A medical surge occurs when patient volumes and/or clinical needs exceed the limits of hospital service capacity. This can occur at any time for a multitude of hazards from mass casualty incidents to infectious disease outbreaks. A surge can be brief or protracted – spanning from days to weeks or weeks to months – and can involve 1 or all of the 4 “S” domains of hospital service capacity: staffing, supplies, space, and systems.

A medical surge’s impact on health care delivery can occur across a continuum, ranging from conventional to contingency to crisis operations (see Keywords). Based on the premise that “ready or not” incidents will occur and patients will present, hospitals must have plans and processes established to be able to care for those patients.

The Hospital Surge Preparedness and Response Index is an all-hazards template developed by a group of emergency management and disaster medicine experts from the United States (Figure 1). Multiple working group plenary sessions were convened between November 2020 and April 2021, with a consensus on the index items derived via a modified Delphi process. While the US experience may differ from those of other nations in terms of logistical detail, the key principles in disaster preparedness and response are generally well conserved. It should be noted, however, that in areas with developing infrastructure, the ability to coordinate information and to consistently access supply chains may be limited. Further, political capacity to induce change will vary across local/regional/national jurisdictions. These bureaucratic constraints can impact the development of disaster-related policy measures and governmental roles, both of which can in turn affect the ability of hospitals and health care systems to effectively manage a surge.

Figure 1. Hospital Surge and Preparedness Index. Fields denoted by “X” refer to institution-specific parameters to-be-filled by administrators.

The Hospital Surge Preparedness and Response Index can improve planning by linking action items to institutional triggers across the surge capacity continuum. This responder tool is a non-exhaustive, high-level template: administrators should tailor these elements to their individual institutional protocols and constraints for optimal efficiency. We acknowledge that, in practice, the trigger points described herein are not inherently linked (see Figure 1). Indeed, they may often be in flux so that an activation of one surge domain does not necessarily imply an activation in other domains. There are also aspects within the index that may apply to all surge domains (eg, active palliative care, load-balancing). An appropriate, phased response is not only contingent upon effective disaster planning, but also on staunch incident command. The above limitations notwithstanding, the Hospital Surge Preparedness and Response Index can be used to provide administrators with a snapshot of their facility’s current service capacity in order to promote efficiency and situational awareness both internally and among regional partners. See service capacity descriptions below.

Staffing: ability to provide needed care with the available medical personnel. Assessment of staffing need considers different levels of care, including: Intensive Care Unit, Emergency Department/Triage, Monitored/Intermediate care, Medical/Surgical (general floor) care, and so forth.

Space: physical area and infrastructure needed to provide care considering patient need, that is, airborne infection isolation (eg, negative pressure) rooms, oxygen, electrical, monitoring double/triple occupancy, alternative care sites/areas, security, and so forth.

Supplies and equipment: items needed to provide care (eg, personal protective equipment, ventilators, medications, dialysis machines, telemetry and pulse oximetry equipment, linen, medication pumps, disposables such as needles, IV supplies)

System: mechanisms for effective decision-making about resource utilization and coordination of actions at the facility/hospital level, as well as across health care systems to provide needed care. This often involves engagement with local and regional coalitions (eg, load balancing, sharing resources intra- and inter-facility/system, policy, information sharing).