Strategies to improve pediatric disaster surge response: Potential mortality reduction and tradeoffs

Objective: To estimate the potential for disaster mortality reduction with two surge response strategies: 1) control distribution of disaster victims to avoid hospital overcrowding near the scene, and 2) expand capacity by altering standards of care to only “essential” interventions. Design: Quantitative model of hospital mortality. Setting: New York City pediatric intensive care unit and non–intensive care unit pediatric hospital capacity and population. Measurements and Main Results: Mortality was calculated for a hypothetical sudden disaster, of unspecified mechanism, assuming 500 children per million population need hospitalization, including 30% severely ill/injured warranting pediatric intensive care unit care, with high (76%) predisaster hospital occupancy. Triage rules accommodated patients at lower levels of care if capacity was exhausted. Specified higher relative mortality risks were assumed with reduced levels of care. In a pessimistic baseline scenario, hospitals near the disaster scene, considered to have 20% of regional capacity, were overcrowded with 80% of the surge patients. Exhausted capacity at overcrowded hospitals near the scene would account for most of the 45 deaths. Unused capacity would remain at remote facilities. If regional surge distribution were controlled to avoid overcrowding near the scene, then mortality would be reduced by 11%. However, limited pediatric intensive care unit capacity would still require triage of many severe patients to non–intensive care unit care. Instead, if altered standards of care quadrupled pediatric intensive care unit and non–intensive care unit capacity, then mortality would fall 24% below baseline. Strategies 1 and 2 in combination would improve mortality 47% below baseline. If standards of care were altered prematurely, preventable deaths would occur. However, additional simulations varying surge size, patient severity, and predisaster occupancy numbers found that mortality tradeoffs would generally favor altering care for individuals to improve population outcomes within the range of federal planning targets (500 new patients/million population). Conclusion: Quantitative simulations suggest that response strategies controlling patient distribution and expanding capacity by altering standards of care may lower mortality rates in large disasters.