Unfortunately, little has been published in the scientific literature to date regarding the needs of such populations, despite the fact that special populations appear to account for the majority of patients “stranded” in areas of limited health care resources, particularly following natural disasters.1 At the same time, the effective surge capacity of emergency departments in the United States has fallen sharply during the past 15 years, perhaps by as much as one-third, when one takes into account both the increase in annual visits to emergency departments and the decrease in the number of emergency departments.2 The Health Resources and Services Administration set targets for surge capacity in the nation’s hospitals at 500 cases per 1 million population for large-scale bioevents and 50 cases per 1 million population for blast and radiation injury.3 However, it is unclear whether these targets, extrapolated largely from the Israeli experience, are truly applicable to the far larger American healthcare system—a system not used to managing major disasters and manifestly lacking the military training and experience of the Israeli population—let alone the American healthcare system as used by American children.4-6

ON-THE-GROUND SUCCESSES: STATE OF THE ART

Outside assistance following a major disaster cannot be expected to arrive before 24 hours, and may arrive as late as 96 hours, even though the peak demand for emergency services can be expected to occur within the first 24 hours—84 to 90 percent for conditions manageable on an ambulatory basis.7 The majority of hospitals in densely populated urban environments appear to have well-established incident command systems; protocols for hospital lockdown, early discharge, and cancellation of elective operations; designated victim overflow areas; predisaster “preferred” vendor agreements; emergency medical services–compatible communications systems; a minimum of 3 days’ worth of supplies on hand; and daycare for children of staff. However, mutual aid agreements with law enforcement, other hospitals, and long-term care facilities are generally lacking, while few hospitals have fully engaged in community-wide disaster planning or have involved other agencies in their disaster training. Moreover, less than one-third of such hospitals may have reliable surge capacity in excess of 20 beds or access to 6 or more ventilators, while less than one-half may have access to pharmaceutical stockpiles.8



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