Surge Beds Research Articles

293. Association of a Hospital Stress Indicator with Device Associated Infections

Abstract Background Hospital surges during the COVID-19 pandemic provided an opportunity to assess the effects of strained hospital resources on patient safety outcomes and identify predictors of resilience. We sought to examine the relationship between a composite indicator of hospital stress and device-associated infections (DAI) including central-line associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) in California acute-care hospitals. Methods We used data from the California Hospital Association daily survey to create a composite variable indicating hospital stress. Hospitals were considered stressed on a given day if they reported patients in surge beds, ventilated COVID-19 patients in the emergency department, or a critical staffing shortage. We matched data from the National Healthcare Safety Network (NHSN) on CLABSI and CAUTI occurring between June 2020 and December 2021 to inpatient discharge data from the California Office of Healthcare Access and Information (HCAI) by sex, birthdate, admission date, and hospital. Patients were considered exposed to hospital stress if the hospital was stressed on any day between their admission and infection onset or discharge. We used propensity score weighting for risk adjustment for patient characteristics including month of admission, age, sex, race, expected payer, principal diagnosis, type of admission (emergency/urgent, trauma, or elective) and comorbidities from linked HCAI records (Table 1). Odds ratios were calculated using logistic regression with the generalized estimating equation to account for clustering within facilities. Results 2,843 CLABSI and 2,870 CAUTI were successfully matched to patient records. Forty seven percent of patients were exposed to hospital stress. Risk-adjusted odds ratios were between 2 and 3 and significant at α=0.05 for all DAI, CLABSI, and CAUTI (Table 2). Conclusion These findings validate that our measure of hospital stress was associated with increased risk of individual patient-level DAIs in 2020-2021. Further research will focus on generalizing results beyond 2020-2021 and assessing facility-level factors that mitigate the stress-patient outcome association. Disclosures All Authors: No reported disclosures

The San Francisco Health Systems Collaborative: Public Health and Health Care Delivery Systems’ Response to the Covid-19 Pandemic

The Covid-19 pandemic challenged health care delivery systems worldwide. Many acute care hospitals in communities that experienced surges in cases and hospitalizations had to make decisions such as rationing scarce resources. Hospitals serving low-income communities, communities of color, and those in other historically marginalized or vulnerable groups reported the greatest operational impacts of surges. However, cross-institutional collaborations within jurisdictions offer unique opportunities to prevent or mitigate health disparities in resource utilization and access to care. In January 2020, in response to the emerging coronavirus epidemic, the San Francisco Department of Public Health (SFDPH) and local hospital and health systems partners convened to align and coordinate medical surge planning and response. Adopting a governance structure of mutual accountability and transparency, the San Francisco Health Systems Collaborative guided local medical and public health response in the areas of medical surge, vaccination administration, testing, and therapeutics. Four principles guided the collaborative response: (1) shared priorities, (2) clear governance and accountability, (3) data transparency, and (4) operational coordination. High-level priorities established included protecting vulnerable people, protecting health care workers, and maintaining health system capacity. The governance structure consisted of three layers: local hospital and health systems’ CEOs coordinating with SFDPH executives; hospital chief medical and nursing officers coordinating high-level surge capacity assessments and mitigation plans; and local clinical operational managers working with public health response operational leaders to coordinate scarce resource utilization. Fluctuating with the tempo of the disease indicators and medical surge, governance and coordination were maintained through a tiered meeting and reporting system. Data visibility and transparency were key principles facilitating operational decision-making and executive-level coordination of resources, including identifying additional surge bed capacity for use systemwide, as well as ensuring efficient and equitable vaccine distribution through implementation of five mass-vaccination sites with prioritized access for vulnerable communities. Applying these four principles of shared priorities, accountability, transparency, and operational coordination and pragmatism helped the public health and individual hospital systems make contributions to the overall response that were aligned with their unique strengths and resources. Publication here represents the first official public use of the name San Francisco Health Systems Collaborative (which had served as the term used internally to refer to the group) and the first time codifying this structure. Through this coordination, San Francisco achieved one of the lowest Covid-19 death rates and had one of the highest vaccination and booster rates, compared with rates across California or the United States. Similar principles and implementation methods can be adopted by other health jurisdictions for future emergency outbreak response.

Mobilizing PACU Nurses to Provide Critical Care during the Covid-19 Pandemic

Background InformationIn March 2020, a New York State mandate required our institution place a moratorium on elective surgery for an unknown period of time to ensure adequate Covid-19 surge hospital bed availability. This resulted in extremely low patient volumes for perioperative services. Conversely, critical care was experiencing an influx of patient volume and acuity, necessitating additional nursing support.Objectives of ProjectOur aim was to bolster the hospital's critical care service line by pooling available nursing resources. The perioperative and critical care leadership teams further identified this initiative as an opportunity to strengthen relationships between nurses that share a common skill set.Process of ImplementationHospital command center meetings to address surge bed capacity reinforced the partnership between perioperative and critical care services. Team nursing models were reviewed collaboratively. The PACU nurse manager requested volunteers to staff critical care based on a team model. Five highly experienced PACU RNs and five newer PACU RNs without prior ICU assignments volunteered, with goals to expand knowledge, improve critical assessment skills, and help a service in need. The ten PACU nurse volunteers were assigned into five pairs, consisting of one experienced RN and one newer RN. The five teams of two were consistently matched with their partner, and worked every shift in the ICU as a pair.Statement of Successful PracticeThis collaborative effort between the perioperative and critical care nursing services achieved the goal of providing safe and competent care to a population in dire need during the height of the Covid-19 pandemic. This initiative also strengthened relationships between the services, thereby promoting improved communication and increased efficiency.Implications for Advancing the Practice of Perianesthesia NursingThe future implications of Covid-19 are largely unknown, and this initiative mobilized nursing resources in a systematic fashion to provide necessary specialized care. A framework was established that could be easily replicated, thereby strengthening our ability to collaboratively approach emergency preparedness moving forward.

Abstract P120: The Covid Effect on Stroke Response

Background & Significance: The Covid-19 pandemic has created a host of challenges for healthcare systems and hospital teams that have put unprecedented stress on staff and leaders to re-design care and management of not only the Covid positive patient but also the hospitalized non-Covid patient. As this large healthcare system began to prepare for a Covid surge of patients, stroke program leaders recognized the need for alternative placement and management plans. With the re-designation of units and beds and deployment of staff into non-primary units, program leaders were concerned with not only placement of stroke patients outside of regular stroke and Neurocritical Care Units but also with non-trained stroke nursing staff caring for the patient. In response, this stroke program convened a working group to create alternative guidelines for care of the stroke patient during Covid surge and critical bed shortages. Design & Methods: The need for established criteria to guide all sites in the care of patients post IV thrombolytic or mechanical thrombectomy was the key objective. The alternative guideline was drafted and submitted to the system Covid clinical command center for emergent approval. Once approval given, education was provided to all stroke coordinators and key leaders at each site. To provide full access, guidelines were posted and available on the system SharePoint site for access to all team members. Results: The drafting of alternative stroke guidelines allowed for improved patient safety during our 27-hospital healthcare systems Covid surge. Care of multiple patients occurred outside normal critical care and stroke units with a decreased number of assessments for patients from the standard, pre-Covid and without increase safety events or adverse outcomes. The success of the alternative guidelines and this Covid effect on stroke care management not only helped our staff and patients during a time of need in safe care but also provided a new model of care for our stroke program leaders to consider and implement across our organizations.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Utilizing a Pediatric Disaster Coalition Model to Increase Pediatric Critical Care Surge Capacity in New York City.

A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).

Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital

The capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients. To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital. In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016. Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate. Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%. Our estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.

Optimal policies of M(t)/M/c/c queues with two different levels of servers

This paper deals with optimal control points of M(t)/M/c/c queues with periodic arrival rates and two levels of the number of servers. We use the results of this model to build a Markov decision process (MDP). The problem arose from a case study in the Kelowna General Hospital (KGH). The KGH uses surge beds when the emergency room is overcrowded which results in having two levels for the number of the beds. The objective is to minimize a cost function. The findings of this work are not limited to the healthcare; They may be used in any stochastic system with fluctuation in arrival rates and/or two levels of the number of servers, i.e., call centers, transportation, and internet services. We model the situation and define a cost function which needs to be minimized. In order to find the cost function we need transient solutions of the M(t)/M/c/c queue. We modify the fourth-order Runge–Kutta to calculate the transient solutions and we obtain better solutions than the existing Runge–Kutta method. We show that the periodic variation of arrival rates makes the control policies time-dependent and periodic. We also study how fast the policies converge to a periodic pattern and obtain a criterion for independence of policies in two sequential cycles.

Structure, stratigraphy, and eruption dynamics of a young tuff ring: Hanauma Bay, O’ahu, Hawai’i

The Hanauma Bay–Koko Head complex is one of several young volcanic landforms along the Koko fissure, in southeastern O’ahu. The Hanauma Bay region of the complex comprises two nested tuff rings, inner and outer Hanauma Bay, and multiple smaller vents. The internal structure of the inner tuff ring, well exposed due to subsequent breaching by the ocean and wave erosion, indicates that it formed during a minimum of five distinct phases of deposition that produced five mappable units. Significant inward collapses generated major unconformities that separate the units exposed in the inner wall. The planes of failure are cut by narrow steep-walled, locally overhung channels and gullies, suggesting that the collapse events were each followed by short time breaks during which the deposits were eroded by rainfall runoff. Within each pyroclastic unit, there are many local slump scars and unconformities, suggesting that minor instability of the inner wall was a near-constant feature. From bedding sags and surge bed forms, it is apparent that the vent shifted at least twice during tuff ring growth. Ballistic blocks in the youngest unit indicate that the eruption overlapped in time with a separate eruption to the north, most likely to be that of the Kahauloa tuff ring 880 m away.

Influence of sea surface wind wave turbulence upon wind-induced circulation, tide–surge interaction and bed stress

A three-dimensional finite volume unstructured mesh model of the west coast of Britain, with high resolution in the coastal regions, is used to investigate the role of wind wave turbulence and wind and tide forced currents in producing maximum bed stress in the eastern Irish Sea. The spatial distribution of the maximum bed stress, which is important in sediment transport problems, is determined, together with how it is modified by the direction of wind forced currents, tide–surge interaction and a surface source of wind wave turbulence associated with wave breaking. Initial calculations show that to first order the distribution of maximum bed stress is determined by the tide. However, since maximum sediment transport occurs at times of episodic events, such as storm surges, their effects upon maximum bed stresses are examined for the case of strong northerly, southerly and westerly wind forcing. Calculations show that due to tide–surge interaction both the tidal distribution and the surge are modified by non-linear effects. Consequently, the magnitude and spatial distribution of maximum bed stress during major wind events depends upon wind direction. In addition calculations show that a surface source of turbulence due to wind wave breaking in shallow water can influence the maximum bed stress. In turn, this influences the wind forced flow and hence the movement of suspended sediment. Calculations of the spatial variability of maximum bed stress indicate the level of measurements required for model validation.

(P1-103) Utilization of a Pediatric Disaster Coalition as a Model for Regional Pediatric Disaster Planning

PurposeThere remains a lack of comprehensive pediatric emergency preparedness planning worldwide. A disaster or mass-casualty incident (MCI) involving pediatric patients could overwhelm existing pediatric resources within the New York City (NYC) metropolitan region. The NYC Department of Health and Mental Hygiene (DOHMH) recognizing the importance to plan for a MCI with a large number of pediatric victims, implemented a project (the Pediatric Disaster Coalition; PDC), to address gaps in the healthcare system to provide effective and timely pediatric care during a MCI.MethodsThe PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from the NYC pediatric/children's hospitals, DOHMH, Office of Emergency Management, and Fire Department (FDNY). Two committees addressed pediatric prehospital triage, transport, and pediatric critical care (PCC) surge capacities. They developed guidelines and recommendations for pediatric field triage and transport, matching patients' needs to resources, and increasing PCC Surge Capacities.ResultsSurge recommendations were formulated. The algorithm developed provides specific pediatric triage criteria that identify severity of illness using the traditional Red, Yellow, and Green categories plus an Orange designation for continual reassessments that has been adopted by FDNY that has trained > 3,000 FDNY EMS personnel in its use. Triaged patients can be transported to appropriate resources based on a tiered system that defines pediatric hospital capabilities. The Surge Committee has created PCC Surge Capacity Guideline that can be used by hospitals to create their individual PCC surge plans. 15 of 25 NYC hospitals with PCC capabilities are participating with PDC planning; 5 have completed surge plans, 3 are nea completion, and 7 are in development. The completed plans add 92 surge beds to 244 regularly available PICU beds. The goal is to increase the PCC surge bed capacity by 200 + beds.ConclusionsThe project is an effective, multidisciplinary group approach to planning for a regional, large-scale pediatric MCI. Regional lead agencies must emphasize pediatric emergency preparedness in their disaster plans.

(P1-78) Utilizing New York City Pediatric Disaster Coalition Site Visits to Create Hospital Pediatric Critical Care Surge Plans

PurposeThe New York City (NYC) Department of Health and Mental Hygiene (DOHMH) has supported a federal grant establishing a Pediatric Disaster Coalition (PDC) comprised of pediatric critical care (PCC) and emergency preparedness consultants from major city hospitals and health agencies. One of the PDC's goals was to develop recommendation for hospital-based PCC surge plans.MethodsMembers of the PDC convened bi-weekly and among other projects, developed guidelines for creating PCC surge capacity plans. The PDC members, acting as consultants, conducted scheduled visits to hospitals in NYC and actively assisted in drafting PCC surge plans as annexes to existing hospital disaster plans. The support ranged from facilitating meetings to providing draft language and content, based on each institutions request.ResultsNew York City has 25 hospitals with PCC services with a total of 244 beds. Five major hospitals have completed plans, thereby adding 92 PCC beds to surge capacity. Thirteen additional hospitals are in the process of developing a plan. The PDC consultants participated in meetings at 11 of the planning hospitals, and drafted language for 10 institutions. The PDC continues to reach out to all hospitals with the goal of initiating plans at all 25 PCC hospitals.ConclusionsProviding surge guidelines and the utilization of on-site PDC consultants was a successful model for the development and implementation of citywide PCC surge capacity planning. Visiting hospitals and actively assisting them in creating their plans was an effective, efficient and well received, method to create increased PCC surge capacity. By first planning with major hospitals, a significant increase of surge beds (92 or 38%) was created, from a minimal number of hospitals. Once hospitals complete plans, it is anticipated that there will be the addition of at least 200 PCC surge beds that can be incorporated in to regional city-wide response to pediatric mass-casualty incident.

The Averno 2 fissure eruption: a recent small-size explosive event at the Campi Flegrei Caldera (Italy)

The Averno 2 eruption (3,700 ± 50 a B.P.) was an explosive low-magnitude event characterized by magmatic and phreatomagmatic explosions, generating mainly fall and surge beds, respectively. It occurred in the Western sector of the Campi Flegrei caldera (Campanian Region, South Italy) at the intersection of two active fault systems, oriented NE and NW. The morphologically complex crater area, largely filled by the Averno lake, resulted from vent activation and migration along the NE-trending fault system. The eruption generated a complex sequence of pyroclastic deposits, including pumice fall deposits in the lower portion, and prevailing surge beds in the intermediate-upper portion. The pyroclastic sequence has been studied through stratigraphical, morphostructural and petrological investigations, and subdivided into three members named A through C. Member A was emplaced during the first phase of the eruption mainly by magmatic explosions which generated columns reaching a maximum height of 10 km. During this phase the eruption reached its climax with a mass discharge rate of 3.2 106 kg/s. Intense fracturing and fault activation favored entry of a significant amount of water into the system, which produced explosions driven by variably efficient water-magma interaction. These explosions generated wet to dry surge deposits that emplaced Member B and C, respectively. Isopachs and isopleths maps, as well as areal distribution of ballistic fragments and facies variation of surge deposits allow definition of four vents that opened along a NE oriented, 2 km long fissure. The total volume of magma extruded during the eruption has been estimated at about 0.07 km3 (DRE). The erupted products range in composition from initial, weakly peralkaline alkali-trachyte, to last-emplaced alkali-trachyte. Isotopic data and modeling suggest that mixing occurred during the Averno 2 eruption between a more evolved, less radiogenic stored magma, and a less evolved, more radiogenic magma that entered the shallow reservoir to trigger the eruption. The early phases of the eruption, during which the vent migrated from SW to the center of the present lake, were fed by the more evolved, uppermost magma, while the following phases extruded the less evolved, lowermost magma. Integration of the geological and petrological results suggests that the Averno 2 complex eruption was fed from a dyke-shaped shallow reservoir intruded into the NE-SW fault system bordering to the west the La Starza resurgent block, within the caldera floor.

The Holocene Pucón eruption of Volcán Villarrica, Chile: deposit architecture and eruption chronology

The Pucon eruption was the largest Holocene explosive outburst of Volcan Villarrica, Chile. It discharged >1.0 km3 of basaltic-andesite magma and >0.8 km3 of pre-existing rock, forming a thin scoria-fall deposit overlain by voluminous ignimbrite intercalated with pyroclastic surge beds. The deposits are up to 70 m thick and are preserved up to 21 km from the present-day summit, post-eruptive lahar deposits extending farther. Two ignimbrite units are distinguished: a lower one (P1) in which all accidental lithic clasts are of volcanic origin and an upper unit (P2) in which basement granitoids also occur, both as free clasts and as xenoliths in scoria. P2 accounts for ∼80% of the erupted products. Following the initial scoria fallout phase, P1 pyroclastic flows swept down the northern and western flanks of the volcano, magma fragmentation during this phase being confined to within the volcanic edifice. Following a pause of at least a couple of days sufficient for wood devolatilization, eruption recommenced, the fragmentation level dropped to within the granitoid basement, and the pyroclastic flows of P2 were erupted. The first P2 flow had a highly turbulent front, laid down ignimbrite with large-scale cross-stratification and regressive bedforms, and sheared the ground; flow then waned and became confined to the southeastern flank. Following emplacement of pyroclastic surge deposits all across the volcano, the eruption terminated with pyroclastic flows down the northern flank. Multiple lahars were generated prior to the onset of a new eruptive cycle. Charcoal samples yield a probable eruption age of 3,510 ± 60 14C years BP.

Is Efate (Vanuatu, SW Pacific) a result of subaerial or submarine eruption? An alternative model for the 1 Ma Efate Pumice Formation

AbstractThe Efate Pumice Formation (EPF) is a trachydacitic volcaniclastic succession widespread in the central part of Efate Island and also present on Hat and Lelepa islands to the north. The volcanic succession has been inferred to result from a major, entirely subaqueous explosive event north of Efate Island. The accumulated pumice-rich units were previously interpreted to be subaqueous pyroclastic density current deposits on the basis of their bedding, componentry and stratigraphic characteristics. Here we suggest an alternative eruptive scenario for this widespread succession. The major part of the EPF is distributed in central Efate, where pumiceous pyroclastic rock units several hundred meters thick are found within fault scarp cliffs elevated about 800 m above sea level. The basal 200 m of the pumiceous succession is composed of massive to weakly bedded pumiceous lapilli units, each 2-3 m thick. This succession is interbedded with wavy, undulatory and dune bedded pumiceous ash and fine lapilli units with characteristics of co-ignimbrite surges and ground surges. The presence of the surge beds implies that the intervening units comprise a subaerial ignimbrite-dominated succession. There are no sedimentary indicators in the basal units examined that are consistent with water-supported transportation and/or deposition. The subaerial ignimbrite sequence of the EPF is overlain by a shallow marine volcaniclastic Rentanbau Tuffs. The EPF is topped by reef limestone, which presumably preserved the underlying EPF from erosion. We here propose that the EPF was formed by a combination of initial subaerial ignimbrite-forming eruptions, followed by caldera subsidence. The upper volcaniclastic successions in our model represent intra-caldera pumiceous volcaniclastic deposits accumulated in a shallow marine environment in the resultant caldera. The present day elevated position of the succession is a result of a combination of possible caldera resurgence and ongoing arc-related uplift in the region.

An Improvised Oxygen Supply System for Pandemic and Disaster Use

Current disaster planning for pandemic influenza anticipates overwhelming numbers of patients in need of hospitalization. The anticipated use of extra, or "surge," beds is common in both hospital and community disaster response planning. In a pandemic of respiratory illness, supplemental oxygen will be a life-saving intervention. There are currently few options to provide these proposed surge beds with the necessary oxygen. A method of providing an improvised oxygen delivery system for use in a disaster was developed and tested. This system was designed to use readily available commercial materials to assemble an oxygen delivery system. The study consisted of a laboratory design, assembly, and testing of an improvised oxygen system. A liquid oxygen (LOX) Dewar container was used to supply oxygen systems built from inexpensive commercially available plastic tubing and fittings. The system will drive ventilators without significant pressure drop or ventilator malfunction. The final developed system will supply 30 patients with up to 6 L/min (l pm) oxygen each by nasal cannula from a single oxygen Dewar. An improvised system to deliver oxygen for patient beds or ventilator use can be easily assembled in the event of a disaster. This could be life-saving in the event of a pandemic of respiratory illness.

Creation of Surge Capacity by Early Discharge of Hospitalized Patients at Low Risk for Untoward Events

US hospitals are expected to function without external aid for up to 96 hours during a disaster; however, concern exists that there is insufficient capacity in hospitals to absorb large numbers of acute casualties. The aim of the study was to determine the potential for creation of inpatient bed surge capacity from the early discharge (reverse triage) of hospital inpatients at low risk of untoward events for up to 96 hours. In a health system with 3 capacity-constrained hospitals that are representative of US facilities (academic, teaching affiliate, community), a variety (N = 50) of inpatient units were prospectively canvassed in rotation using a blocked randomized design for 19 weeks ending in February 2006. Intensive care units (ICUs), nurseries, and pediatric units were excluded. Assuming a disaster occurred on the day of enrollment, patients who did not require any (previously defined) critical intervention for 4 days were deemed suitable for early discharge. Of 3491 patients, 44% did not require any critical intervention and were suitable for early discharge. Accounting for additional routine patient discharges, full use of staffed and unstaffed licensed beds, gross surge capacity was estimated at 77%, 95%, and 103% for the 3 hospitals. Factoring likely continuance of nonvictim emergency admissions, net surge capacity available for disaster victims was estimated at 66%, 71%, and 81%, respectively. Reverse triage made up the majority (50%, 55%, 59%) of surge beds. Most realized capacity was available within 24 to 48 hours. Hospital surge capacity for standard inpatient beds may be greater than previously believed. Reverse triage, if appropriately harnessed, can be a major contributor to surge capacity.

Phreatomagmatic volcanic hazards where rift-systems meet the sea, a study from Ambae Island, Vanuatu

Ambae Island is a mafic stratovolcano located in the northern Vanuatu volcanic arc and has a NE–SW rift-controlled elongated shape. Several hundred scoria cones and fissure-fed lava fields occur along its long axis. After many decades of quiescence, Ambae Island erupted on the 28th of November 2005, disrupting the lives of its 10,000 inhabitants. Its activity remained focused at the central (crater-lake filled) vent and this is where hazard-assessments were focused. These assessments initially neglected that maars, tephra cones and rings occur at each tip of the island where the eruptive activity occurred < 500 and < 300 yr B.P. The products of this explosive phreatomagmatic activity are located where the rift axis meets the sea. At the NE edge of the island five tephra rings occur, each comparable in size to those on the summit of Ambae. Along the NE coastline, a near-continuous cliff section exposes an up to 25 m thick succession of near-vent phreatomagmatic tephra units derived from closely spaced vents. This can be subdivided into two major lithofacies associations. The first association represents when the locus of explosions was below sea level and comprises matrix-supported, massive to weakly stratified beds of coarse ash and lapilli. These are dominant in the lowermost part of the sequence and commonly contain coral fragments, indicating that the loci of explosion were located within a reef or coral sediment near the syn-eruptive shoreline. The second type indicate more stable vent conditions and rapidly repeating explosions of high intensity, producing fine-grained tephra with undulatory bedding and cross-lamination as well as megaripple bedforms. These surge and fall beds are more common in the uppermost part of the succession and form a few-m-thick pile. An older tephra succession of similar character occurs below, and buried trees in growth position, as well as those flattened within base surge beds. This implies that the centre of this eruption was very near the coastline. The processes implied by these deposits are amongst the most violent forms of volcanism on this island. In addition, the lowland and coastal areas affected by these events are the most heavily populated. This circumstance is mirrored on many similar volcanic islands, including the nearby SW Pacific examples of Taveuni (Fiji), Upolu and Savai'i (Samoa), and Ambrym (Vanuatu). These locations are paradoxically often considered safe areas during summit/central-vent eruptions, simply because they are farthest from the central sources of ash-fall and lahar hazard. The observations presented here necessitate a revision of this view.

Ability of Regional Hospitals to Meet Projected Avian Flu Pandemic Surge Capacity Requirements

Hospital surge capacity is a crucial part of community disaster preparedness planning, which focuses on the requirements for additional beds, equipment, personnel, and special capabilities. The scope and urgency of these requirements must be balanced with a practical approach addressing cost and space concerns. Renewed concerns for infectious disease threats, particularly from a potential avian flu pandemic perspective, have emphasized the need to be prepared for a prolonged surge that could last six to eight weeks. The surge capacity that realistically would be generated by the cumulative Greater Dayton Area Hospital Association (GDAHA) plan is sufficient to meet the demands of an avian influenza pandemic as predicted by the [US] Centers for Disease Control and Prevention (CDC) models. Using a standardized data form, surge response plans for each hospital in the GDAHA were assessed. The cumulative results were compared to the demand projected for an avian influenza pandemic using the CDC's FluAid and FluSurge models. The cumulative GDAHA capacity is sufficient to meet the projected demand for bed space, intensive care unit beds, ventilators, morgue space, and initial personal protective equipment (PPE) use. There is a shortage of negative pressure rooms, some basic equipment, and neuraminidase inhibitors. Many facilities lack a complete set of written surge policies, including screening plans to segregate contaminated patients and staff prior to entering the hospital. Few hospitals have agreements with nursing homes or home healthcare agencies to provide care for patients discharged in order to clear surge beds. If some of the assumptions in the CDC's models are changed to match the morbidity and mortality rates reported from the 1918 pandemic, the surge capacity of GDAHA facilities would not meet the projected demand. The GDAHA hospitals should test their regional distributors' ability to resupply PPE for multiple facilities simultaneously. Facilities should retrofit current air exchange systems to increase the number of potential negative pressure rooms and include such designs in all future construction. Neuraminidase inhibitor supplies should be increased to provide treatment for healthcare workers exposed in the course of their duties. Each hospital should have a complete set of policies to address the special considerations for a prolonged surge. Additional capacity is required to meet the predicted demands of a threat similar to the 1918 pandemic.

噴出物から推定した有珠山１６６３年噴火の推移

The AD1663 ejecta of Usu volcano, western Hokkaido, northern Japan, have a thickness of approximately 200, cm and are divisible into 7 units on the eastern foot of Usu volcano. The basal deposit, Unit-A, is composed of fine-grained, poorly sorted pumice and ash with well-developed stratification. It contains base surge beds near the sources, and is interpreted as phreatomagmatic in origin. Unit-B is typical in many respects of the product of plinian activity. It is characterized by coarse grain size and wide dispersal, combined with low lithic contents and poor development of internal stratification. This fallout deposit (Usu-b tephra) can be seen in the eastern regions of Usu volcano, and has a thickness of about 4 cm at 200 km from the vent. Unit-C, Unit-E, Unit-F, and Unit-G have characteristics that are satisfactorily interpreted as a consequence of phreatomagmatic activity : fine grain size near source, poor sorting, well-developed stratification and base surge bedforms. Unit-D is typical of phreatic deposits, being composed largely of non-juvenile lithic fragments.According to historical records, the eruption was preceeded by earthquake swarms for 3 days from August 13, 1663. The first eruption (Unit-A) occurred on August 16, followed by an eruption associated with a large amount of pumice and ash (Unit-B) on August 17. The explosive eruptions lasted approximately 20 days.The petrographic properties of the plinian product differ considerably from those of the phreatomagmatic products. The pumice clasts of Unit-B contain abundant glass and little phenocryst (plagioclase, orthopyroxene, and hornblende). The glass has a relatively high refractive index (n = 1.490-1.492) and a low SiO2 content. Orthopyroxene in Unit-B has a relatively high refractive index (γ = 1.735-1.740) and low Mg#. The phreatomagmatic products are rich in massive glass. This glass has a relatively low refractive index (n = 1.475-1.490) and a high SiO2 content, with values differing among horizons. The compositional diversity of the 1663 products indicates the existence of some magma. Presumably, their mixing triggered the 1663 eruption of Usu volcano.