which available local and state resources have been depleted, or are in short supply.

However, it has become increasingly clear that much more planning at the local and state levels is required in order to implement a meaningful response to the expected surge in demand for healthcare services that will arise in times of crisis or catastrophe. The Centers for Disease Control and Prevention has adopted such an approach to surge capacity planning, emphasizing the importance of coordinating public health and healthcare-related planning for pandemic influenza under the umbrella of a community Alternate Care System (ACS), composed of select community partners who are essential to delivering care in the setting of a surge response to disaster. The components of an ACS are built around the stratification of care model, with an important emphasis on developing consensus-based, community-wide agreement on the use of triage algorithms, particularly those that relate to the ethical and legal implications of allocating scarce resources in a disaster event. Such a comprehensive system of development emphasizes the inclusion of many groups heretofore not significantly or consistently involved in the planning process for a community’s response to overwhelming surge in demand for care.

IMPLEMENTING A MODEL OF STRATIFIED CARE IN A DISASTER

Increasing attention is being given to the need to broaden surge capacity planning to include the full spectrum of patient care delivery capabilities in a disaster-impacted community. Much of this work started with a focus on alternate care facility planning for extension of hospital-like services in an unregulated, non-healthcare setting. Examples of this include the establishment of federal medical shelters during the responses to the multiple Florida hurricanes in the summer of 2004, Hurricanes Katrina and Rita in 2005, and Hurricanes Gustav and Ike in 2008.

The initial concepts for such planning came from work conducted for the U.S. Army Soldier Biological Chemical Command (SBCCOM) in the late 1990s. These efforts focused on a combination of out-of-hospital capabilities divided between Neighborhood Emergency Help Centers (NEHCs) and Acute Care Centers (ACCs).1,2 The NEHC is intended to function as a community care station that provides a combination of functions including victim triage, and serves as a distribution point for medical countermeasures. The ACC, similar to the FMS concept, serves



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