Mark P. Bernstein
Clinical Associate Professor, Trauma & Emergency Radiology
NYU Langone Health, Bellevue Hospital
Eric A. Roberge
Assistant Professor of Radiology
Uniformed Services University of the Health Sciences
Associate Professor, Emergency Radiology Division, Radiology and Imaging Sciences Department
Indiana University Health
Mark P. Bernstein’s “Mass Casualty Incidents: An Introduction for Imagers” was published in the Winter 2020 issue of ARRS’ InPractice magazine. Below, Bernstein et al. provide a primer for hospitals and health care systems responding to the disaster surge of COVID-19.
The coronavirus disease (COVID-19) pandemic has created a mass casualty disaster of staggering proportions. By April 2020, the novel coronavirus responsible for COVID-19 had forced many parts of the United States into crisis mode, while others race to prepare for the inevitable. In regions where the case numbers have not yet begun to climb, disaster planning teams have time to prepare for a crisis response and implement lessons learned from those who were impacted earlier. The goal is the greatest good for the greatest number of people, so hospitals and health care systems are turning the focus from individual health to population health in their disaster surge response to save as many lives as possible.
Mass casualty incidents (MCIs) can be man-made acts of violence, such as mass shootings, bioterrorism, or exploding bridges, or natural disasters in the form of earthquakes, tornados, tsunamis, and pandemics. Tragedies of intentional violence or infrastructure disasters create a sudden surge, demanding a rapid shift in a hospital’s daily routine, and are usually limited geographically—for example, the site of an active shooter or a train derailment. Natural disasters, however, cover much larger regions (i.e., the path of a tornado), whereas, by definition, pandemics know no boundaries.
One key variable in these disasters is time. Time, in most cases, determines our ability to prepare for and maintain a disaster response. In trauma MCIs, there is a window of time when patients arrive to local hospitals, which is often measured in minutes to hours. In the case of bioterrorism or pandemics, timelines are prolonged, measured in days to weeks. Regarding the ongoing COVID-19 pandemic, the window of time is indefinite and unknown. The disruption of a hospital’s daily routine for prolonged periods of time and the need for resources beyond those available, or worse, outstrips the supply chain, placing severe strain on the health care system. Our best tools to manage these challenges are preparation, planning, and practice.
Preparation and planning take place from the federal and state levels to the community and local health care facility levels. Community planning should be coordinated with local governmental agencies, in accordance with state and federal disaster planning efforts, and integrated with local public health and emergency medical services. With respect to pandemics, community strategies must make every effort to “flatten the curve” in order to break the chain of transmission and slow the spread of infections. At the same time, hospital system strategies “raise the roof” of surge response by increasing health care system capacity (Fig. 1) through predesigned efforts focused on three factors: space, staff, and supplies. The hospital system is the backbone of these three elements.
Strategies for increasing health care system capacity will include conservation and substitution during a conventional response, adaptation and recycling during a contingency response, and, finally, reallocation of resources during a crisis response—essentially, withholding resources from one patient population to use them more effectively on another patient population. These “raise the roof” strategies involve nuanced ethical and legal considerations that must be addressed in advance, authorized by hospital leadership, and communicated clearly to frontline health care workers.
Ultimately, the hospital system component directs the response that determines the allocation of the three critical resources of space, staff, and stuff, which are based on supply and demand.
A robust hospital incident command system provides broad management for a multitude of issues, including: hospital controls (facility access, ventilation), communication (internal and external), community coordination (health care facilities, state and federal agencies, as well as utilities and supply chains), and continuity of emergency health care operation (vis-à-vis utility or other system failures). The hospital incident command should also determine and communicate which disaster response is being utilized. Disaster response can be described, in escalating intensity, as conventional, contingency, and crisis, dependent on surge severity and resource availability. The more severe the surge, the fewer the resources; the lower the hospital’s capacity to take care of victims, the more quickly the disaster response must shift into a higher mode (Fig. 2).
Upon declaration of an MCI, efforts must be made to free up physical space for patients. The size and nature of the disaster will dictate the scope and speed necessary.
The conventional response is for surges causing a 20% increase in patients beyond normal capacity. In this situation, all staffed beds are made available and filled. Elective procedures are postponed or cancelled, and patient discharge plans are activated to dedicate more space and empty beds to the surge.
A contingency response is used for surges that are twice a hospital’s capacity and demands more aggressive actions. As the numbers of patients greatly exceed the available hospital and critical care beds, hospital spaces designed for other purposes, including step-down units, observation units, and procedure suites, can be repurposed to recruit more space to bed patients. Transferring patients to other available facilities for ongoing, nonemergent care can be initiated.
A crisis situation completely overwhelms a health care facility. Patients fill hallways, and makeshift spaces, such as tents and offices, need to be devised. Erecting tent hospitals with intensive care units in city parks, converting convention centers into field hospitals, and docking of the United States Naval Ship (USNS) Comfort in Manhattan and USNS Mercy in Los Angeles are evidence that our nation is in crisis because of the COVID-19 pandemic.
As more space becomes available, achieving appropriate staffing and obtaining adequate supplies for the surge of patients is vital. The hospital incident command system should be convened for action as soon as a disaster is declared to urgently alert and mobilize necessary staff. The type of injuries that are expected (e.g., blunt trauma, penetrating trauma, or biological agent) will determine the type of staff best suited to respond. If staffing levels are insufficient, measures to increase staffing may be warranted, including expanding the scope of responsibilities, lengthening shifts, and enlarging patient-to-nurse ratios.
In a conventional response, trained and credentialed staff are able to care for patients with minor modifications, while maintaining usual standards of care.
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The standard of care is challenged in a contingency response, as adequately trained staff must train and supervise off-service staff to safely provide care. Bringing in additional staff should be considered, and outside staff need to be given emergency privileges and credentialing.
A crisis response demands staff to perform clinical functions outside their usual domain. Aggressive staff recruitment and rapid training are necessary to meet the patient care demands and volume. During crisis mode, triage becomes necessary to ensure that acceptable care is provided for the largest number of people. Over- and under-triage can result in higher mortality rates.
Supplies include medications, medical equipment, and personal protective equipment (PPE). Considerations must also be made for laboratory reagents, diagnostic testing, as well as for food, water, and linens.
The hospital system must be aware of onsite and offsite supply storage and availability through supply chains. The ability to adapt, reuse, and reallocate becomes necessary in both contingency and crisis situations.
In the current COVID-19 pandemic, we are witnessing contingency and crisis responses. Hospitals are experiencing severe shortages of ventilators and PPE, meaning patients may be deprived of life-saving care and health care providers are likely to be infected with dire, cascading ramifications.
Radiology Department Response
A departmental incident command team should be in place to implement a disaster management plan and engage in clear and consistent communication. The radiology department must have containment and mitigation strategies that ensure the safety of all staff and patients being imaged. For COVID-19, these measures include ensuring adequate PPE, especially for frontline technicians performing imaging studies, enforcing physical distancing, and limiting in-person interactions. Remote reading should be instituted, where possible. Decontamination protocols must be defined and executed. Nonemergent studies should be halted, including interventional procedures, to preserve PPE and limit exposure.
All real-time changes to address incident-specific issues should be frequently updated and communicated. Implementing these types of measures allows radiology departments to provide safe and appropriate care during surges and helps to ensure sustainable operations.
The lessons we learn from responses nationally and internationally should be incorporated into our hospital and departmental MCI and disaster planning process. Our ability to plan and prepare by focusing on system, space, staff, and stuff will make all the difference in the number of lives saved.
- Christian MD, Devereaux AV, Dichter JR, Rubinson L, Kissoon N. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146:8S–34S
- Institute of Medicine (US) Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Altevogt BM, Stroud C, Hanson SL, Hanfling D, Gostin LO, eds. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. Washington, DC: The National Academies Press, 2009
- Institute of Medicine (US) Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations; Hanfling D, Altevogt BM, Viswanathan K, Gostin LO, eds. Crisis standards of care: a systems framework for catastrophic disaster response. Washington, DC: The National Academies Press, 2012
- Institute of Medicine (US) Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers; Hanfling D, Hick J, Stroud C, eds. Crisis standards of care: a toolkit for indicators and triggers. Washington, DC: The National Academies Press (US), 2013
The views expressed are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. Government.