Annals of Disaster Medicine
| ISSN:1684-193X
|
Updated
July 18, 2003
|
|
Contents:
Volume 2, Number 1; July, 2003 |
|
Evolution of the Hospital Capacity for SARS in Taipei |
Tzong-Luen Wang, MD, PhD; Kuo-Chih Chen,
MD; I-Yin Lin, MD; Chien-Chih Chen, MD; Chun-Chieh Chao, MD; Hang
Chang, MD, PhD
|
From the Department of Emergency Medicine ( Wang
TL, Chen KC, Lin IY, Chen CC, Chao CC, Chang H), Shin-Kong Wu
Ho-Su Memorial Hospital.
Correspondence to Dr. Hang Chang, Department
of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95
Wen Chang Road, Taipei, Taiwan. E-mail M001043@ms.skh.org.tw
|
Abstract
|
|
|
To assess the medical severity index for a disaster, there are three
capacities that should be considered. They were medical rescue capacity
(MRC), medical transport capacity (MTC) and hospital response capacity
(HRC). We retrospectively analyzed the capacities of Taipei City and tried
to find the limiting factor for severe acute respiratory syndrome
(SARS) before and after the endemics this year. On April 9 2003, the
available isolation beds were totally 128, whereas total number
of beds enrolled in Emergency Response Hospitals in Taipei City was 20,160.
In other words, the percentage of isolation beds was only 0.63%.
Ideal HRC for those hospitals should be 630 patients per hour that
was significantly higher than the real needs (0.38 cases per hour).
Because of the cumulative reported cases being 518 in northern area
and the consideration of case accumulation from April 10 to June
10, however, the hospitals could work within their capacities in
only 14 days. The total isolation facilities in Taipei cities were
630 beds (3.1%; P<0.01 v 0.63%) in July 2003 and accounted for
70 working days (P<0.01 v 14 days). In conclusion, the total
number of the isolation facilities instead of the HRC was the critical
factor that limited the SARS management
Key words--- SARS; Isolation Facilities;
HRC; Emergency Medicine |
|
|
Introduction
|
|
|
|
Severe acute respiratory
syndrome (SARS) is a disease manifested by atypical pneumonia and
rapid progression to respiratory distress. 1-4
It has been proven to be caused by the coronavirus.5-7 In
the viewpoint of disaster medicine, the preparedness for such an
infectious disease should be similar to that for bioterrorism. According
to Advanced Health in America,10 hospitals have multiple missions:
patient care, clinical education, clinical research, and community
service. Two of them, or patient care and community service, combine
together when a community prepares for an emergency or disaster.
The hospitals are responsible for patient care along the disaster,
whereas their community service begins at the usual time as they
develop and implement their disaster plans. The hospitals should
therein be engaged in the development of emergency response systems,
staff training, and logistics in order to continue caring for their
patients and their own staffs under sufficient supply of equipment
and medicine.
No matter the internal disasters or external disasters, the hospitals
were expected to have their reasonable estimation of their own capacities
of management. The capacities depend upon many factors such as personnel,
incident command system, logistics, transportation and communication.
Although an all-hazard model provides a well-established response
style, the capacities for different disasters may still be different
and need to be carefully estimated.
However, there have never been any events of bioterrorism or devastating
infectious diseases such as SARS in recent decades. Some planning
of preparedness for the above events may become a so-called ˇ§paper
plan syndromeˇ¨. We therein retrospectively analyzed the capacity
and actual demand of isolated facilities and hospital response capacity
(HRC) in Taipei City in order to find the limiting step in the management
of the endemics.
|
|
|
Methods |
Definition |
When the capacity of a region's
medical resources are exceeded during an incident then it can be
termed a disaster. Categories of casualties included: (1) dead and
dead-on-arrival; (2) life threatening cases needing immediate attention;
(3) non life-threatening cases requiring hospital treatment; (4)
casualties not necessarily requiring hospitalization. The following
three categories (or capacity) should be considered. The first was
severity of an incident in terms of injury (S). It implied that
if many seriously wounded casualties are expected (categories 2
and 3) then the S value is 1.5. If only many slightly injured persons
are expected then the S value is 0.5. Intermediate situations such
as traffic accidents have an S value of 1.0. Hospital treatment
capacity (HRC) was defined to be the hourly treatment capacity is
the number of category 2 and 3 casualties that can be treated according
to normal medical standards in one hour. For general hospitals this
is estimated as 3% of the total number of beds. Since most hospitals
can work efficiently for up to 8 hours the total capacity is taken
to be 8 times the hourly treatment capacity. Medical rescue capacity
(MRC) meant that the rescue capacity depends on the number of trained
medical professionals available at the disaster site. A trauma team
with surgeon anesthesiologist nursing support and supplies can handle
about 10 category 2 and 3 patients per hour. Under difficult conditions
the capacity to deliver care is reduced. The rescue capacity should
equal the hourly hospital treatment capacity of the region. Medical
transport capacity (MTC) meant that the transport capacity depends
on the number of ambulances with drivers and it is affected by the
ease of evacuation the distribution plan and the size of the event.
A typical ambulance crew can be expected to handle 2 patients per
hour but this may be reduced by poor conditions. The transport capacity
should try to match the hourly hospital treatment capacity of the
region. Medical severity index (MSI) was defined to be the result
of casualty load times severity of incident divided by capacity
of the region.
According to the definition of the World Health Organization (WHO), 11
a suspected case is the person with a documented fever (body temperature
> 38˘J), lower respiratory symptoms, and contact with index
patients. A suspected case that had chest radiographic findings
of pneumonia, acute respiratory distress syndrome, or unexplained
respiratory disease resulting in death with autopsy results demonstrating
the pathology comparable with SARS is considered a probable case.
|
|
|
|
Data enrollment |
We collected the data of all emergency
response hospitals in Taipei provided by Department of Health, Taipei
City Government. There were 12 administrative areas and overall
53 emergency response hospitals which accounted for 20,160 beds
in Taipei City in 2002. Of the hospitals, seven were the tertiary
care medical centers and the remaining 46 secondary hospitals. The
isolation facilities of these hospitals and the average duration
of hospitalization for the victims of probable SARS were measured.
|
|
Statistical anaylsis |
The categorical data were inputted in Microsoft Excel
2000 for descriptive statistics and further qualitative analysis.
These results were analyzed using the chi-squared test. ANOVA with
a Newman-Keuls post hoc test was used to determine whether any significant
differences existed among continuous data. A P<0.05 was
considered to be statistically significant. |
|
Results |
|
HRC before SARS |
|
According to the data obtained
from Taipei City Government, the isolation beds available were totally
128 in April 9 2003. The total number of beds enrolled in Response
Hospitals in Taipei City was 20,160. In other words, the percentage
of isolation beds was only 0.63%. Ideal HRC for those hospitals
should be 630 patients per hour which was significantly higher than
the real needs (0.38 cases per hour). Because of the cumulative
reported cases being 518 in northern area and the consideration
of case accumulation from April 10 to June 10, however, the hospitals
could work within their capacities in only 14 days.
If only seven medical centers were enrolled as analysis, the total
number of beds was 9,792, and that of the isolated beds 70. In other
words, the percentage of isolation beds was only 0.71% (P=NS v 0.63%
for total hospitals). However, under the policy of gathering the
patients into medical centers, the 7 medical centers had to take
care of at least 70% of the cases of probable SARS and could tolerate
only 10 days.
The total isolation facilities in Taipei cities were 630 beds in
July 2003. In other words, the percentage of isolation beds was
3.1% that was significantly higher than the value before April 10
2003 (P<0.01). Accordingly, the hospitals could work within their
capacities in 70 days (P<0.01 v 14 days in April 10 2003) if
the similar event occurred.
In the mean time, the isolated beds in 7 medical centers were 238.
In other words, the percentage of isolation beds was 2.4% (P=NS
v 3.1% for total hospitals) but significantly higher than the value
in April 10 2003 (P<0.01). However, the insignificantly lower
percentage found in these medical centers accounted for the policy
that the cases with highly transmittable disease should be deposited
to so-called isolation hospitals.
|
|
|
|
Discussion |
|
|
|
According to Advanced
Health in America, 10 mass casualty
incidents that result from infectious causes are different from
all other types of disasters for many reasons, including: (1) the
onset of the incident may remain unknown for several days before
symptoms appear; (2) even when symptoms appear, they may be distributed
throughout the communityˇ¦s health system and not be recognized
immediately by any clinicians; (3) the initial symptoms may be similar
to those of the flu or the common cold so that the health system
will have to care for both those infected and the ˇ§worried
wellˇ¨ (such as the suspected cases of SARS but finally tested
negative); (4) After being undetected for days, some infectious
agents may already transmitted in their ˇ§second waveˇ¨
before the first wave is identified; (5) public confidence in government
officials and health care authorities may be striked by the initial
uncertainty about the cause of and treatment for the outbreak; (6)
health care authorities want to restrict those infected to a limited
number of hospitals but the public may seek care from a wide range
of institutions; and (7) health care workers may be reluctant to
place themselves or family members at increased risk of work.
Mass casualty incidents always overwhelm the resources of health
institutions, and require a sustained demand for health services
rather than the other short-acting smaller scale disasters. This
situation imposes many new considerations and issues to preparedness
planning for hospitals. Because of their emergency services all
the time, hospitals will be considered by the public as a vital
resource for diagnosis, treatment, and follow-up for both physical
and psychological care. The question is whether the SARS endemics
are one of mass casualties. Because of its contiguous nature, the
disease control of SARS needed more personnel than a usual mass
casualty did. It should be logistic that the endemics be considered
as a long-standing mass casualty. Furthermore, the long-standing
character of the event caused the limiting step to be the total
capacity (or the number of isolated facilities) instead of three
categories of MSI, as our report demonstrated.
The WHO guidelines on diagnosing SARS emphasize respiratory tract
symptoms such as cough, shortness of breath, and breathing difficulty. 11
However, these clinical symptoms in the WHO case definitions do
not feature strongly in the early stages of the illness, when patients
are highly infectious but before they are hospitalized. In screening
patients for SARS systemic symptoms such as fever, chills, malaise,
myalgia, and rigors may be better discriminators than the symptoms
listed in the WHO guidelines, which were based on study of patients
who were already in hospital. The low sensitivity of the WHO criteria12
made it a tendency to enroll at least 4 times of the people admitted
to the isolated facilities. In Taiwan, the ratio of confirmed cases
and reported cases were also similar. In other words, the reserve
for isolation should be at least 4 times of the actual need. Most
of the studies revealed that SARS is a disease transmitted by droplets
or close contact. If some infectious disease that was highly infectious
and transmitted by air-borne route, the situation will be more difficult.
In conclusion, the total number of the isolation facilities instead
of the HRC was the critical factor that limited the SARS management.
Adequate reserve for isolation may be the most important step for
preparedness of bioterrorism or other infectious disease such as
SARS.
|
|
|
References |
|
|
|
1. |
Severe acute respiratory
syndrome (SARS). Wkly Epidemiol Rec. 2003;78:81-3 |
2. |
Acute respiratory syndrome China,
Hong Kong Special Administrative Region of China, and Viet Nam.
Wkly Epidemiol Rec. 2003;78:73-4 |
3. |
Tsang KW, Ho PL, Ooi GC, et al.
A cluster of cases of severe respiratory syndrome in Hong Kong.
N Engl J Med. 2003;348:1977-85 |
4. |
Lee N, Hui D, Wu A, et al.
A major outbreak of severe acute respiratory syndrome in Hong Kong.
N Engl J Med. 2003;348:1986-94 |
|
5. |
Poutanen SM, Low DE, Henry B,
et al. Identification of severe acute respiratory syndrome in Canada.
N Engl J Med. 2003;348:1995-2005 |
|
6. |
Update: outbreak of severe acute
respiratory syndrome: worldwide, 2003. MMWR Morb Mortal Wkly Rep.
2003;52:269-72 |
|
7. |
Peiris J, Lai S, Poon L, et
al. Coronavirus as a possible cause of severe acute respiratory
syndrome. Lancet. 2003;361:1319-25 |
|
8. |
Ksiazek T, Erdman D, Goldsmith
CS, et al. A novel coronavirus associated with severe acute respiratory
syndrome. N Engl J Med. 2003;348:1953-66 |
|
9. |
Drosten C, Gunther S, Preiser
W, et al. Identification of a novel coronavirus in patients with
severe acute respiratory syndrome. N Engl J Med. 2003;348:1967-76 |
|
10. |
American Hospital Association.
Hospital preparedness for mass casualty. Final report. August 2002 |
|
11. |
World Health Organization. Case
definitions for surveillance of severe acute respiratory syndrome
(SARS). Available at http://www.who.int/csr/sars/casedefinition/en/.
Accessed May 12, 2003 |
|
12. |
Rainer TH, Cameron P, Smith DV,
et al. Evaluation of WHO criteria for identifying patients with
severe acute respiratory syndrome out of hospital: prospective observational
study. BMJ 2003;326:1354-8 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|