Reverse Triage Increases Hospital Beds During Disaster

By Todd Neale, Staff Writer, MedPage Today
Published: April 08, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

LITTLE FALLS, N.J., April 8 -- Discharging noncritical patients appears to be an effective way to increase a hospital's capacity for emergency admissions during a public disaster, researchers found.

Explain to interested patients that this study examined the potential impact of discharging noncritical patients during a hypothetical disaster for freeing up hospital bed space.

In three hospitals in a single health system in Maryland, so-called reverse triage contributed to 50%, 55%, and 59% of the creation of surge capacity during a hypothetical disaster of short duration, Gabor Kelen, M.D., of Johns Hopkins in Baltimore, and colleagues reported online in Disaster Medicine and Public Health Preparedness.

"Making hospital beds available for victims of a mass emergency may be easier than once thought," Dr. Kelen said. "Reverse triage . . . can significantly increase surge capacity without a corresponding increase in resources."

Hospitals in the U.S. are expected to function without outside help for up to four days during a disaster.

But the researchers cited concerns about their ability to absorb large numbers of casualties. So they set out to explore how the reverse triage of low-risk patients during the first 96 hours of a hypothetical disaster would affect surge capacity.

Within a single health system in Maryland, they canvassed inpatient units for 19 weeks at a 1,017-bed inner-city university hospital, a 355-bed teaching hospital in a working class neighborhood, and a 260-bed community hospital in a mostly wealthy county.

Nurseries, pediatric units, and ICUs were excluded.

Any patients who did not require any critical intervention -- used as a proxy for a consequential medical event -- within four days of the hypothetical disaster were deemed suitable for early discharge.

Critical interventions ranged from CPR and defibrillation, major surgery, and dialysis to blood transfusion and lumbar puncture.

Of 3,491 total patients, 44% qualified for early discharge (40% at the university hospital, 47% at the teaching hospital, and 59% at the community hospital).

After accounting for normal patient discharges and full use of staffed and unstaffed beds, the researchers estimated gross surge capacity -- beds available for disaster victims only -- at 77%, 95%, and 103% for the three hospitals, respectively.

After further accounting for normal emergency but nondisaster-related admissions, the net surge capacity was 66%, 71%, and 81%, respectively.

Reverse triage accounted for the bulk of the surge bed creation at each hospital, with additional contributions from unused licensed beds, routine discharge, and unused staffed beds.

"Reverse triage offers an important new approach in the creation of surge capacity, requiring no substantial resource increment," the researchers said.

Most of the surge capacity would have been available within 24 to 48 hours in an actual disaster situation.

And, the researchers said, "an even larger percentage of patients could be safely sent home or avoid admission, should the concept of hospital at home be available during a disaster."

They acknowledged that the study did not provide a method for predicting in advance which patients are unlikely to require a critical intervention in the coming days, "but it does show that if a system predicting risk can be harnessed, it would be a powerful tool."

The findings might not apply to a longer-term disaster, such as an influenza outbreak, they said.

The study was funded in part by the Agency for Healthcare Research and Quality and by a Department of Homeland Security Center of Excellence Grant.

The authors made no financial disclosures.
Primary source: Disaster Medicine and Public Health Preparedness
Source reference:
Kelen G, et al "Creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events" Disaster Med Public Health Prep 2009; DOI: 10.1097/DMP.0b013e3181a5e7cd.