA by different countries, and third is innovations in the optimization of surge capacity for
future ETSA.
The general principle of surge capacity in disaster management comprises staff, stuff,
structure, and system as the essential elements to increase surge capacity (12–14). The
principle of surge capacity is explained and concluded with various terms and classifications
(23). For example, the article that discusses specific disasters caused by CBRNe states that
the principles are individuals, organizations, and technology. This principle is actually in line,
where individuals can be included on the staff, organizations can be included in the system,
and technology can be classified into stuff. Therefore, from that onward, principles will be
discussed in terms of stuff, staff, structure, and systems.
These essential elements should be the core in building the surge capacity planning and
strategy for future ETSA in the hospital EDs. In the 2016 ETSA in Melbourne, Australia,
hospitals and ambulance services were in a precarious state, and some health services were
also experiencing shortages of asthma reliever medications (15). Similar situations were also
felt by some health services in the 2016 ETSA that occurred in Kuwait (24). The situations
could have been prevented if plans and strategies for optimization in the domain of staff,
stuff, structure, and systems had been prepared in advance. For example, in the staff domain,
preparing a plan for the exact steps that will be taken when additional medical staff or
personnel are needed and preparing a particular work allocation plan during emergencies
such as during ETSA can also greatly assist critical conditions in EDs and ambulance
services during ETSA. Moreover, in the domain of stuff, healthcare facilities can store more
asthma medications than usual, especially during the thunderstorm season

Regarding preparing medicines in advance, in an article that discusses ETSA disaster

planning at three levels, patient, institution, and country, it is stated that one of the keys at the
patient level is the prescription of inhaled corticosteroids to patients who sneeze or wheeze
during TSA related season (25). This suggests that inhaled corticosteroids are one of the
drugs that must be prepared for future ETSA. In addition, short-acting β2 agonist medication
should also be prepared since it is helpful for the treatment of mild asthma (26). Moreover,
Austin Hospital, Melbourne, Australia, has initiated drug preparation. They came up with
TSA packs containing the necessary drugs for TSA patients and a patient information sheets
about TSA (19).

Although ETSA has occurred several times in several countries, articles discussing how
affected countries managed it are still limited (2). Clear reports about what is happening and
what response is taken by local healthcare establishments are only found in Australia,
specifically about the 2016 ETSA in Melbourne, Australia (15). According to the Victoria
State Government report, the initial actions taken by Australia were quite good even though
the incident occurred very suddenly and severely (15). It is important to note that the initial
steps taken by the hospital were following the elements of the general principle of surge
capacity in disaster management discussed previously (13,15).

The actions taken by the hospital to add medical and non-medical staff are very much in line
with the staff element (13,15). Involving non-medical staff represents the first direct
demonstration of using support from external efforts as the precision strategy to augment
surge capacity (14). In addition to increasing the number, the optimization of staff elements
carried out by the hospital is by extending the work shifts of several staff and delaying their
break time (15). Calling back staff who were resting and not on duty was also carried out
(15). In this case, it should be noted that a large number of staff alone does not guarantee the
optimization of this element; a qualified staff is also essential (13,27,28). Previous articles
found that one of the causes of defective healthcare during a disaster is the lack of training of
existing staff on disaster management (27,28). For ETSA in the future, it is crucial to activate
staff who are indeed well-educated about TSA and disaster management, both medical and
non-medical (if needed) (29).

The management reports obtained from Iran and China are more about medicines preparation
(16,17). The article from Iran highlighted that in EDs. Short-acting β2-agonists were the most
used medicines (16), aligning with our previous recommendation to include short-acting β2-
agonists as one of the drugs that should be stocked in TSA-related season. This article also
emphasizes that more than 80% of patients receive oxygen (16), and hence, oxygen storage
and its use in EDs for future ETSA should also be considered. It should also be noted that
many patients in Iran were not receiving first-line therapy for asthma (16). This could be due
to surge conditions causing stress for medical personnel and limited supplies of first-line
drugs (15,30). Meanwhile, the article from China shows that TSA can also occur in children
(17), whereas in other countries, TSA occurs typically in people aged 20-50 years old (1,3).
Drug recommendations that must be prepared are approximately the same as adults, and this
article also reminds us that apart from asthma medications, treatment for allergic rhinitis also
needs to be prepared because allergic rhinitis is a well-known risk factor for getting TSA
(2,3,15–17).

The increasing burden on ETSA due to air pollution and climate change that continue to
occur and increase demands innovations in surge management in the hospital EDs for the
future ETSA, which is predicted to be even more severe (7–9). Associating it with one of the
principles for managing hospital surge due to disasters caused by CBRNe, which is
technology (11), and also combining the fact of the rapid pace of technological development
nowadays as seen by the telemedicine trend (18,31,32), the use of technology as an
innovation in ETSA management in the future will certainly to be much-anticipated
innovations.
The results of this review suggested that the use of telemedicine could create a better
communication between healthcare establishments during a disaster (18). Suppose there is
innovation in telemedicine, which is specially made for ETSA to enhance communication
between healthcare establishments. In that case, it will undoubtedly be beneficial because,
according to the Victoria State Government report, the biggest problem during the 2016
ETSA in Melbourne, Australia, is the lack of good communication methods between
healthcare establishments resulting in an uneven activation of surge capacity in the hospital
EDs (15). However, the telemedicine model that will assist ETSA management still needs
further research.

The need for technology in ETSA management was also specifically addressed by an article
discussing the importance of electronic prescription and documentation during the 2016
ETSA in Melbourne, Australia (19). Prevention of severe adverse events and staff
accountability can be carried out and guaranteed by electronic clinical documentation.
Moreover, electronic clinical documentation allows other staff at the same time to access
patient data if needed without being limited to distance and time (19). This pattern of results
is consistent with previous literature, which states that the advantage of electronic clinical
documentation reduces errors in the administration of drugs and prescriptions and adverse
effects and ensures staff adherence to clinical guidelines (33). Another article also
emphasizes that electronic clinical documentation can provide superior information because it
can be provided in a form that cannot be obtained paper-based, such as graphics, improve the
relationship between healthcare professionals and healthcare professionals with patient
families through easily accessed data, and make healthcare professional workflows more
effective (34).

In a disaster situation, including in ETSA, hospital EDs will experience insufficient resources
and be forced to prioritize care services (15,35,36). In such circumstances, services will be
focused on the most critical patients and determining which patients will be prioritized
requires a triage process (35,36). A proper and fast triage process is fundamental, which
means technology that can assist this process will significantly help. The results of this
review found an experimental test of mobile technology that can help speed up the triage
process and ensure its accuracy during an MCI (20). A similar method can be used as a
reference for future research to develop a unique ETSA mobile technology.

Apart from technology, the triage system during a disaster can be modified in another form of
innovation. One of the steps taken by the hospital in Melbourne during their ETSA in 2016
was the release of patients who were not urgent so they can provide more beds to increase
their surge capacity (15). As obtained from the results of this review, the method of early
discharging non-urgent patients or known as reverse triage has been shown to increase
hospital capacity by up to 20% (21), and some previous literature has also proved an increase
in surge capacity by reverse triage (13,37,38). To expedite and ascertain which patients
deserve to be released early, a checklist to decide which patients can be discharged early
should be developed like the EDAC checklist, which has proven feasible and reliable in this
regard (22). For ETSA, the EDAC checklist may be modified according to the characteristics
of TSA patients requiring intensive care (39).

Limitations

There are limitations to this review. One of the limitations is we restricted our search to two
databases dan limited to English language publications. There is a possibility of publications
missing, but we have collected essential materials needed by conducting further reference
screens to find additional articles and grey literature. Moreover, the restriction of publication
years to 20 years resulted in excluding articles that discussed the ETSA event occurring
before 2001. Related to this, we experienced difficulties in finding information about the
management of ETSA in each country that had experienced ETSA due to the lack of
publicity about it, and there were several cases of TSA that were not fully reported in most
countries. Finally, the limitation that we consider the most important in this review is that
almost all articles on surge capacity provide general information that is not specific enough to
be implemented in ETSA. In addition, quantitative data and research evidence are also
lacking in this topic.

Conclusions

This review is the first attempt to compile the latest available literature on hospital surge
capacity for ETSA. Our findings conclude that the strategy for future ETSA should be based
on general principles of surge capacity in disaster management and lessons from previous
events, and there should be more research for innovation, especially in the form of
technology that can help optimize the surge capacity of the hospital EDs. Our findings
support the need for an evidence-based approach to prepare emergency preparedness plans
and increase surge capacity in the hospital EDs during ETSA.
Tables
Table 1: Summary of included studies.
Authors Title Study Aim Key Findings R
(Year) Characteristics

General Principles of Surge Capacity in Disaster Manageme

Razak S, Emergency Systematic To understand hospital EDs Hospital EDs are acknow
Hignett S, Department Review response to CBRNe related preparation system for C
Barnes J Response to to detection, essential elements:
(2018) Chemical, decontamination, and (1) organization: readine
Biological, diagnosis to provide patients
Radiological, information for future (2) technology: readiness
Nuclear, and clinical procedures and electronic-based support
Explosive policies by analyzing (3) individual: the readin
Events: A essential factors.
Systematic
Review. (11)

Seda G, Augmenting Review To emphasize the Essential components of

Parrish JS Critical Care optimization of surge (1) personnel: doctors, cr
(2019) Capacity in a capacity during a disaster therapists,
Disaster. (12) (2) equipment: monitors,
drugs, mechanical ventila
(3) room: room for patien
(4) structure: ICU readin
Sheikhbardsir Surge Capacity Systematic Conduct a systematic Ways to increase the cap
i H, Raeisi of Hospitals in Review review of the surge structure, and system.
AR, Nekoei- Emergencies capacity of the hospital (1) Staff: extending work
Moghadam and Disasters during emergencies and
(2) Stuff: make the best u
M, Rezaei F With a disasters with a
according to the location
(2017) Preparedness preparedness approach.
(3) Structure: increase tre
Approach: A
with the aim of increasin
Systematic
emergency, integrate hos
Review.(13)
(4) System: command an
continuity of operations,

Shen W, Jiang Precision Review - Surge capacity co

To summarize experiences
L, He X Augmentation supplies, and syst
of precision augmentation
(2020) of Medical - Principles in prec
of medical surge capacity.
Surge Capacity (1) Precise launching
for Disaster endogenous surge
Response.(14) (2) Precise use of ext
(3) Centralized respo
(4) Altering standard
Management of ETSA by Different Countries
State of Review of Government To report on Victoria, Quick actions taken by th
Victoria response to the Report Australia’s 2016 ETSA and (1) arranging for addition
(2017) thunderstorm provide recommendations nursing, pharmacists, exe
asthma event to support improved support staff
of 21-22 preparedness and response
(2) clearing of non-urgen
November. to emergencies.
available
(15)
(3) rapid transfer of emer
awaiting admission to wa
(4) creating additional tri
(5) establishing respirato
management clinics
Forouzan A, An overview Overview To report the characteristics (1) short-acting β 2-a
Masoumi K, of and treatment strategies of patients were discharg
Haddadzadeh thunderstorm- all patients with acute (2) Aminophylline w
Shoushtari M, associated bronchospasm who were (3) Oxygen was adm
Idani E, asthma presented to the emergency
Tirandaz F, outbreak in departments of Ahvaz, Iran,
Feli M, et al. southwest of following the occurrence of
(2014) Iran. (16) a thunderstorm on
November 2, 2013. 

Xu Y-Y, Xue Retrospective To describe the epidemic Recommendations to pre

T, Li H-R, analysis of and retrospectively analyze (1) early identification of
Guan K epidemic the demographic and
(2) standard treatment of
(2021) thunderstorm clinical aspects of the
asthma in involved children. (3) proper diagnosis of p
Retrospective
children in Analysis (4) prescription of preven
Yulin,
northwest
China. (17)

Innovations in the Optimization of Surge Capacity for Future E

Rolston DM, Telemedicine Review To understand the role of - Telemedicine is a

Meltzer JS in the intensive telemedicine in care.
(2015) care unit: its emergencies and disaster - Designating a tele
role in management system could imp
emergencies coordination of d
and disaster
management.
(18)

Anderson BJ, Thunderstorm Retrospective To compare medication - medication docum

Harding AM, asthma Audit ordering and administration thunderstorm asth
Taylor SE, medication documentation during - highlights the imp
O’Keefe C. management surge (thunderstorm documentation du
(2020) during an asthma) and non-surge - additional local s
 external (control) conditions. hospital since 201
emergency documentation du
(Code Brown): which is Thunder
An
observational
study of the
impact of
electronic
prescribing and
clinical
documentation.
(19)

Boltin N, Mobile Experimental To present and evaluate a - The app reliably d

Valdes D, Decision study new mobile tool for through a self-ser
Culley JM, Support Tool assisting emergency hospital resources
Valafar H. for Emergency department personnel in
- The mobile techn
(2018) Departments patient management and
patients on the go
and Mass triage during a chemical
system in which t
Casualty mass casualty incident.
Incidents
(EDIT): Initial
Study. (20)

Esmailian M, Reverse Triage Cross-sectional To investigate the role of Running RT added 20%
Salehnia M- to Increase the study RT to create additional
H, Shirani M, Hospital Surge hospital surge capacity in
Heydari F Capacity in one of the major referral
(2018) Disaster academic hospitals of
Response. (21) Isfahan, Iran.

Feizolahzadeh The Feasibility Cross-sectional to determine the feasibility - A checklist was m

S, Vaezi A, of Increasing study of increasing hospital surge Early Discharge A
Taheriniya A, Hospital Surge capacity during disasters - EDAC assesses p
 Mirzaei M, Capacity in through identification of are abnormal vita
Vafaeenasab Disasters patients suitable for safe hospital intervent
M, through Early early discharge. - initial assessment
Khorasani- Patient dischargeable and
Zavareh D Discharge. one third of patie
(2019) (22) appropriate tool t
dischargeability i

Abbreviations: TSA = Thunderstorm Asthma, EDs = Emergency Departments, CBRNe =

Chemical, Biological, Radiological, Nuclear, and Explosive Events, ETSA = Epidemic
Thunderstorm Asthma, EDIT = Emergency Departments and Mass Casualty Incidents, RT
=Reverse Triage, EDAC = Early Discharge Assessment Checklist
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