Hospital staff are typically required to follow formal protocols, i.e., escalation policies or legal/regulatory policy, or emergency response programs, to respond when demand increases or capacity is reduced in emergency events [15, 16]. However, these policies are distillations that fail to capture real difficulties faced by practitioners, lack of illustration about event dynamics, or the full extent of the early adaptations of initial receiving hospitals. The study evidenced that only depending on the policies or guidelines for the preparedness plan did not contribute readiness to the varied scales of MCIs altogether. To achieve the study’s objectives, the paper highlights the following themes: preparation for varying surge capacity, preparing system capacity, and adapting to longer sustained time, to support learning and rethinking preparedness planning for beyond surge capacity events.
Surge capacity preparation
Surge capacity is generally defined as an ability to evaluate and care for a substantially increased volume of patients that exceeds normal operating capacity. Specifically, hospitals with different levels of surge capacity following a mass casualty incident fall into three basic categories depending on the magnitude of the event to individual hospitals: conventional, contingency, and crisis. Conventional capacity was defined as “The spaces, staff, and supplies used are consistent with daily practices within the institution.” Contingency capacity was defined as “The spaces, staff, and supplies used are not consistent with daily practices but maintain or have minimal impact on usual patient care practices.” Crisis capacity was defined as “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 (i.e., provide the best possible care to patients given the circumstances and resources available)” .
During the MCIs after the explosion, the initial receiving hospitals were pushed into a position that required them to develop additional surge capacity for the provision of emergency care to the mass casualties. The present study assigned each of the four hospitals a difficulty level (extreme, high, moderate, and low) of responding to the MCIs. According to the definitions of the three basic categories of surge capacity, "extreme" can be implied as a crisis circumstance for the surge capacity, "high" and "moderate" indicated as a contingency, "low" suggested as a conventional situation. And Tables 4 and 5 showed how individual hospitals adaptively responded to the difficulties in each level, based on their contextual concerns. The study indicated that hospitals might face the demanding challenges of any of the three categories of surge capacity after an unexpected beyond-surge-capacity event. Hospitals should be better-prepared staff to offer patients timely and appropriate care, no matter their accreditation level. Referring to the study’s synthesized findings, f hospitals can learn how to expand their disaster preparation investments in multiple simulation cases for surge capacity planning from this one case. They can use Fig. 1 (overload patterns) and Tables 3, 4 and 5 for the planning to capture an overall understanding of what challenges could occur over time and how hospitals responded to these difficulties to extend emergency care in each category. Also, emergency planners can consult the responses described in more detail in individual publications regarding two hospitals at an extreme and high level [6, 7].
Using the integrated adaptation framework to support system capacity planning
The FFCDE event challenged multiple hospitals in varied demand for surge capacity. The initial receiving hospitals adaptively provided the best possible care to the patients based on their available personnel, equipment, and supplies. The beyond surge capacity event analysis revealed several primary responses to approaching or reaching saturation (overload & shortages) and revealed essential functions for successful adaptation (Table 4 and 5 and reference 6, 7). In terms of four critical interdependent factors (four Ss) that contribute to an effective surge response: system, space or structure, staff, and stuff (i.e., supplies and equipment) [17, 18], the study synthesized hospitals' adaptations into 19 functional adaptations for the burn MCIs. Each adaptation involves specific goals for expanding capacity, e.g., clinicians, ICU beds, medical materials, according to the characteristics and contextual situations of the particular hospitals. In addition, the study findings indicated that the adaptations to mobilize and deploy resources must root in good coordination and communications across units and functions to be successful.
Emergency experts advocated that the other three variables cannot be appropriately managed without the underlying system components, although each of these "four Ss" is important to responses to MCIs . And, in preparedness planning for overwhelming MCIs, having a capable "system" capacity is imperative for seamless integration with the other three capacities for the varying scale of incidents. System capacity generally refers to integrated policies and procedures (e.g., the 4Cs: command, communication, coordination, and control) for effective disaster response management . The links between individual adaptations in the integrated 19 functional adaptations framework present the coordinated interactions, communication, and interdependency (command and control) across units and functions to cope with specific situations accordingly. The integrated framework reflects a holistic and systematic structure of the development of the four Ss in response to the MCIs and provides practical knowledge for preparedness planning. The framework itself demonstrates "system" capacity that shows the interrelations among adaptations via the 4Cs, which can help emergency planners make projections regarding the four Ss' systemic cascade effect.
Successful responses to MCIs are wholly dependent on effective coordination and communication between individuals and across units and roles during critical stages . By examining the adaptation framework and the interrelations between adaptations, hospitals can obtain a systemic understanding of holistic disaster response and interaction needs, which they can use the integrated knowledge to redesign existing preparedness plans to support coordinated cross-unit adaptations. Besides, the evaluation of results from ongoing planning plays a vital role in preparedness planning . The present framework can then serve as a visualizable checking tool to direct practitioners’ attention. Emergency planners can address or mark the weaknesses of system capacity on the framework when evaluating, organizing, practicing, and implementing preparedness plans for a specific scenario .
A complementary approach adapting to longer sustained time
The intensified pressure and the increased scale of demand caused by the FFCDE far exceeded the hospitals' reasonable expectations or planning capacity. Examining the varying adaptations presents a specific opportunity to learn regarding the most effective response to the same event. The FFCDE event and the study indicated that preparatory investments are needed to have the adaptive capacity when challenges arise in the future. The four overload patterns and corresponding metrics show four types of patient surge arriving hospitals and the varied overload time before resuming to normal operations in EDs. Notably, the overload caused by the influx of FFCDE patients was shorter in duration than that in other large-scale events, such as an earthquake crisis. If the MCI had extended for a longer period, strain from overwork and sustaining adaptations might have led to clinician attrition. To invest in building adaptive capacity in advance for such beyond-surge capacity events need to be considered.
This paper suggests using the four overload patterns with the overload metrics and the integrated adaptation framework as a complementary approach to supporting preparedness planning for beyond surge capacity events. The four overload patterns provide varying situations that more comprehensively illustrate patient load changes to EDs against the prepared surge capacity over time than conventional MCI guidance. Suppose emergency planners consider additional scenarios associated with longer overload time. They can adapt the approach to develop new scenarios with longer overload time and indicate the gaps between capacity and loading in each simulation. Subsequently, the integrated adaptation framework can be used as a directive map guide to compare the current plan and identify planning insufficiencies. Doing so would facilitate understanding differences in hospitals' overload situations, the cascade effects of possible adaptations, and preparedness planning improvement in advance.