Israel has developed robust hospital surge capacity through centralized coordination of resources, standardized procedures, and regular drills. Key aspects of their system include nationally monitoring capacity, designating expandable facilities, coordinating EMS with hospitals, and clearing emergency departments promptly. While the US has made efforts to coordinate response through frameworks and organizations, it faces unique challenges due to its federal system, staffing shortages, and lack of national surge monitoring.

1. Hospital Surge Capacity :
Lessons from Israel
2LT Laura Cookman
Jim Holliman, M.D., F.A.C.E.P., Program Manager
Afghanistan Health Care Sector Reachback Project
Center for Disaster and Humanitarian Assistance Medicine
(CDHAM)
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences (USUHS)
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.
February 2010

2. Lecture Objectives
• To define surge capacity and surge capability
• To outline the basic principles of surge capacity
including the 3 S’s and patterns of sudden impact
versus prolonged events
• To outline Israel’s disaster response plans with
suggestions of what can be applied to the United
States (U.S.)
• To identify challenges facing the U.S. in disaster
planning

3. Definition of Surge by Webster’s
Dictionary 1
“to rise suddenly to an excessive or
abnormal value”

4. 2
Definition of Surge Capacity
“a healthcare system’s ability to manage a
sudden or rapidly progressive influx of
patients within the currently available
resources at a given point in time” :
American College of Emergency Physicians
(ACEP)

5. 3
Definition of Surge Capability
“refers to the ability to manage patients
requiring unusual or very specialized
medical evaluation and care” :
U.S. Department of Health and Human
Services (HHS)

6. U.S. Department of Homeland
Security (DHS) Defined Critical
Infrastructure and Key Resources
• Agriculture and Food • Energy
• Banking and Finance • Government Facilities
• Chemical • Healthcare and Public Health
• Commercial Facilities • Information Technology
• Communications • National Monuments and Icons
• Critical Manufacturing • Nuclear Reactors, Materials & Waste
• Dams • Postal and Shipping
• Defense Industrial Base •Transportation Systems
• Emergency Services • Water

7. DHS Critical
Infrastructure and Key
Resources Sectors

8. The Basic Problem for Disaster
Planning :
Demand > Supply

9. The 3 S’s
From Koenig and
Schultz’s Disaster
Medicine, 20104
(And maybe there should be a 4th “S”: System)

10. Surge Capacity
Sudden Impact Event Prolonged Event
Earthquake, hurricane, bomb, chemical attack Pandemic Influenza, Bioterrorist attack,
Can lead to… outbreak
Staff
Stuff
Structure
System

11. Sudden Impact Event versus
Prolonged Event
Sudden Impact Event Prolonged Event
Earthquake, hurricane, Pandemic Influenza,
bomb, chemical Bioterrorist attack
From Barbisch and
Koenig5

12. Israel
Background Information6
• Area : 20,330 sq. km (7,850 sq. miles)
• Population : 7.23 million
• Similar to New Jersey in size &
population
Key Differences vs. U.S.:
• Health insurance for all residents
• One national Emergency Medical Service (EMS)
– Magen David Adom (“Red Star of David”)
• No military hospitals
– General hospitals treat both civilian and military casualties
• History of repetitive attacks on country
– Since independence in 1948 : 7 major conflicts fought
– Terrorist suicide bombs, rocket attacks, etc.

13. The Middle East

15. Excellent Summary Reference
Peleg K, Kellermann A. Enhancing hospital
surge capacity for mass casualty events. JAMA
2009; 302(5): 565-567.

16. Peleg and Kellerman’s List of Key
Planning Principles 7
1. Nationally coordinate 6. Avoid ED crowding and
resources. promptly clear EDs.
2. Establish goals and prepare 7. Reinforce medical
standard operation workforce and designate
procedures. adjoining site to treat pts
3. Constantly monitor surge with minor injuries.
capacity. 8. Designate a triage
4. Design expandable hospital.
facilities. 9. Practice, practice, practic
5. Coordinate EMS with e.
healthcare facilities.

17. 1. Nationally Coordinate
Resources
• Supreme Health Authority
– Defines and enforces the nation’s health
policies for disasters and mass casualty
events
• Result of having centrally coordinated
authority is clear command, control and
communication
• Stockpiles prepositioned at each hospital
and some national distribution centers

18. 2. Establish goals and prepare
standard operation procedures
(SOPs)
• National standard
– Every hospital must be
prepared to care for
additional 20 % of normal
hospital capacity
• SOPs
– Based on national doctrine
written by Israeli Ministry of
Health (MOH)
– Uses internal and
external call-up systems
– Standard procedures
for each hospital nationally

19. 3. Constantly monitor surge
capacity
• Standard format
• Daily report to MOH
– Inpatient and
Intensive Care Unit
(ICU) occupancy by
specialty
– Hospital’s overall
bed capacity
– Number of patients
receiving ventilator
support out of ICU

20. 4. Design Expandable Facilities
• Capability to quickly expand in Mass
Casualty Event (MCE)
Edith Wolfson Medical Center’s
Basement 500 Bed Expansion
Emergency Department

21. Examples of expandable
facilities
Left : Rambam Hospital, Haifa, Israel
Right : Sheeba Tel HaShomer Hospital,
Tel Aviv

22. 5. Coordinate Emergency Medical
Services (EMS) with healthcare
facilities
• EMS coordinated by national
and regional command &
control centers
– Command and control center
notifies the hospitals closest to
event
• Distributes severely injured
casualties among several
hospitals
• EMS liaison at each
receiving hospital

23. 6. Avoid Emergency Department (ED)
crowding and promptly clear EDs
• Israeli hospitals aim to keep ED clear
• No boarding
• In Israel it takes 10-15 minutes to CLEAR ED after MCE
• Nearest hospitals notified by EMS
Tel Aviv Sourasky
Medical Center

24. 7. Reinforce medical workforce and
designate adjoining site to treat
patients with minor injuries
• Nonemergency
physicians and other
health care providers
report to staging area
next to ED
• Patients with minor
injuries and psych
trauma placed in
temporary walk-in clinic
in close proximity to ED

25. 8. Designate a triage hospital
• When casualties overwhelm resources,
the hospital stops functioning as an
admitting hospital and converts to a
triage hospital

26. 9. Practice, practice, practice
• Annual Drills : Nationally coordinated
• MOH determines scope, type and timing
• Evaluators at each hospital
• After action review (AAR) following drill

27. Other Lessons from Israel
• Maintenance of outdated ambulances as
“back-up” vehicles for MCE’s
• Extensive use of case simulation training
for EMS personnel
• Armored ambulances

28. Israeli EMS Simulation Training
Simulation Training Center at Sheeba Medical
Center in Tel Aviv

29. Israeli Armored Ambulances
Armored Corps Museum, New MDA armored
Latrun, Israel ambulance (2010)

30. Application of the Israeli lessons
learned to the United States

31. Application to U.S.:
1. Nationally coordinate resources
• National Response Framework (NRF)8
– Guide to how the Nation conducts all-hazards response
– Gives authority to organizations
– 15 Emergency Support Functions (ESFs)
• ESF # 8 : Public Health and Medical Services; Department of Health and
Human Services (HHS)
• National Disaster Medical System (NDMS)5
– Partnership between Department of Health and Human Services
(HHS), Departments of Defense (DOD), Veterans Affairs (VA), Federal
Emergency Management Agency (FEMA)
– Coordinating agency is HHS
– 3 primary missions: field medial response, patient transport, and
definitive care
• Strategic National Stockpile (SNS)
– Designed to supplement and re-supply state and local governments
with medical material supplies
– Federal Medical Stations : designed to provide for 250 non-acute and
special needs patients over 30 days

32. Application to the U.S.:
1. Nationally coordinate resources
(continued)
• However must consider…
– State sovereignty : U.S., unlike Israel, has 50
sovereign states
– Communication : Different organizations must
learn to communicate with one another
• New Idea :
– Give authority to members of the organizations
that are coordinating with other organizations
– Instead of DOD calling the Pentagon with HHS’s
request, have the Pentagon send a DOD member
with authority to allocate Pentagon resources

33. Application to the U.S.:
2. Establish goals and prepare
SOPs
• Establish goals
– No national standard for surge capacity
– Blanket 20 % for all hospitals may not be
appropriate for U.S. with diverse
geographical and population distribution
– Resources / needs should be assessed

34. Application to the U.S.:
2. Establish goals and prepare
SOPs (continued)
• Prepare SOPs :
– Joint Commission does some of this, however broad.
• Plan must contain 4 components of Comprehensive Emergency
Management (Mitigation, Preparedness, Response, Recovery)
• Must include hospital emergency incident command system (HEICS)
• Hospitals required to test emergency management plan 2x / year either in
response to actual emergency or planned exercise
• Must conduct at least one exercise / year that includes an influx of actual or
simulated patients
• If defined role in the community, must participate in at least 1 community
exercise a year (table top ok)
• Planned activities must be based on hazard vulnerability analysis
• Evaluate key components
• Identify strengths / weaknesses
– More guidance on SOPs ; no JCAHO requirement for surge capacity
– Tabletops are helpful, however actual live drills should be conducted
regionally every few years

35. Application to the U.S.:
3. Constantly monitor surge
capacity
• No national requirement for hospitals to report capacity
– Exceptions
• Federal hospitals
• ICU beds : if all ICU beds are closed then ED may go on diversion
• Absolutely essential to know what resources are in case
of a disaster; once the disaster happens it is too late to
determine surge capacity of nearest hospitals
• Develop National Capacity Monitoring Tool
– Medical Capability Assessment and Status Tool (MCAST)
• Sponsor federal and non-profit hospitals to report capacity
• Under development
– Record capacity status of each hospital so that if an event happens
patient delivery can be coordinated based on status

36. Application to the U.S.:
4. Design Expandable Facilities
• ED Design Guide by ACEP9
– Decontamination shower / area addressed but no room allocated
for “surge”
• Structure Lacking
– 1990 to 1999 hospitals lost 103,000 staffed medical-surgical beds
& 7,800 ICU beds10
– 2001 study : 38 % ED directors reported doubling up patients in
exam rooms and 59 % reported using hallway stretchers11
– Must address staff issue also; empty beds do not take care of
patients
• In U.S. there is limited space and financial resources
– Adjust existing structures rather than build new structures
– Use of outside facilities i.e., schools, churches12
– Hospitals can work together: share resources and capability
status in case of a disaster

37. Application to the U.S.:
4. Design Expandable Facilities (continued)
• An example of a
federal, a military, and a
private hospital working
together13
– In Bethesda, Maryland :
National Naval Medical
Center (NNMC), Suburban
Hospital Healthcare System
(SHHS), and the National
Institutes of Health Clinical
Center (NIHCC)
– Have conducted 4 complex
drills to test
communication, coordinatio
n, planning, and educational
efforts
From Henderson et al

38. Application to the U.S.:
5. Coordinate EMS with the Healthcare
Facilities
• “EMS system models in the U.S. are numerous and
varied making a fully encompassing description
impossible”14
• Governmental and privately supported
• Most coordinated by state or region
– No national coordination
• Attempt made to distribute severely injured casualties
by chief EMS officer on site
– However no national surge monitor (unsure of what area
hospitals’ capacities are)
• No EMS liaison at each hospital
– This could benefit U.S. system

39. Application to the U.S.:
6. Avoid ED crowding and promptly clear
EDs
• Over ½ of all EDs are at or over capacity
– National Hospital Survey 200715 : 65 % of urban hospitals at or
above; 73 % of teaching hospitals at or above
• Ambulance Diversion
– 56 % of urban and 64 % of teaching hospitals have been on
ambulance diversion in past year
– 13 % of urban hospitals have spent 20 % or more time on
diversion
• Boarding is a Big Problem in U.S.
– 22 % of patients in emergency department had already been
admitted but were waiting for an inpatient bed11
– Real world example: Dr. Jim Holliman while working at Hershey
Medical Center in Hershey, Pennsylvania reported for a day
shift and of the 45 available beds in the ED, 42 were occupied
by already admitted patients

40. Application to the U.S.:
6. Avoid ED crowding and promptly clear
EDs (continued)
• How can the U.S. handle a surge of
patient’s if we operate at or above
capacity on a daily basis ?
• Need solutions for ED crowding
• Must be a hospital approach and
therefore a hospital priority
– Patients admitted to inpatient services
should be held and cared for in an inpatient
setting and not in the ED (“duh”)

41. Application to the U.S.:
7. Reinforce medical workforce and designate
adjoining site to treat patients with minor injuries
• Reinforce medical workforce
– Staff already in short supply
• 116,000 RN vacancies as of December 200615 with projected
400,000 by 2020
• 55 % of hospitals experienced gaps in specialty coverage for the ED
– Increased difficulty maintaining physician ED call coverage
– More than a third of hospitals now pay extra for some physician
specialty ED call coverage
– Coverage issues are most prevalent in orthopedics and
neurosurgery
– Disaster plans may erroneously assume 100 % attendance of
staff during disaster
• The percent of healthcare workers who show up depends n their
perceived risk to themselves and their families
• Adjoining site
– Several disaster plans contain a plan for this and recognize
the importance of having separate area to treat patients

42. Application to the U.S.:
8. Designate a triage hospital
• Not done in the U.S.
• Emergency Medical Treatment and Labor Act
(EMTALA)
– Est. 1986; Federal law that requires anyone coming to an
emergency department to be stabilized and treated,
regardless of citizenship, legal status or ability to pay
– Every patient presenting to ED wishing to be treated
must be seen and evaluated; only if stable or written
consent can they be transferred
– Agency for Healthcare Research and Quality (AHRQ)16 :
“Recommendation : Federal officials should specifically
address EMTALA-related issues, rather than waiting for
a mass casualty "test case".”
– This needs to be clarified before a MCE

43. Application to the U.S.:
9. Practice, practice, practice
• Per the Joint Commission’s
requirements 2 drills done per year
• 1 has to involve the community however
this can be a table top
• Broader multi-institution regional drills
ought to be conducted more frequently

44. Unique Planning Challenges
for the U.S.
1. 50 Sovereign states
2. “Staff,” “Structure,” and “Stuff” shortages
3. Public / private hospitals
4. Uninsured patients
5. Financial constraints
6. No national surge capacity monitoring
system
7. Voluntary and not mandatory
8. No frequent repetitive domestic events

45. 1. 50 Sovereign States
• 50 sovereign states within United States
• Medical and nursing licensing is state
based
• Requires coordination of
federal, regional and state resources
• Activation of federal resources and
National Guard dependent on state
governor

46. 2. “Staff,” “Structure,”
“Supply” Shortages
• Structure
– Majority of hospitals function at or greater than capacity (AHC 2007
survey)
– 1993 to 2003 : ED visits increased 26 % however number of EDs decreased
by 14 %. National survey of 250 EDs : 28 % of ED directors reported
doubling up patients in exam rooms and 59 % of directors reported using
hallways as patient care areas
– Ambulances on diversion
• Staff
– Nursing shortage: as of December 2006, hospitals had an estimated
116,000 nurse vacancies
– Approximately 55 % of EDs have gaps in specialty coverage (esp.
orthopedics and neurosurgery)
• Supply
– “Just-in-time” basis
– Expensive to stock and keep updated excess supplies
Problem: “Disasters are local” with an “erosion” of hospital capacity

47. 3. Public / Private Hospitals
• Large, complex healthcare system(s) in
the United States
– Nonprofit
– Private for-profit
– Government
• Generally, poor communication between
facilities
• No national requirements to develop
integrative disaster plans or to report
surge capabilities (with exceptions)

48. 4. Uninsured patients
• In U.S. unlike Israel health insurance is a
privilege and not a right
• Over 43 million U.S. residents under 65 years old
lack health coverage17
– $99 billion spent in 2001 for uninsured
• Included out of pocket expenses, insurance payments if
insured for part of the year, worker’s compensation, charity
– $30 billion annually to compensate hospitals and
clinics for services provided to the uninsured (IOM)
– $5 billion annually donated by physicians

49. 5. $$$$$
• Uninsured driving up healthcare costs
• Money not being allocated specifically
for surge
• Much of healthcare expenses related to
behavioral problems
(obesity, violence, smoking, driving
while intoxicated, etc.)

50. 6. No national surge capacity
monitoring system
• Unlike Israel only federal hospitals are
required to report hospital surge
capacity daily

51. 7. Voluntary not mandatory
• No national requirement for surge
capacity
• Joint Commission : has several
requirements for hospitals but very
general

52. 8. No frequent repetitive
domestic events
• Although the U.S. has had several MCE
including 9/11 and Hurricane Katrina, it is
not at the same frequency as Israel
• Unfortunately we become complacent
with day-to-day activity
• Often takes a disaster to motivate
change

53. One Lesson Israel Could Learn
from the U.S.
• Better security and “chemical proofing” of
major EMS dispatch and communication
facilities
Tel Aviv MDA Dispatch Center with open
unguarded doors

54. IPRED Conference
• International Preparedness and Response to
Emergencies & Disasters
• Tel Aviv, Israel
• 11 to 14 January 2010
• Organized by the State of Israel Ministry of Health and
the Israeli Defense Forces Home Front Command
• Over 750 attendees
• International Attendance : 30 countries
– Israel, U.S., Germany, U.K., Italy, Kenya, Jordan, etc.

55. IPRED Conference Hall

56. Orange Flame Drill 4
• National project held every 2 years
• Simulated bioterrorism event
• Integrates all regional components of the medical and
interface agencies that cope with such an event in the
first 48 hours from its detection
• Participating regional institutions in 2010 included :
– 3 acute care hospitals, 14 civilian and 3 military primary care
clinics, the Regional Health District bureau, EMS services,
police force, Home Front Command district, Local Municipalities
and additional first responders
• Participation of the IPRED delegates

57. Orange Flame Drill 4
• This year  smallpox outbreak affecting
~1000 people + isolation and treatment of
~20,000 people + national vaccination
campaign

58. Day 1
• Detection Phase
– HMO clinic
• Magen David Adom (EMS) control center
• Outbreak Phase
– Wolfson Medical Center

59. Detection Phase

60. Magen David Adom

61. Magen David Adom

62. Outbreak Phase
Wolfson Medical Center, Tel Aviv

63. Outbreak Phase

64. Outbreak Phase

65. Day 2
• International Press Conference
• Operation of Centers for Mass
Immunization and Prophylaxis

66. International Press Conference

67. Mass Prophylaxis

68. Mass Prophylaxis

69. Summary of Lessons the U.S. can learn
from Israel regarding surge capacity…
1. National Coordination : absolutely key; ensure clear communication and give
individuals from national organizations that are communicating with one another
the authority to make decisions and allocate resources.
2. Goals & SOPs : Should have surge capacity national requirement based on
individual hospitals and not blanket set percentage; More guidance on standard
operating procedures from hospitals.
3. Monitor surge: Need for national surge capacity reporting and monitoring.
4. Expandable facilities : ED planning should include area for expandable facilities;
additionally work with local community and area hospitals to design disaster
plans.
5. Coordinate EMS : Have EMS liaison at hospital; ensure city/regional center is
coordinating various EMS units responding to disaster.
6. Avoid ED crowding : Decrease ED crowding / boarding ; must be hospital
response.
7. Reinforce medical workface : Increase RN training positions at schools.
8. Designate a triage hospital : EMTALA needs to be addressed with regards to
what happens during MCE.
9. Practice, practice, practice : don’t wait until actual disaster !

70. References
1. Merriam-Webster online dictionary. “Surge” definition. Available: http://www.merriam-webster.com/dictionary/surge.
Accessed January 24, 2010
2. ACEP. “Health Care System Surge capacity Recognition, Preparedness, and Response.” Available:
http://www.acep.org/practres.aspx?id=29506. Accessed on January 24, 2010.
3. HHS. Medical Surge Capacity Capability Handbook. Available:
http://www.hhs.gov/disasters/discussion/planners/mscc/index.html. Accessed on January 24, 2010.
4. Koenig, KL & Schultz, CH. (Eds). (2010). Disaster Medicine Comprehensive Principles and Practices. CITY: STATE:
PUBLSHER.
5. Barbisch, DF & Koenig, KL. Understanding surge capacity: essential elements. Acad Emerg Med 2006: 13: 1098-1102.
6. CIA-The World Factbook. Israel. Available: https://www.cia.gov/library/publications/the-world-factbook/geos/is.html.
Accessed on January 15, 2010.
7. Peleg, K & Kellermann, AI.Enhancing hospital surge capacity for mass casualty events. JAMA. 2009; 302(5):565-567.
8. FEMA. National Response Framework. Available: http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf. Accessed on
January 19, 2010.
9. Huddy, J. Emergency Department Design A Practical guide to planning for the future. ACEP 2002.
10. CDC. Department of Health and Human Services. Data and Statistics.
11. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emergency department crowding: a point in time. Ann Emerg Med
2003; 42(2):167-172.
12. Kanji, AH, Koenig, KL, Lewis, RJ. Current hospital disaster preparedness. JAMA. 2007. 298 (18): 2188-2190.
13. Henderson, DK et al. Bethesda hospitals’ emergency preparedness partnership: a model for Tran institutional
collaboration of emergency responses. Disaster Medicine and Public Health Preparedness, 2009.3(3):168-173.
14. Pozner, CN, et al. International EMS systems: The United States: past, present, and future. Resuscitation. 2004; 60: 239-
244.
15. American Hospital Association. National Health Survey 2007.
16. Agency for Healthcare Research and Quality. Reopening Shuttered Hospitals to Expand Surge Capacity. Available at:
http://www.ahrq.gov/research/shuttered/shuthospapd2.htm. Accessed on January 29, 2010.
17. Institute of Medicine. Consequences of Uninsurance. Available at:
http://www.iom.edu/Activities/HealthServices/InsuranceStatus.aspx. Accessed on January 27. 2010.

71. Acknowledgements
Special thanks to the faculty and staff at
CDHAM including Dr. Jim Holliman, Dr.
Carlos Williams, Dr. Kevin Riley and Dr.
J.D. Malone and finally, from Tel-Aviv
University, Israel, Dr. Kobi Peleg

72. Hopeful sign from
a refugee camp in
Kabul

73. QUESTIONS ?
Thanks for Your Attention