Improving Surge Capacity For Biothreats: Experience From Taiwan

Improving Surge Capacity for Biothreats: Experience from Taiwan Fuh-Yuan Shih, MD, Kristi L. Koenig, MD

Abstract This article discusses Taiwan’s experience in managing surge needs based on recent events, including the 1999 earthquake, severe acute respiratory syndrome in 2003, airliner crashes in 1998 and 2001, and yearly typhoons and floods. Management techniques are compared and contrasted with U.S. approaches. The authors discuss Taiwan’s practices of sending doctors to the scene of an event and immediately recalling off-duty hospital personnel, managing volunteers, designating specialty hospitals, and use of incident management systems. The key differences in bioevents, including the mathematical myths regarding individual versus population care, division of stockpiles, the Maginot line, and multi-jurisdictional responses, are highlighted. Several recent initiatives aimed at mitigating biothreats have begun in Taiwan, but their efficacy has not yet been tested. These include the integration of the emergency medical services and healthfacility medical systems with other response systems; the use of the hospital emergency incident command system; crisis risk-communications approaches; and the use of practical, hands-on training programs. Other countries may gain valuable insights for mitigating and managing biothreats by studying Taiwan’s experiences in augmenting surge capacity. ACADEMIC EMERGENCY MEDICINE 2006; 13:1114–1117 ª 2006 by the Society for Academic Emergency Medicine Keywords: surge, surge capacity, biothreat, bioevent, Taiwan

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aiwan has experienced a multitude of disasters in recent times, including yearly typhoons and floods, a huge earthquake in 1999,1 airplane crashes in 1998 and 2001,2 and severe acute respiratory syndrome (SARS) in 2003.3 These mass casualty or complex incidents created demands that challenged the medical and public health infrastructure. Emergency medical preparedness programs evolved in response to medical surge needs for these disasters. Several approaches have been adopted to expand medical-care delivery systems aimed at managing increased volumes of patients with unusual medical needs. Medical response plans in Taiwan and many other Asian countries (because of their similar cultural backgrounds and social norms) have several characteristics that differ from plans in the United States. These include the following:

From the Emergency Department of National Taiwan University Hospital (F-YS), Taipei, Taiwan; and the University of California at Irvine, School of Medicine (KLK), Orange, CA. Received June 19, 2006; revision received June 27, 2006; accepted June 30, 2006. Presented at the Academic Emergency Medicine Consensus Conference, ‘‘Establishing the Science of Surge,’’ San Francisco, CA, May 17, 2006. Address for correspondence and reprints: Kristi L. Koenig, MD. E-mail: [email protected].

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ISSN 1069-6563 PII ISSN 1069-6563583

1. The plans require immediate dispatch of hospitalbased physicians to incident sites without first assessing whether the scene has been secured or whether physician care on the scene would improve patient outcomes.4,5 The emergency medical services (EMS) system of Taiwan was established in 1995, and the responding firefighters were trained to be emergency medical technicians (EMTs).6 Nearly half of the EMTs are EMT-I trained (60 hours training), and the remainder are EMT-II trained (264 hours training). Despite this, people believe that physicians at the scene can provide better medical care than can firefighter–EMTs. There is an expectation from both the public and the politicians that physicians will report to the scene of an incident after a media call for help. Although some physicians may possess the experience and training to improve scene triage and provide definitive medical care when indicated at an event scene, many hospital physicians lack the requisite skills in scene safety and austere trauma care. In addition, when personnel from the emergency department (ED) of a smaller hospital are deployed to the scene, the hospital then may lack adequate capacity to receive patients. Requests for physician assistance at the scene also can be confusing when the frontline of an event is obscure, as for example in the case of a biothreat. 2. The plans tend to call for all off-duty personnel to report immediately to the hospital.7 Although this

ª 2006 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2006.06.044

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procedure can generate adequate human resources for the first few hours, it can prematurely deplete personnel resources in a prolonged emergency, because there is no backfill to relieve the first wave of staff. The time curve of casualty numbers found and treated after the Chi-Chi earthquake in 1999 (Figure 1) is available because of a requirement that health care workers report casualty encounters to the central government. The curve illustrates the effects of a procedure that calls for all available personnel to report to work immediately after a disaster. The data show that patient treatment dips precipitously 24 hours after the event. It is probable that this occurred because most of the rescue workers and medical personnel were exhausted after working continuously for a prolonged period, so operations were temporarily shut down. 3. The plans rely on a substantial number of volunteers responding to the surge demand. There is a belief that there will be many volunteers during disasters, and it is socially inappropriate to refuse their participation.2 Functions filled by volunteers include provision of psychological support, transportation, and supplies needed for activities of daily living. For disasters that are familiar to civilians such as earthquakes, typhoons, or multivehicle traffic collisions, a simple call from the media can activate thousands of volunteers. The situation changes when the hazards are exotic and substantial perceived risk exists for the responders.8 For example, in the SARS outbreak in Taiwan in 2003, when a community hospital was isolated because of the internal spread of disease, only dozens of people volunteered despite a vigorous countrywide government-run campaign.8 Some surveys predict that the same phenomenon will happen in radiation and hazardous material (hazmat) incidents in Taiwan.9 4. The plans usually designate specialty receiving centers.3 Because it is easier and more cost-effective to provide equipment and personnel training to a limited number of hospitals, specialty hospitals are designated in some cities for natural disasters, multiplecasualty incidents, hazmat incidents, radiation accidents, and biohazard events. Medical societies embrace this policy because these designated hospitals are the only ones required to maintain training and equipment. This approach is problematic, however, because it does not account for self-presentation of victims after a disaster or emergency to a nearby facility, rather than a designated one. This is especially true for an emerging infectious-disease scenario.10 5. The plans tend to lack the necessary functionalarea expertise for a robust incident command structure and overemphasize clinical skills, especially for chemical- biological- radiological-nuclearexplosive (CBRNE) events. Medical and health infrastructures are poorly organized for an emergency situation. Most of the command structures are staffed by experts from the medical profession, whereas the logistics, administration and finance, and planning personnel are not activated.11 For a familiar and short-lasting hazard, such a command structure has been shown to be effective; however, for an unfamiliar and long-lasting event, logistics support within such a command structure usually is insufficient.

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Figure 1. Casualty flow after 1999 Taiwan earthquake.

A biothreat is different from other disasters in several ways: it is usually insidious in onset with a covert origin; it is relatively slow at first but progressively escalating; and victims require unique laboratory and epidemiologic investigations and may not be easily recognized. Countermeasures that successfully augment medical capacity and capability in other hazards may not be effective against this threat. There are several mathematical myths inherent in many response plans: 1. The myth of simple multiplication of individual care. Mathematically, one times one thousand equals one thousand times one, but separate care for one thousand individual victims is not equivalent to population care for one thousand people at a time. We tend to manage multiple-casualty incidents with the same model used for a single trauma patient by simply providing an extraordinary number of responders. In fact, the mainstay of many emergency plans is to summon as many responders as possible. This may be effective in some limited-scale events, but in more complicated situations such as SARS, the logistics for individual care escalate exponentially when casualty numbers increase, and the system collapses if we fail to adapt and provide a population-care model.12,13 2. The myth of simple division of a stockpile. If there are one thousand apples for one hundred people, mathematically, each person will have ten apples. However, in reality, the efficiency of dispatch determines who gets the apples and how many. Resource management is more than simple division. Too often we focus on how many resources we have in a pharmaceutical stockpile, coupled with the number of victims who require medications, but we forget that the supply management is the determinant factor.12,13 3. The myth of the Maginot Line. In the wake of World War I, the French constructed the Maginot Line, a line of concrete fortifications, tank obstacles, machine-gun posts, and other defenses along its borders with Germany and Italy. They believed that this fortification would provide time for their army to mobilize and would compensate for their relatively small numbers, but this plan failed. Likewise, despite lack of a comprehensive strategy, we believed that a fortification line of specialty receiving centers, experts, and specialized laboratories would provide time for responders to mobilize in the event of an attack and would also compensate for numerical weakness. For example, during the SARS epidemic in Taiwan, a failure in a single

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IMPROVING SURGE CAPACITY FOR BIOTHREATS: EXPERIENCE FROM TAIWAN

hospital resulted in community-wide spread of the disease to the entire metropolitan area. The infrastructure of the health system should be fortified and adequate training and equipment provided, especially for general care, casualty transportation systems, surveillance, sanitation, public education, crisis risk communication, and information technology.14 4. The myth of multi-jurisdictions. In a cage, there are birds, rabbits, and monsters. In total, there are 12 heads and 41 legs. Can we determine the numbers of birds, rabbits, and monsters? We cannot, because we do not know how many heads and legs one monster has. When a complex event occurs, multiple disciplines may be called into action, including public safety, public health, human resources, and emergency management. Because these communities do not routinely work together, they are unfamiliar with each other’s procedures. In emergency response, the monsters, which are the untrained, uncontrolled, and unreliable responders, will cause the system to become paralyzed. Other hazards include the self-proclaimed experts and the omnipotent media, which can be more destructive than well-meaning people who simply are ignorant.15

an all-hazards approach that focuses on the operational skills that health care providers are asked to perform after an incident. Through these efforts, Taiwan plans to build a robust and efficient framework for health authorities that maximizes their ability to provide adequate medical evaluation and care for all kinds of mass-casualty and complex incidents that exceed the normal medical capacity and capability. This will be a critical component of the community safety network. CONCLUSIONS Taiwan is a country with vast experience in managing disasters and that has much knowledge to share regarding how to enhance surge capacity for a bioevent. Although new initiatives remain untested, other systems can gain valuable insights by studying the pros and cons of various approaches to increasing surge capacity, the mathematical myths for a biothreat, and the actions initiated by Taiwan after the SARS outbreak and in the face of the looming threat of avian influenza. References

Facing the potential challenges from avian influenza, some actions have been adopted based on the experience of SARS. In comparison to other Asian countries, the medical resources in Taiwan are luxurious. In Taipei City, population 2.6 million, there are 13,000 hospital beds, and 30% of them are typically unoccupied. Despite these abundant resources, coordination between systems needs improvement. To augment the surge capacity and capability of the medical system, several projects have recently been implemented: 1. The out-of-hospital and health care facility medical systems are being integrated with other emergency response systems, including hazmat and nuclear accident and bioterrorism medical care systems. Medical resources can be shared by different hospitals to optimize care of patients received from the field. 2. Hospitals are required to adopt an emergency incident command system that balances command, operations, and logistics in emergencies. No hospital is immune to disasters, so basic medical preparedness for all hospitals is mandatory per new hospital-accreditation criteria. 3. Crisis and risk communication training is provided for appropriate personnel. CBRNE is exotic for this community, so public concern and confusion can paralyze the health care system. A robust and honest risk-communications program that directs people to medically appropriate care can ease the risk to the public and preserve the health care system for those who truly need medical attention. 4. Practical, hands-on training is provided for medical and health responders. The objective of the training is to ensure that responders will be able to competently and efficiently perform their jobs according to the plan and is not to convert health care providers into instant experts. The training programs have shifted their focus from biological incidents to

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