The ongoing global health crises and increasing frequency of natural disasters highlight a critical vulnerability in healthcare systems: surge capacity. When hospitals and traditional medical facilities are overwhelmed, the ability to rapidly establish and operate Alternative Care Sites (ACS) becomes paramount. This article delves into the essential aspects of ACS planning, with a particular focus on the Disaster Alternate Care Facility Selection Tool, a vital resource for communities and healthcare organizations aiming to bolster their emergency preparedness.
The Imperative of Alternative Care Sites
The COVID-19 pandemic starkly illustrated the fragility of even well-resourced healthcare systems when faced with a surge in patient volume. Similar pressures arise from institutional failures, large-scale accidents, or natural disasters. In these scenarios, Alternative Care Sites (ACS) are no longer optional; they are a necessary component of a robust disaster response strategy. ACS, located in non-traditional healthcare settings, can provide a spectrum of care, from ambulatory and acute to sub-acute and chronic, effectively expanding healthcare capacity when and where it’s needed most. Proactive development of ACS capabilities is the critical step that transforms disaster preparedness from theoretical discussions into tangible action, yielding significant benefits when crises inevitably strike.
Instances throughout history underscore the urgent need for adaptable healthcare solutions. Following the devastating 1999 earthquake in Turkey, makeshift medical facilities emerged spontaneously in streets and damaged buildings, demonstrating immediate post-disaster resourcefulness.1 Months after Hurricane Katrina, the New Orleans Convention Center served as an impromptu medical center, treating thousands of vulnerable patients monthly, long after the initial emergency response faded from public attention.2 The 9/11 attacks saw a New York City high school repurposed as a medical aid station, highlighting the adaptability required when infrastructure is compromised.3 More recently, the global pandemic spurred rapid construction of hospitals and the deployment of temporary facilities like tent hospitals and the repurposing of hotels, stadiums, and shuttered healthcare facilities as ACS.4 These reactive measures, while necessary, underscore a critical point: proactive planning and resource allocation for ACS are essential to mitigate the impact of predictable, if infrequent, large-scale emergencies.
Key Considerations in Establishing an ACS
Successfully establishing an ACS involves navigating a complex web of interconnected issues. Clear decision-making frameworks and pre-established protocols are vital. Key questions that must be addressed include:
- Authority and Governance: Who holds the authority to activate an ACS? Under whose jurisdiction will the site operate? Ideally, these decisions should be predetermined at a regional level, ensuring coordinated action.
- Operational Leadership: Who will be responsible for directing the daily operations of the ACS? Clear lines of command are crucial for efficient management.
- Patient Profile and Acuity: What types of patients will the ACS accommodate? Will it primarily serve to alleviate pressure on hospitals and nursing homes, or will it provide primary care services? What level of patient acuity can the facility manage? Will oxygen-dependent patients be accepted? Defining the patient population informs resource allocation and staffing needs.
- Facility Selection Criteria: Which available facilities are suitable for conversion into an ACS? What criteria will guide the selection process? How will necessary approvals for facility use be obtained? What existing infrastructure dependencies need to be considered? Or will pre-designated portable or temporary shelters be utilized? A systematic selection process is paramount, and this is where a disaster alternate care facility selection tool becomes invaluable.
- Staffing and Resource Allocation: Who will staff the ACS, including medical professionals, support personnel, and volunteers? Comprehensive staffing plans that account for various skill sets and potential volunteer contributions are essential.
- Supplies and Equipment: What durable and disposable medical supplies and equipment will be required? In what quantities? Logistical planning for procurement, storage, and distribution of essential resources is critical.
- Operational Support Systems: What operational support services will be necessary, such as meals, sanitation, waste management, and infrastructure maintenance? ACS functionality depends on robust support systems.
- Policies and Documentation: What policies and patient documentation procedures will be implemented at the ACS? Streamlined administrative processes are crucial in emergency settings.
- Deactivation and Closure Protocols: Who will decide when to close the ACS? What criteria will trigger deactivation? Predefined closure protocols ensure a smooth transition back to normal operations.
Overcoming Implementation Challenges
Despite the recognized need for ACS, effective planning and implementation often face significant hurdles. Resource constraints, both financial and personnel-related, coupled with the complexities of inter-agency coordination, frequently lead to inadequate preparedness. The common approach of conceptually designating a location, such as “the stadium,” without detailed planning, proves woefully insufficient when a real disaster strikes. The American Medical Association’s 2020 letter to US Congressional leaders, urgently requesting funding for alternative care sites during the COVID-19 pandemic, highlighted the critical gap between conceptual planning and actual operational readiness.5
A major obstacle lies in fostering collaboration between diverse groups that may not typically work together in routine operations. Successful ACS implementation demands a unified, multi-sectoral approach.
Command, Control, and Closure: Defining Authority
Establishing clear lines of ownership, command, and control is arguably the most critical factor in successful ACS deployment. These are inherently political and administrative decisions that should be resolved at the local or regional level, rather than solely within individual institutions. Predetermining who has the authority to decide when, where, and how an ACS is activated, and who is responsible for its ongoing operation, is paramount.6,7
Activating an ACS carries significant bureaucratic and financial implications. While a single hospital might technically initiate an ACS independently, a regional, multi-agency approach, often with governmental support, is generally more effective and sustainable.
If a hospital chooses to establish an ACS as part of its emergency operations plan, it assumes a substantial burden, requiring significant resources and capacity. This includes facility procurement, staffing, equipping, policy development, operational management, coordination with emergency services and community organizations, and financial responsibility. While bypassing bureaucratic complexities might seem advantageous, the sheer scale of such an undertaking presents formidable challenges for most individual institutions.
In exceptional circumstances, when formal leadership is lacking or unprepared, individual clinicians and support staff may need to take the initiative to establish an ACS. The post-Hurricane Katrina response in St. Bernard Parish, Louisiana, where family practitioners established a medical facility in a refinery lobby, using salvaged supplies and volunteer support, exemplifies such grassroots action. This facility was later integrated into a more formal disaster medical assistance team (DMAT) response.
Just as crucial as activation protocols are pre-defined exit strategies and closure criteria. Establishing clear, widely understood guidelines for ACS deactivation simplifies the closure process. However, unforeseen events, such as the threat of Hurricane Rita necessitating the abandonment of ACS facilities established after Hurricane Katrina, can override even well-laid plans.
Defining the Role of the ACS: Functionality and Scope
The intended function of the ACS dictates numerous operational aspects, including staffing, equipment, supplies, and facility type. Defining the ACS’s role is, therefore, the foundational decision. Potential functions include:6, 7
- Quarantine and Isolation Facility: Providing a dedicated space for isolating individuals with contagious illnesses.
- Lower Acuity Patient Housing: Accommodating patients with lower acuity needs discharged from hospitals and nursing homes, freeing up acute care beds.
- Ambulatory Care and Vaccination Clinic: Serving as a point of access for routine medical care and mass vaccination efforts.
- Primary Triage Center: Functioning as an initial assessment point to direct patients to the most appropriate level of care.
- Acute Care Inpatient Facility: Providing inpatient care for patients requiring a hospital level of service.
- Palliative Care Setting: Offering compassionate end-of-life care for patients who do not require intensive hospital resources.
- Step-Down Discharge Facility: Housing patients discharged from hospitals who require continued monitoring or support before returning home.
- Multi-Functional Facility: Combining several of the above functions to adapt to evolving needs.
Many ACS evolve to perform multiple functions as the emergency situation unfolds. However, it is critical to ensure that expanded roles remain within the structural, staffing, and logistical capacity of the facility.
Facility Selection: Leveraging the Disaster Alternate Care Facility Selection Tool
Selecting appropriate facilities to serve as ACS is not an exact science and depends heavily on the nature of the disaster and available resources. “Facilities of opportunity,” or “buildings of convenience,” non-medical structures adaptable for ACS use, are most commonly employed.6, [7](#b7-wjem-21-484] The selection process is most effective when the intended role of the ACS is clearly defined beforehand. Commonly utilized ACS locations are listed in Table 1. An often-overlooked strategy is leveraging long-term care facilities; if ACS can accommodate nursing home residents, those existing nursing home beds can be repurposed for acute care, often with pre-existing oxygen infrastructure.
Table 1. Buildings/structures typically used as alternative care sites during disasters.6,7
| Adult detention facility | Aircraft hanger | Church |
|---|---|---|
| Community/recreation center | Convalescent care facility | Fairground |
| Government building | Hotel/motel | Meeting hall |
| Military facility | National Guard armory | Same-day surgical center/clinic |
| School | Shuttered hospital | Sports facility/stadium |
| Trailer/tent (military or other) |
When multiple facility options exist, particularly in pre-disaster planning, a systematic evaluation process is crucial. This is where a disaster alternate care facility selection tool proves invaluable. Even the most suitable facility will require improvisation and adaptation to become fully functional, but a structured selection process minimizes potential shortcomings. Table 2 outlines key questions to guide facility assessment.
Table 2. Questions to ask when selecting an alternative healthcare site.8
| – Will the structure accommodate the expected number of patients and staff, and the planned activities? – Is the structure located in a relatively safe area (culturally and geographically)? Is it structurally sound? – Is it easily accessible by ambulance, foot, and automobile/public transportation? – Is there adequate electrical power (plus back-up power or the capacity to tie in to large portable generators)? – Is there adequate potable water, ventilation, refrigeration, and lighting? Are the ventilation and lighting systems on the back-up generator? Are there also other back-up electrical outlets for critical equipment, such as ventilators? – Are there kitchen facilities adequate for the number of people expected (patients, staff, visitors)? – Is the entire patient care area wheelchair/stretcher accessible? If elevators are needed, are they on the back-up power system? – Will there be separate space for other necessary functions, such as staff sleeping/rest areas, communications center, command center, waiting area, security office, pharmacy, equipment supply and storage areas, chapel/family counseling area, and a morgue? – Can the building be secured? Can you control patient and staff traffic? – Are there phone and computer access lines? Will cellular phones and radios (two-way, ambulance, public sector, and ham) work within the building without interference? – Can lights be dimmed in sleeping and patient care areas? – Are the doors > 33 inches wide to permit ambulance stretchers to move through them? – Are there areas to load and unload patients and supplies? Ideally, these will accommodate forklifts. – Is there parking for patients, staff, and visitors? – Are toilet and shower facilities adequate for the anticipated number of patients, staff, and visitors? (*) – Does the facility have oxygen or will it be readily available? (*) – Is the facility easy to clean for patient use? |
|---|
(*)Important and often overlooked in planning alternative care sites.
Structural Criteria: Utilizing a Selection Matrix
A structured approach to facility evaluation involves using pre-set criteria and a rating system, as exemplified by the disaster alternate care facility selection tool. Table 3 presents key criteria to consider when evaluating potential ACS sites. Each criterion can be rated on a scale (e.g., 1 to 5) based on its similarity to hospital standards. Facilities with the highest cumulative scores become the top candidates for ACS designation. Deficiencies in critical areas, such as security or essential utilities, may disqualify a facility entirely.
Table 3. Criteria to consider in alternative care site selection.
| Infrastructure |
|---|
| Door sizes and stairways adequate for gurneys |
| Parking for staff and visitors |
| Ventilation |
| Toilet facilities/showers (number of) |
| Total space and layout |
| Auxiliary spaces (pharmacy, counselors, chapel) |
| Lab specimen handling area |
| Mortuary holding area |
| Patient decontamination areas |
| Pharmacy area |
| Utilities |
| Electrical power (Backup present? Adequate for anticipated equipment?) |
| Lighting |
| Refrigeration |
| Communications |
| Communication (number of phones, local/long distance, intercom) |
| Two-way radio capability to main facility |
| Other factors |
| Ability to lock down facility |
| Oxygen delivery capability |
| Ownership/other uses during disaster |
| Accessibility/proximity to public transportation |
A sample rating scale could be: 5 = equivalent to a hospital; 4 = similar to a hospital with minor limitations; 3 = similar to a hospital with major limitations; 2 = not similar to a hospital but adaptable with minimal modifications; 1 = not similar to a hospital requiring significant modifications; 0 = non-existent or inapplicable.
Once a facility is selected, internal space should be logically organized. A grid system for bed placement, for instance, facilitates patient location and staff rounds (e.g., bed A4). Public health considerations, such as safe food and water, sanitation, and waste disposal, are paramount.6,7
Staffing, Security, and Volunteer Integration
After facility selection, staffing and credentialing healthcare professionals become critical. ACS staff may comprise volunteers, off-duty personnel from primary facilities, retired clinicians, military medical staff, or designated disaster response teams like DMAT. Table 4 provides an idealized staffing model for a 50-bed inpatient ACS operating on 12-hour shifts.
Table 4. Idealized staffing for a 50-bed alternative care site per 12-hour shift.6,7
| Physician, 1 | Physician Extender (Physician Assistant/Nurse Practitioner), 1 | Registered Nurse or Licensed Practical Nurse, 6 |
|---|---|---|
| Health Technician, 4 | Unit Secretary, 2 | Respiratory Therapist, 1 |
| Case Manager, 1 | Social Worker, 1 | Medical Assistant/Phlebotomist, 1 |
| Food Service, 2 | Chaplain/Pastoral, 1 | Day Care/Pet Care, 1 |
| Volunteer, 4 | Engineering/Maintenance, 0.25 | Biomedical Engineer, 0.25 |
| Security, 2 | Housekeeper, 2 | Lab, 1 |
| Patient Transporter, 2 |
Staffing considerations extend beyond clinical roles to include logistical and support functions. Volunteer coordination is essential, recognizing that volunteers may have varied skills and comfort levels with different tasks. Clear role assignments are crucial. Proximity to colleges or universities offers access to a readily available volunteer pool (e.g., student groups, sports teams) for tasks such as patient transport and equipment setup.6,7
Security is a paramount concern in chaotic disaster situations, especially when local law enforcement resources are stretched thin. Implementing robust security plans, including staff identification systems and patient/family access control, is critical. Prioritizing security personnel with experience in patient interactions, particularly those with behavioral health considerations, is advisable. Potential security resources include off-duty hospital security staff, law enforcement officers, National Guard personnel, and vetted volunteers.6 Visible security presence, even ROTC cadets, enhances safety perceptions for both patients and staff.6
Flexibility and adaptability are key. In an ACS environment, staff members must be prepared to perform tasks outside their usual roles, contributing to the collective effort.
Essential Supplies and Equipment: Oxygen and Pharmaceuticals
The specific supplies and equipment required for an ACS are determined by its intended mission, ranging from basic to near-hospital level capabilities (excluding specialized services like operating rooms or radiology). Crucially, limitations in essential resources, such as oxygen, can restrict the ACS’s scope of care. Oxygen and pharmaceuticals are frequently challenging to procure during disasters.
Oxygen Delivery Strategies
Oxygen, typically readily available in modern hospitals, becomes a scarce and costly resource in disaster settings. Table 5 outlines various portable oxygen delivery systems, their flow rates, power requirements, and costs. In resource-constrained environments, oxygen concentrators are often utilized, although large-scale units may require advance procurement. A common, albeit limiting, solution is to restrict ACS admission to non-oxygen-dependent patients. Industrial-grade oxygen, often more readily available, can be a viable alternative in resource-scarce situations. However, biomedical engineers may be needed to adapt industrial oxygen connections for medical equipment due to purity differences compared to medical-grade oxygen.10 Strategies to optimize oxygen utilization, such as reassessing oxygen needs for patients who may not require it, may also be necessary.
Table 5. Oxygen equipment typically available.11
| Oxygen generation systems | Oxygen flow rate (L/min) | Power required (kW) | Cost of unit $1000 | Oxygen purity (%) |
|---|---|---|---|---|
| Expeditionary deployable oxygen concentration system | 120 | 8 | 131 | 93 ± 3 |
| Portable therapeutic oxygen concentration system | 45 | 7 | 40 | 93+ |
| Portable oxygen generation system | 33 | 12 | 35 | 93–95 |
| Patient ventilation oxygen concentration system | 20 | 4.3 | 35 | 93 ± 3 |
| Home oxygen compressor | 3 | 0.2 | 2.5 | 93 ± 3 |
Pharmaceutical Stockpiling and Alternatives
Pharmaceutical needs for an ACS depend on its patient population and scope of services (acute vs. chronic care). In the post-Hurricane Katrina St. Bernard Parish ACS, the pharmacy primarily dispensed chronic medications to military and rescue personnel, utilizing salvaged supplies. It’s important to recognize that many medications have readily available and effective substitutes, which pharmacists should proactively recommend in disaster scenarios.12 Essential pharmaceutical stockpiles for most ACS should include medications for respiratory therapy, hemodynamic support, pain management, anxiety, infection control, and behavioral health maintenance.6,7
Leveraging Disaster Alternate Care Site Tools and Resources
Recognizing the critical need for structured ACS planning, the US Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) issued the Federal Healthcare Resilience Task Force Alternate Care Site (ACS) Toolkit in 2020. This comprehensive toolkit provides detailed guidance on staffing and, importantly, includes a checklist to assess facility suitability for ACS conversion.13 The HHS Healthcare Emergency Preparedness Information Gateway offers a wealth of free resources on ACS, including monographs and training materials (Topic Collection: Alternate Care Sites (including shelter medical care)).14 The California Department of Public Health’s Government-Authorized Alternate Care Site Training Guide is another highly valuable resource.7 Furthermore, the Agency for Healthcare Research and Quality (AHRQ) published three freely downloadable resources in 2009 to aid in ACS identification and operation: the monograph Disaster Alternate Care Facilities: Selection and Operation, and two interactive tools: the Disaster Alternate Care Facility Selection Tool, and the Alternate Care Facility Patient Selection Tool.6 These tools and resources represent invaluable assets for communities and healthcare systems seeking to enhance their disaster preparedness through robust ACS planning and implementation.
REFERENCES
Section Editor: Mark I. Langdorf, MD, MHPE
Full text available through open access at http://escholarship.org/uc/uciem_westjem
Disclaimer: Due to the rapidly evolving nature of this outbreak, and in the interests of rapid dissemination of reliable, actionable information, this paper went through expedited peer review. Additionally, information should be considered current only at the time of publication and may evolve as the science develops.
Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.
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