DM
Planning for the next influenza pandemic: Using the science and art
of logistics
O. Shawn Cupp, PhD; Brad G. Predmore, MHA
Abstract
The complexities and challenges for healthcare
providers and their efforts to provide fundamental basic
items to meet the logistical demands of an influenza
pandemic are discussed in this article. The supply chain,
planning, and alternatives for inevitable shortages are
some of the considerations associated with this emer-
gency mass critical care situation. The planning process
and support for such events are discussed in detail with
several recommendations obtained from the literature
and the experience from recent mass casualty incidents
(MCIs). The first step in this planning process is the
development of specific triage requirements during an
influenza pandemic. The second step is identification of
logistical resources required during such a pandemic,
which are then analyzed within the proposed logistics
science and art model for planning purposes. Resources
highlighted within the model include allocation and use
of work force, bed space, intensive care unit assets, venti-
lators, personal protective equipment, and oxygen. The
third step is using the model to discuss in detail possible
workarounds, suitable substitutes, and resource alloca-
tion. An examination is also made of the ethics sur-
rounding palliative care within the construction of an
MCI and the factors that will inevitably determine
rationing and prioritizing of these critical assets to pal-
liative care patients.
Key words: pandemic, influenza, logistics, bed
space, oxygen
Identifying the problem
Influenza, specifically influenza A, has historically
caused several pandemics. This disease takes various
DOI:10.5055/ajdm.2011.0063
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CASE STUDY
forms and possesses widely ranging levels of attack rates
and case fatality rates during those pandemics. There
have been 13 pandemics in the United States since
1729.1 Since the past 100 years, four pandemics have
occurred in 1918, 1957, 1968, and 2009. A recent analysis
showed that the pandemic of “1918 and 1919 killed over
550,000 in the United States and between 50 million to
100 million people worldwide.”2 Other pandemics during
1957 and 1968 killed ⬃6 million people across the globe.3
Today, “30,000 to 50,000 persons die in the United
States as a result of influenza virus infection and the
global death toll is about 20 to 30 times as high.”4 If
influenza is part of a pandemic, the length of the out-
break and the number of sick and dead can rise
dramatically. “It has been estimated that the next pan-
demic influenza could cause 75 to 100 million people to
become ill, and lead to as many as 1.9 million deaths in
the United States.”5 The planning figures on the US
government Flu Web site determined the requirement
for providing outpatient medical care was the same
whether the pandemic is categorized as “severe” as in
1918 or “moderate” as in 1958-1959. As a planning fac-
tor,45 million Americans will seek outpatient medical
care.6 In response to these numbers, the Department
of Health and Human Services has emphasized the
need for prior planning.7
Over the past decade, a highly pathogenic avian
influenza virus H5N1 made headlines across the globe,
and the mortality rate of those who were infected was
more than 60 percent.8 The possible impact of a pan-
demic based on this type of the influenza virus brought
global planning to the forefront of priorities for medical
healthcare providers (HCPs) and health administra-
243
 Table 1. Summary of statistics for influenza epidemic/pandemics
Pandemic/ Influenza A Attack rate,
Year
epidemic virus type percent
1918-1919 Pandemic H1N1 28
1957-1958 Pandemic H2N2 2513
1967-1968 Pandemic H3N2 10-2016
1997-present Epidemic H5N1
2009 Pandemic H1N1 (S-OIV)18 3.59
tors. However, after it became apparent that the H5N1
variant did not transmit easily during human to
human contact, planning efforts waned and emphasis
on preparation slowed down greatly. Not until 2009,
did fears of a pandemic influenza surface again. The
H1N1 (swine-origin influenza virus [S-OIV]) novel
virus reassorted from swine, human, and avian genetic
material produced a reported attack rate of 3.5
percent9 and a case fatality rate of 0.026 percent.10
Table 1 depicts the information of previous influenza
pandemics and the significant H5N1 epidemic.
Need for planning
Planning for the unknown is extremely difficult.
Part of the challenge is being able to plan to reduce or
otherwise mitigate extraordinary situations into ones
that are at least manageable. Manageable is based on
the simple fact that we will have finite resources to
allocate to the extraordinary situations. Those finite
resources are not going to be enough for the next
influenza pandemic. There will never be enough
resources to meet required demands of the surge in
medical care. HCPs must make decisions “in advance
of a disaster, planners must determine minimal quali-
fications for survival to best allocate their resources
for those who are most likely to benefit.”11 The failure
to at least properly plan for the next influenza pan-
demic will set the following conditions:
 Healthcare facilities (HCFs) will not have
planning processes for alternate standards
of care; thus, some standards will be
244 American Journal of Disaster Medicine, Vol. 6, No. 4, July/August 2011
Case fatality US Worldwide deaths
rate, percent deaths (estimated)
2.511 550,00012 50-100 million1
0.210 69,80014 4 million15
0.210 33,80014 2 million15
618 017 29617
0.02610 17019 42919
dictated by lack of assets. This also
includes inadequate planning for trans-
portation of patients and traffic control at
healthcare centers.
 Patients will suffer needlessly.
 Patients will die as a result of the lack of
critical supplies.
 Some HCFs will have to refuse care to
some patients, even palliative care.
Within the most recent literature concerning
emergency mass critical care (EMCC),12 mass casu-
alty event/incident (MCE or MCI), recent medical
journal findings, and medical task force reports
describe an influenza pandemic in a variety of ways.
Numerous recommendations are suggested to plan for
such an event. However, the logistics of supporting
and sustaining an HCF during an influenza pandemic
received less than sufficient analysis within the litera-
ture. Many items were covered singly in various jour-
nal articles. However, a holistic approach to supporting
and sustainment of critical resources during influenza
pandemic requires greater attention and analysis.
This analysis is necessary to ensure adequate support
during an influenza pandemic.
Logistics required for the problem
Many task forces13,14 and panels have studied and
debated the requirements for planning logistics for an
influenza pandemic. Most of their conclusions were
based on one or a few parts of the logistics system sup-
porting such a catastrophic event. In this study, this
problem is viewed in a more holistic manner and a
logistics planning construct is suggested. Just-in-time
supply chains may not15 and probably will not provide
the surge capacity necessary for increased capacity or
supply items. On the basis of the current medical prac-
tices, we cannot prevent a pandemic from occurring;
the next logical step is to prepare and plan to meet the
next MCE. The fundamental logistical issues sur-
rounding an influenza pandemic involve HCPs and the
resources available to care for the patient surge. These
assets include critical resources that are already con-
strained, finite, or involve supply chains that operate
under just-in-time procedures.16 A recent Government
Accountability Office (GAO) report stated that one of
the four key components related to preparing for a pan-
demic patient surge was “increasing hospital capacity,
including beds, workforce, equipment, and sup-
plies.”17,18 An earlier article detailed “The Science of the
Surge” and displayed a listing of the components that
make up a surge capacity.19 These assets have the fol-
lowing in common within the context of an influenza
pandemic: a requirement to plan for use, supply chains
will impact availability of these items, development of
alternative solutions will be required to meet surge
(increased need for HCF resources), capacity require-
ments, and initial prioritization of assets should take
place before an influenza pandemic. The most difficult
challenge “would be to increase medical capacity and
resource availability (e.g., hospital beds, drugs, and
supplies)”1 during an influenza pandemic. Healthcare
professionals (HCPs) and policy makers will ultimately
increase the likelihood that their treatment facility
could endure a surge and sustain medical support dur-
ing an influenza pandemic. Previous articles suggest
that HCPs and healthcare workers (HCWs) could use
the following terms MCI or EMCC in describing the
unique and crucial planning required. An influenza
pandemic-based EMCC (IPB-EMCC) event will clarify
the conditions and simplify the terminology for this
event care category.
During an IPB-EMCC event, “it is necessary to tar-
get the resources available to those who are most likely
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to benefit in order to maximize overall survival.”20 This
recommended management premise suggests the
appropriate fiscal and resource management decision
to prepare for IPB-EMCC. Planning for support of IPB-
EMCC is even more important than discussing or set-
ting the standards for healthcare during such an event.
Alternative levels of care may be dictated simply by the
lack of available resources if proper, deliberate, and
prior planning is not conducted. Many state and local
disaster plans assume that “in any large-scale mass
casualty event, healthcare delivery will continue to
adhere to established standards of care.”21 A recent
review of emergency preparedness documents from
20 states by the GAO determined that “only 7 of the
20 states interviewed were planning to implement
altered standards of medical care in response to a mass
casualty event.”22
Importance of triage
The overarching medical process used during IPB-
EMCC is triage. A major challenge faced by healthcare
providers lies in their capacity and capability to make
an operational shift from individual-based care to pop-
ulation-based care.20 An overlying framework to help
develop a system of allocating resources to those in
need is required for proper triage to occur. “A disaster is
characterized by an imbalance between needs and sup-
plies.”23 Recommending a particular triage method
during a disaster such as an IPB-EMCC is beyond the
scope of this document. There are many recently pub-
lished articles with recommended solutions.21,24,25
However, certain viewpoints of prearranged triage
standards are necessary to understand within the con-
text of an IPB-EMCC. Under these circumstances,
HCPs must understand that triage, specifically tai-
lored, is the first step in preparing an HCF for the
impact of an IPB-EMCC surge. Triage practiced under
these conditions includes the following: 1) “even after
modification of critical care standards, available
resources will remain taxed”26; 2) “when resource
scarcities occur, tenets of biomedical ethics dictate that
triage protocols be used to guide resource allocation”27;
and 3) “triage protocol can help to direct resources to
patients who are most likely to benefit and help
decrease the demands on critical care resources.”28
245
A triage protocol must be predeveloped. To set the
stage for success, “protocols must be developed, vali-
dated, and available before a crisis.”29 A part of triage is
the actual flow of patients, traffic patterns of all vehi-
cles (emergency and caregivers), and traffic manage-
ment of transportation assets moving patients to other
facilities. Movement of patients within facilities should
conserve and involve as few resources as practical.
Identification of patients requiring movement should
be done as early as possible to decrease transportation
time and increase treatment times within HCFs.
Hospitals and emergency vehicles are also resources
that require planning for and consideration when
bringing patients to and from treatment facilities or
moving them to alternative care centers (ACCs).
Movement to such facilities should be done in route
with transportation assets. Once patients are admitted
to seek medical treatment they should remain in that
facility. Moving patients from one facility to another is
dangerous based on additional exposure to HCWs and
other patients to infected patients.
The importance of triage is evident, but who should
be conducting the triage classification or developing
the protocol for critical care? Classification of symp-
toms is essential for both treatment and transporta-
tion if necessary.30 In most cases, it is recommended
that the “classification process should be carried out by
Figure 1. Logistics science and art model.
246
the most senior and experienced physician.”30 Another
important aspect to consider about triage in a surge
situation is “as time passes during a pandemic, the
triage rule can and will need to be refined.”29 Adjusting
the triage pre-event classification standards is the key
based on the constantly changing requirements to
meet the surge demands. The unstable nature of this
event requires continuous monitoring of the situation
and modification of triage measures as appropriate. An
additional impact of triage is anticipating the require-
ments for IPB-EMCC “federal and state public health
officials, health care providers (HCPs), and regulatory
bodies must confront the need to alter the ways in
which healthcare is administered.”31 This prior plan-
ning is especially important before and during the
event when strategically communicating with the pub-
lic to manage expectations.
Logistics science and art model
As seen in 2009, nature even changes fundamen-
tal assumptions of the influenza virus and can deter-
mine a new path. The H1N1 (S-OIV) virus demonstrated
a completely new reassortment integration of genetic
material from human, avian, and swine sources.15
Even when this new and novel change in the disease
occurred, hospital planners can still “determine the
gap between existing resources and those resources
American Journal of Disaster Medicine, Vol. 6, No. 4, July/August 2011
that would ideally be required” for supporting an IPB-
EMCC event.32 The “first goal of health care emer-
gency preparedness planning is to augment the actual
capacity and capabilities of the system. The secondary
goal is to make the system ‘fault tolerant’ or to ‘bend’
rather than ‘break’ ” during an IPB-EMCC event.22
What we can change is the HCP’s ability to support
and sustain the logistical requirements necessary to
care for those affected by an influenza pandemic. The
logistics science and art model used to analyze this
problem will allow stakeholders to better prepare for
an influenza pandemic. Figure 1 outlines these resource
considerations while viewing the problem through the
eyes of a logistician.
The top half of the figure outlines the assets to con-
sider with reference to requirements and capabilities
or the science of logistics. In this case, hospital admin-
istrators and HCPs can use planning assumptions in
Figure 1 based on infection rates, morbidity, and hospi-
talizations (or requirements). These are the resources
required during an influenza pandemic. These will be
calculated against the work force, bed space, intensive
care unit (ICU) assets needed, ventilators required,
personal protective equipment (PPE), and oxygen
available for an influenza pandemic (or capabilities). In
the model, this computation must also take into consid-
eration the constraints (external forces) and the limita-
tions (internal restrictions), such as the traffic patterns
and the ability to transport patients to other facilities,
when processing the final requirements. External
forces include the reliance and dependence on an exter-
nal supply chain for most logistical assets. Most of
these requirements are consumption based. However,
oxygen, personnel resources, bed spaces, and so forth
are disposal of used assets. How do we properly dispose
of the enormous quantities of infected patient secre-
tions? Where and how do we dispose of the large num-
bers of masks and other medical waste that would be
produced during such a crisis? Some of this waste could
be incinerated to be used for power and maybe even
power in times of limited electricity from the power
grid or during emergencies time periods such as an
IPB-EMCC. The hospital facility requires that these
supplies come on an as-needed or “just-in-time” basis.
The internal restrictions are mainly focused on the
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physical plant of the facility. There is only a finite
amount of space in the facility, no matter how it is
manned, configured, or equipped. This planning factor
also takes into consideration the functions that the
physical plant is dependent on. The most significant of
these is electrical power. Without electrical power, or a
feasible backup on site, a hospital facility cannot meet
the demands of an EMCC. Once the requirements ver-
sus capabilities are calculated and considered against
the constraints and restrictions then the result will
include either shortfalls (shortages) or excess capacity
(capacity of resources still available). It is important to
note that “healthcare institutions vary considerably in
their surge capacity and capability, as well as the
amount of personnel, supplies, and equipment they
have.”33
The bottom part of Figure 1 is a depiction of the
art of logistics. In other words, these are the creative,
preplanned, and proactive measures enacted to miti-
gate or reduce the overall requirements during a
surge of an IBP-EMCC event. These actions reduce
the impact of the crisis on the capacities currently
residing in HCFs. Planning for these reductions may
assist in means to augment the supply chain. For
example, one way to mitigate the projected shortfalls
is with workarounds. These workarounds begin in
triage. What are the ways to defer patients to levels
of care that are not necessary based on reduced levels
of critical assets? Which patients who would defi-
nitely require ICU assets? What about complex
patients or patients who already present more than
one medical condition such as pregnancy, diabetes, or
have previously compromised immune systems?
Also, under suitable substitutions, what are the
assets that would provide the same benefits as per-
manent oxygen supply and mechanical ventilators in
nontraditional or alternative care facilities? What
alternative means can patients be cared for and what
nontraditional ways may patients be transported to
other treatment facilities? Another example of a
workaround is an ACC, which may help alleviate
physical hospital space requirements. In regard to
excess capacity, or the other factor within the art of
logistics, HCWs could reallocate resources to where
they are needed. All hospital planners must under-
247
stand that an IPB-EMCC situation is very unstable.21
The assets and the model must be constantly
reassessed to realign assets underutilized or distrib-
ute critical assets where they will ultimately save
the most lives.
If the logistical problems previously discussed are
ignored then their impact will certainly be accentu-
ated during an IPB-EMCC event. Deliberate and
methodical planning is necessary and key to ensure
that all aspects of logistical support are considered
and accomplished when the most time is available—
before the influenza pandemic occurs. Identification of
the problem, factors impacting the problem, and usage
of the model will improve readiness of HCPs and
administrators to prepare for the next influenza pan-
demic. Using the logistics model detailed in Figure 1
will be a significant step in a hospital planner’s ability
to mitigate the effects of an influenza pandemic and
to provide the most assets to the largest number
of patients. However, what are the logistical assets
required to plan for an IPB-EMCC event?
Resources
Work force
Work force limitations will probably be a difficult
challenge to overcome during a surge for critical
care. It is extremely hard to increase work force
capacity of mass casualty trained providers during a
critical care situation. The number of HCWs avail-
able will probably be the most critical resource for
hospital planners in an IPB-EMCC event. Some
studies suggest that “up to 40% of the available
workforce may be absent for periods of about two
weeks at the height of a pandemic wave.” 30 Faced
with this dilemma, hospital administrators must
remember to resist the urge to “enlist whichever doc-
tors happened to be on duty”21 during an EMCC. This
is often “counterproductive, thus as part of any mass
casualty plan, the immediate availability of physi-
cians, particularly surgeons, trained in mass casu-
alty triage and treatment must be included.” 21 One
already identified shortage is in critical care
providers. Certain allied health providers who are
specially cross-trained and used by the military and
248
inner city hospitals are respiratory therapists. These
therapists are critically skilled people and useful in
any event that requires ventilators.
Will HCWs show up for work during an IPB-
EMCC? What are the reasons they will not? In a study
conducted in New York City, more than 6,400 workers
provided the following reasons for not being able to
report to work during a catastrophic event: the most
frequently cited reasons were transportation issues
(33.4 percent), childcare (29.1 percent), personal
health concerns (14.9 percent), and eldercare respon-
sibilities (10.7 percent).29 Thus, personal health fears
seemed to be less of a reason than others for HCWs to
show up for work. The same study also found that
after “controlling for age, gender, childcare, and elder-
care obligations, physicians and emergency medical
technicians (EMTs) were significantly more likely to
be both able and willing to report to duty during a cat-
astrophic event.”34
Bed space
There are many ways to increase overall hospital
bed space. Up to “20 percent of a hospital’s capacity
can be freed up by discharging existing patients,
canceling surgeries, and calling in off-duty staff.”21
However, beyond these measures, creating additional
bed space in most hospitals is problematic. Bed space
costs money so “physical space creation in many hospi-
tals is difficult and depends on flexibility of space
because little reserve space is available.”27 Another
consideration for bed space is ACCs. There are several
considerations to be made with regard to an ACC. The
first is planning for them, where they are, and what
services they will provide. The second is the point at
which an ACC will “be activated once a hospital is
beyond 120% capacity.”5 The third is that the logistics
of establishing an ACC should be comprehensive, pre-
determining needs, procuring the necessary equip-
ment and supplies, and providing for an adequate
work force to staff the facility. A fourth consideration
is analyzing the risk involved in opening these areas
versus the placement of infectious patients in cafete-
rias, gyms, waiting rooms, and other areas. It might
not be worth the additional risk of putting patients
there with little or no HCP support.
American Journal of Disaster Medicine, Vol. 6, No. 4, July/August 2011
ICU assets
In the United States, vacant ICU beds are rare.35
Nevertheless, ICU assets are critical for the care of
ventilated patients. Recently in New York during the
H1N1 (S-OIV) pandemic (July 8, 2009), of 909 patients,
225 (25 percent) required ICU care.36 Thus, even with
pandemics expressing low case fatality rates, the
requirement for ICU assets can become enormous. The
requirement for ICU assets is often based on treatment
to patients for immune systems diseases. For example,
the primary reason that patients were admitted
to ICUs during the H1N1 (S-OIV) pandemic in New
York during July 2009 was for treatment of viral
pneumonia.37 In any set of circumstances, it is expected
that some nontraditional rooms will be modified for
ICU use.
Ventilators
The lack of supplies including specialized equip-
ment such as ventilators will cause significant chal-
lenges for hospitals during an IPB-EMCC. Hospitals
usually have enough ventilators to meet everyday
demand, but not enough for peaks.38 Ventilators assist
the patient in breathing when the virus begins to
impact the lungs ability to exchange oxygen. Medical
care during a pandemic would require thousands
more ventilators than are available. Many patients
would have to survive without the use of these devices.
Examples include bag-valve manual, automatic resus-
citator, portable ventilators, full-feature mechanical
ventilator, and anesthesia machine.38 The bag and
mask systems of ventilation requires a provider such
as a registered nurse, registered respiratory therapist,
or any trained medical doctor. The anesthesia machine
used as a ventilator has different requirements. It
requires an even higher skill level anesthesiologist or
certified registered nurse anesthetist. This, however,
may not be an effective use of such personnel except to
transport critically ill patients on ventilators. Many
smaller hospitals simply cannot afford to purchase,
maintain, and store full-feature mechanical ventila-
tors. Data for the National Health Care Safety
Network show the majority of ICUs with “over 70%
filled with patients receiving invasive mechanical ven-
tilation.”24 This requirement in turn demonstrates the
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number that would be necessary during an IPB-
EMCC situation. Only 10,000 full-feature ventilators
would probably be available for use across the United
States.24
Oxygen
Oxygen is available for hospitals in four distinct
delivery forms: compressed gas cylinders, oxygen gen-
erators, bulk liquid oxygen (LOX) systems, and LOX
systems.39 The type of system available and used dur-
ing an IPB-EMCC depends on the supply chain and a
hospital’s expected requirements. Each of these forms
has its own characteristics.
Oxygen cylinders have several supply chain choke
points associated with their use. Vendors have only a
fixed number of cylinders. They depend on hospitals
and other medical care facilities to return empty tanks
for refill. Cylinders also take up space within a hospi-
tal. They must be appropriately stored to assure
access and usage. The storage areas require lockable
doors, storage room, and ventilation systems, which
are all based on the volume of gas stored. Many hospi-
tals simply do not have the required space available to
store substantial quantities necessary for emergency
events. On the basis of the storage and supply chain
issues, “reliance upon compressed gas cylinders is not
a long-term solution for pandemic events.”40
Another source of oxygen is oxygen concentrators.
These mainly serve low-flow oxygen therapy normally
associated with home applications. They are expensive
and require moderate to large amounts of electricity
to operate. They generate their own oxygen, which is
an advantage over cylinder systems that must be
recharged by vendors—a time-consuming process.
In addition to providing oxygen on demand, oxygen
generators may also be used to refill gas cylinders.
Trailer-based systems may be an option for federal,
state, and local government under emergency condi-
tions. These larger systems require additional space
for operation. The cost equals or exceeds the cost of a
bulk liquid system. These large generator or concen-
trator systems are build for a specific facility-based
requirement. Thus, order-to-ship time requires much
prior planning and would increase the cost to benefit
ratio for the purchase of these systems.
249
 The bulk LOX systems are what most hospitals
use. These provide ⬃50 psi on demand to patient care
areas. These systems are dependent on gas-separation
plants as opposed to gas cylinder filling plants. This is
another component of the “just-in-time” logistics oper-
ating system that hospitals depend on.
Personal protective equipment
PPE provides the HCW with protection from the
influenza virus. PPE is “essential for controlling trans-
mission of influenza in hospitals.”11 Many studies
have provided recommendations on how much PPE a
hospital should maintain on-hand for an IPB-EMCC
situation. The most consistent estimates suggest that
every hospital should stockpile or have assured access
to PPE for 8 weeks.23 However, what is 8 weeks of
PPE? A recent article provided an example for calcu-
lating these requirements for a 300-bed hospital in
Tokyo, given for a set number of HCWs and a high risk
to those employees. For such a scenario, the following
was computed: 10,528 N95 respirators (with exhala-
tion valve), 8,848 N95 respirators, 122,192 surgical
masks, 21,880 goggles and gowns, 34,832 aprons, and
172,880 pairs of gloves for a total expense of US
$553,420 ($1 ⫽ 100 yen).41 This is a planning figure
but provides some fidelity to the enormous stockpile of
PPE necessary to support an IPB-EMCC situation.
Along with providing these supplies, disposal of them
is another consideration in planning. The massive
amounts of medical waste including infectious fluids,
used PPEs, syringes, and others contaminated and
consumable supplies must be disposed of in an appro-
priate manner. The planning to dispose of infectious
fluids is probably the most involved and the one factor
that is often overlooked.
Fiscal resources
Currently, the US federal government has no plan
to compensate hospitals for losses during a pandemic.42
Hospitals did lose money during past surge events.
Following the 9/11 attacks on the World Trade Center,
public entities requested that hospitals cancel elective
services, which amounted to more than $200 million in
lost revenues that were never reimbursed by the fed-
eral government.43 The financial impact on all hospitals
250 American Journal of Disaster Medicine, Vol. 6, No. 4, July/August 2011
from an IPB-EMCC would be significant. Within the
guidelines of current disaster assistance system, much
of a hospital’s financial loss is not reimbursable. Based
on this fact, hospitals should include their financial
planning as part of their pandemic plan.44 Costs associ-
ated with planning for an IPB-EMCC event are recom-
mended within the literature. An average hospital of
164 beds would require $200,000 in 2006 for developing
a specific pandemic plan.45
Palliative care
Palliative care is defined by the World Health
organization as an approach that “improves the quality
of patients and families who face life-threatening ill-
ness, by providing pain and symptom relief, spiritual
and psychosocial support to patients from diagnosis to
the end of life and bereavement.”22 Palliative care is
difficult to plan for even under normal patient loads.
During a surge of requirements in an IPB-EMCC, this
care category would be negatively impacted by lack of
planning and reduced assets available. This includes
the reality that “many people with clinical conditions
that are survivable under usual health-care system
conditions may have to forgo life-sustaining interven-
tion owing to deficiencies in supply or staffing.”22
Why is palliative care so important during an MCE?
Arguments for addressing palliative care under this situ-
ation include “humane treatment, diversion of dying peo-
ple away from overburdened hospitals, more effective use
of scarce resources, and provide care that patients
want.”20 Palliative care is a necessary function to plan for
and resource during an IPB-EMCC event. It is critical for
the ethical and humane conduct of care that “honoring
the humanity of the dying and those who serve them by
providing complete social, psychological and spiritual
support.”34 Planning for palliative care unfortunately
includes “diversion of dying people away from overbur-
dened hospitals, more effective use of scare resources,
and providing patients what they want have moral
weight.”20 The fact is hospitals will have to provide an
area for patients that will not survive to live out their
remaining hours or days in relative comfort. It is an ethi-
cal and moral mandate but has even more significant
logistical implications. Decisions based on triage to move
patients to palliative care wards or sites will save lives.
Recommendations
Work force
There are considerations about having a trained
work force to meet this surge capacity requirements, but
what measures do we put into a plan to meet or try to
meet these possibly overwhelming requirements?
Automatic extension of hours would provide an initial
surge of available workforce. A “staggered recall of off-
duty personnel and the recruitment of ICU nurses from
other departments” could also help bolster the initial
workforce capacity.32 This is a short-term fix to a mid- or
long-term problem of staffing. “Surge plans should incor-
porate rates for staff attrition due to illness that are
equal to or greater than those calculated for the overall
population.”31 Ultimately, the requirement for day care,
transportation, eldercare, and pet care, all of which were
already discussed, should be included to mitigate the
overall requirements for work force shortfalls. Another
important aspect with personnel is the requirement to
make time and resources available to cross-train indi-
viduals on medical devices and procedures. We will not
have enough medical personnel show up for the next
influenza pandemic. To increase the chances of success,
cross-training of personnel to meet projected shortfalls
in coverage is vital during our planning efforts.
Bed space
Bed space within the HCF must first be prioritized
to properly use the space that is available. Also, the bed
space for critical care can be located almost anywhere
within an HCF. “A multi-professional team of critical
care health professional should establish selection cri-
teria for placement in various critical care sites.”38
Besides allocating space available more effectively,
alternate care facilities would be able to provide some
relief for bed space. These could be nonemergency
areas such as schools, gymnasiums, or cafeterias.
These alternate locations could provide much needed
bed space. However, these spaces would be for noncriti-
cal patients. The outfitting of nontraditional spaces
with integrated monitors, power supply, and oxygen
delivery would present large logistical hurdles.39
Hospital planners must integrate their plans to use the
bed space available in the most effective manner.
www.disastermedicinejournal.com
ICU assets
The surge capacity of a hospital will test resident
ICU assets. Opening and operating additional ICU space
while resource intensive it is not an insurmountable
task. Extra space for ICU assets can be set up in other
locations within the hospital. Lynn et al. and Mahoney et
al. described the use of “ICU carts” within the hospital or
at alternate sites.37 A detailed list of supplies is described
along with a basis of allocation dependent on calculating
the required ICU assets. This is a feasible option only if
properly planned for before the event.
Ventilators
Triage of patients that need ventilators is critical
in the use of this resource. “Triage based on underly-
ing disease state aims to ventilate patients who do not
have diseases that would predict a protracted or poor
response to treatment.”42 Thus, the first technique to
reduce requirement is to ensure that all patients
using ventilators have a good prognosis to respond to
this treatment. Second, the reassessment of ventilated
patients must take place on a continual basis. This
would allow for the confirmation of patient progress
and also provide the justification for reassignment of
this critical resource to patients with a better progno-
sis of survival.
Oxygen
Oxygen consumption factors and alternatives are
aspects of an IPB-EMCC that require further study.
Hospitals need to know before a large-scale event
what their projected oxygen requirements will be and
plan accordingly. There are alternatives that will help
to mitigate the reduction or stoppage of oxygen
through the just-in-time supply chain. “Administering
oxygen only for documented oxygen saturations
<90%” would reduce total oxygen required and used.34
One primary way to reduce the requirement for oxy-
gen is to administer it only to patients who require it.
This decision is made initially during triage. Such a
decision at the farthest end of the spectrum would
reallocate oxygen to only those patients with an
appropriate chance of survival.40 Other options to con-
sider include the use of reservoir and rebreathing
masks, low flow rates, and even closed circuits.
251
Other critical resources
Other resources necessary for an HCF to function
within the crisis of an influenza pandemic include food,
water, electrical power, and use of effective neu-
raminidase inhibitors. “Pre-event discussions between
ICU directors and heating, ventilation, and air condi-
tioning supervisors are required to ensure adequate
backup systems are available if primary systems
fail.”21 During Hurricane Katrina, many HCFs had
backup water, food, and power systems but they were
not protected. These supplies and backup generators
must not only be on-hand, maintained, and protected
but also be secured from possible pilferage during an
IPB-EMCC event. The use of the logistics science and
art model would assist in providing a “determination of
the gap between existing resources and those
resources that would ideally be required.”21,41 Other
resources to consider include telecommunications,
sewage disposal, and garbage removal.46 The neu-
raminidase inhibitors used for influenza include
oseltamivir and zanamivir. These two effective drugs
have major drawbacks in their use. Oseltamivir is
dependent on a key ingredient called shikimic acid.47
This is either derived from the star anise plant, which
is imported from China or Vietnam, or produced within
a long extraction process, which is costly and involves
an azide explosive intermediate compound. Zanamivir
“has similar wide efficacy but its presentation as an
inhaled powder has limitations.”48 In either case,
resistance to these drugs is always an issue with
influenza A. For example, “there have been cases of
resistance documented during human outbreaks of the
H5N1 avian influenza virus, specifically in SE Asia.”48
Conclusions
Hospitals and healthcare planners must ensure
that plans include cooperation with other hospitals to
cover the logistics requirements for an IBP-EMCC.
Local, area, regional, state, and federal levels of prior
coordination are necessary, but the details of these
agreements are the key factors. Plans should include
different scenarios with different levels of cooperation
and sharing or transferring of assets. These plans
should be documented and flexible to increase or
decrease support required on a least daily scale.
252 American Journal of Disaster Medicine, Vol. 6, No. 4, July/August 2011
Relationships are critical in a time of crisis.
Reaching out to other hospital administrators and
planners now will increase the likelihood of increased
logistical support during projected times of need. HCPs
can use the logistics science and art model as the basis
for detailed planning to prepare an IBP-EMCC event.
Planning for eventual crisis requires HCPs and admin-
istrators to interact and coordinate their efforts.
Another issue to consider is that during 1918,
“there were no antiviral medications, antibiotics,
mechanical ventilators, IV fluids, oxygen or intensive
care units.”23 Thus, the 2.5 percent case fatality rate
could have been much lower with these more modern
medical assets available to treat these patients. In the
future, these assets themselves may mitigate some of
the fatality rates of the next influenza pandemic.
“There will not be enough beds, supplies, or trained
staff to take care of all the sick people, using normal
practice standards.”23 HCPs and planners will be
required to ration care to provide the best care for the
greatest number of patients. “Any community that fails
to prepare (for an influenza pandemic) with the idea
that somehow, in the end, the federal government will
be able to rescue them will be tragically wrong.”11 “If the
intended scope of critical care is defined pre-event, pre-
paredness efforts can maximize the likelihood that key
resources will be available during a response” and more
probably meet the needs of a pandemic surge.49 In fact,
some of the issues concerning logistical support needs of
an influenza pandemic can be resolved and accounted
for with detailed, advanced planning.
Planning for an IPB-EMCC event is imperative for
success nominally or otherwise. The use of resources to
support the care of patients is necessary. Planning to
use those resources should include a systematic or
model approach to ensure the best care for the most
patients. Planning for complex patients as part of the
patient population is critical. Obesity, pregnancy, and
elderly complex patients will undoubtedly provide even
greater challenges during an influenza pandemic.
Acknowledging the existence of these unique cases
and planning for them is essential. These complex
patients, as we saw during the 2009 H1N1 (S-OIV),
resulted in “increased risk for complications and mor-
tality from this infection.”50
 Needless death and suffering during an IPB-
EMCC event are always tragic, but deaths due to poor
or inadequate planning for logistical resources are cat-
astrophic in terms of medical care and public health-
care. Acknowledging the challenges of supporting such
an event is the first step in preparing for the next
influenza pandemic.
Acknowledgments
The authors have no conflict of interest, including direct or indi-
rect financial interest that is included in the materials contained or
related to the subject matter of this article. The views and conclusions
expressed in the context of this document are those of the authors
developed in the freedom of expression and in the academic environ-
ment of the US Army Command and General Staff College. They do
not reflect the official position of the US Government, Department of
Defense, United States Department of the Army, or the US Army
Command and General Staff College.
O. Shawn Cupp, PhD, Associate Professor, Force Management and
Maneuver Sustainment, Department of Logistics and Resource
Operations, US Army Command and General Staff College, Fort
Leavenworth, Kansas.
Brad G. Predmore, MHA, Assistant Professor, Force Management
and Maneuver Sustainment, Department of Logistics and Resource
Operations, US Army Command and General Staff College, Fort
Leavenworth, Kansas.
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