Guidelines for Pediatric Hospital Responses to Increased Patient Volume

Activation of the surge capacity plan should be performed either on hospital notification (from police, emergency medical services control, public health officials, or another established mechanism) that a mass casualty event has occurred, or once clinicians in the emergency department (ED) have made the determination of need. 

Activation of the Surge Capacity Plan: The Hospital Incident Command System (HICS)—Hospital Command Group ⁶

The emergency physician who activates the hospital surge capacity plan should contact hospital telecommunications personnel ("operators") who must, in turn, notify essential personnel. Hospital operators should also be responsible for notifying personnel when the surge capacity plan is deactivated.

Once a surge capacity plan is activated, a defined group of individuals known as the Hospital Command Group (HCG) (Figure 1) should convene in a location identified as the Hospital Command Center (HCC). The HCG typically receives valuable input from the emergency department attending (serving as the Medical Technical Specialist: Medical Staff Officer) and comprises the Administrator on Duty (Incident Commander), Public Information Officer, Safety Officer, Liaison Officer, as well as other members of hospital leadership. Although the exact responsibilities of each member are unique to the specific disaster plans for each health care facility, the HCG has responsibility to:

• Activate the necessary HICS positions.
• Coordinate the institutional response to the surge capacity plan.
• Receive, interpret, and communicate information from emergency medical services and public health communication networks, including updates of the facility's bed capacity.
• Coordinate hospital activities during activation of the surge capacity plan.
• Rapidly discharge inpatients capable of outpatient or delayed management.
• Monitor the flow of disaster patients as they move through the hospital's systems.
• Receive and communicate information between hospital departments.
• Ensure that elective admissions are postponed, depending on the scope of the disaster.
• Formulate plans for the next operational period.
• Determine recovery strategies and devolution of the surge capacity plan.

Each member should be clearly identified by means such as a vest with the wearer's responsibility written on it (e.g. Medical Technical Specialist: Medical Staff Officer).  Each member should also read his/her facility-specific HICS Job Action Sheets that delineate individual responsibilities during the disaster. The ED Disaster Team Leader (physician leadership based in the ED) should designate a predetermined location in the ED as the ED Disaster Command Post. Here, the ED-based strategies are formulated and management objectives are defined. These strategies are shared with the HCC staff to better coordinate surge activities outside of the ED. Once the surge capacity plan is activated, each member of the HCG should immediately attend a status/action plan meeting in the HCC. Any communication with patient families or the press must remain under the control of the Public Information Officer who works with the Incident Commander and the Medical Technical Specialist: Medical Staff Officer. Once convened, the HCG priorities should include:

• Ensure that primary response and support departments (nursing, critical care, radiology, respiratory care, security, janitorial services, etc.) have received the alert and are prepared.
• Receive briefing from the Situation Team Leader regarding patient census and bed status.
• Consider canceling elective procedures and admissions.
• Ensure Logistics Section Chief is able to deploy resources as needed.
• Ensure contact with senior hospital executives.
• Activate the Documentation Team Leader individual to maintain the Incident Action Plan for post-incident debrief notes.

The HCC should be stocked with sufficient supplies to ensure operations of the HCG. Supplies should include communication sets, clerical supplies, redundant communication systems, mobile communication assets, HICS Incident Team Chart, hospital and city emergency contact directories, WebEOC and State Bed Tracking site log-in information, disaster related tracking forms, hospital charts, patient flow board, and reference documents such as triage protocols, surge capacity plans, patient reporting guidelines, HICS Job Action Sheets, area maps, copies of vendor memoranda of understanding, and risk communication templates and protocols. 

Communication sets should not interfere with other networks used by the police, emergency medical services, and fire departments. Tactical radio channels such as those used for local communications have many different configurations. Some systems are dedicated emergency medical services (EMS) channels, some share channels with fire or police operations, and others have special channels for on-scene operations. In a small event, such as a motor vehicle crash, first response agencies may operate on a single channel. As operational complexity increases, incident commanders should decide the point at which communications transition from a single channel to a tactical (or "on-scene") channel. The use of tactical channels prevents the overload of the primary EMS channel and prevents interference between agencies with different primary function. The incident commander or Medical Technical Specialist: Medical Staff Officer from the ED and other agencies should, however, communicate on a predesignated (mass casualty incident) channel when needed. 

Emergency department communication nets should use multichannel portable radios that have talkaround capacity, although these systems are susceptible to missed messages if a dispatcher transmits over direct messages. Usually the portable radios used in ED communications are relatively low power and therefore have a limited service radius. 

Several items can improve communications efficiency. First, an adequate supply of batteries for portable radios should be readily available to keep communications open as long as necessary. Second, it is important to use plain English and avoid coded language.  This decreases the amount of radio traffic by eliminating phrases such as "at this time" or "be advised" and greatly decreases the potential for miscommunication. Third, radio users should remember to key the radio for a full second before speaking to ensure the beginning of the message is not missed. 

Not all mass casualty incidents demand a hospital-wide response. For example, incidents that involve one or two clinical areas that can be handled with normal hospital staffing and are resolved in less than 8 hours can be often be handled with improved coordination between clinical services. In these limited cases, a Labor Pool can be staffed with minimal personnel to assist the activated HICS members with information management and to relieve workload on specific services (e.g., patient transport or radiology). Examples of these incidents include: alteration of ED operations without immediate threat to life or property, one or two operational areas involved (e.g., ED and radiology), considerable media attention, or an initial response to an unconfirmed external emergency.

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