Introduction

Disasters cause physical, economic or social losses by leading to many damages in the places where they occur. As a result of disasters, for hospitals and the general public, when an event that causes a large number of acute injuries and/or patients occurs, it is important to evaluate and plan the number of available beds according to the need. The ability of a hospital to adapt to the sudden influx of patients who need to be hospitalized due to disasters or any other reason is called the ‘surge capacity of hospitals’ (1). Plans for surge capacity should allow the activation of more than one capacity from the routine level to the highest level of the healthcare facility. Therefore, before the disaster, plans for the surge capacity to accommodate a large number of patients should be made for each level.

Correct assessment of the surge capacity is also important when faced with outbreaks of infectious diseases that occur naturally or as a result of bioterrorism (2). In fact, surge capacity is not a new concept, as auxiliary hospitals were used in past smallpox and pandemic influenza events (3). Infectious disease outbreaks such as Severe Acute Respiratory Syndrome (SARS) or pandemic bird flu can potentially be considered as other examples of large-scale events (4).

Hospital Surge Capacity in Disasters

Outbreaks of infectious diseases in recent years have demonstrated the importance of emergency preparedness for major events affecting many people. To be able to respond effectively to events that generate a large influx of patients disrupting daily operations requires an increase in capacity. The main components of the surge capacity can be considered as “personnel, materials, structures and systems”. In addition, a critical component of responding to large-scale disasters is the surge stress capacity (4). Effective health emergency preparedness requires planning of large-scale events that affect many people.

Emergencies and disasters can cause disorganization in social and organizational activities. On the other hand, effective management of these destructive and damaging events depends on anticipating the problems associated with these events and making plans to effectively respond to them. The first and foremost demand of people in these events is their health and well-being; Health systems should therefore play a key role in reducing deaths and injuries. All preparations and planning made by the hospital to cope with disasters constitute an important part of the health system programs used to reduce the loss and disability that may occur (5).

Hospital surge capacity is defined as the ability to provide acute care to both critical and non-critical mass events at the same time, and is an indicator of the ability to provide emergency care in the event of a disaster. The best international practice models for mass patient care state that the number of available operating rooms and the ability to take simple X-rays are the measures of the capacity to care for both critical and non-critical patients. The number of intensive care unit (ICU) beds is also one of the physical indicators of the capacity to provide care to critically hospitalized patients, but there is no internationally accepted criterion for this (6).

Many studies consider the ability to increase capacity in addition to using available resources to manage the sudden flow of injured people or patients with respect to surge capacity. Hospital surge capacity has 3 main components:

1. Human resources,

2. Specific/non-specific equipment,

3. Physical area.

The hospital surge capacity program is dynamic and needs to be constantly reviewed and updated when necessary. Excessive surge capacity programs should be developed and implemented on the basis of assessment and risk analysis. Therefore, before developing this program, risks or hazards threatening hospitals must be identified and hospital’s security gap must be evaluated (5).

Surge capacity is an essential element of hospital disaster management plans and organizational endurance plans. However, the lack of a coherent and integrated approach has consequences that can leave some health facilities and surrounding communities vulnerable. Therefore, fluctuations that may occur in the scenarios created in hospital disaster plans drills may create a problem for hospital managers. For this reason, there is a need for fluctuation capacity protocols based on comprehensive plans that can be implemented in emergency situations (7).

Hospitals may not have sufficient space to accommodate patients in need of emergency medical care. Managers can take action for the sudden provision of additional medical services to meet the increased demand in response to surge capacity. Operational strategies that increase the surge capacity should be studied and how these can be implemented in the most effective way according to the characteristics of the hospitals should be determined (8).

1. Components of Surge Capacity

Surge capacity is defined as a significant increase in resource demand compared to basic demand. Regarding healthcare, surge represents a significant increase in demand for medical or public health resources. In addition to mass influx (volume ratio), surge also consists of event (type, scale and duration) and resource demand (consumption and deterioration) components. Figure 1 shows the surge response capacity as a function of surge capacity (resource availability) and surge (resource demand) components (9).

For natural disaster events, the components of the surge capacity are only defined broadly and many subcomponents are not defined. Also, the relative effect of the various components under different event scenarios is largely unknown. Nevertheless, surge response capacity, which is a new concept, can be expressed as a function of surge capacity and surge characteristics (9).

1. Use of Capacity in Hospitals

To interpret the relationship between the concepts of daily patient capacity and surge capacity; both concepts are similar in terms of struggling a large increase in both medical and public health resource demand and questioning system capacity. However, surge capacity, which is a term used for disaster events, is larger in scale, more complex, and has nonlinear multicomponent interactions incremental with capacity, compared to the simpler daily patient capacity (9).

In an event with a large number of patients, hospital surge capacity is the core of the hospital medical intervention and is an integral part of the total medical capacity of the affected community (10). Hospitals are the first structures that come to mind in health care, but expanded care facilities, community health centers, laboratories and public health departments also constitute the structural component of the surge capacity (4).

Operational decisions involved in managing surge capacity can be evaluated within a broader conceptual framework consisting of four stages: preparedness, response, recovery and mitigation (Figure 2).

Hospitals establish the hospital capacity during the preparation phase and determine the resources that can be used in emergency situations. During the response phase, the hospital responds to the emergency and controls its negative effects. During the recovery phase, the hospital continues its normal operations. In the mitigation phase, the hospital takes measures to reduce the severity and impact of an emergency on its operations (11).

Pandemic

Pandemics are disease outbreaks that are widespread, mostly as a result of the spread of infection from person to person and are declared by the World Health Organization (WHO) (12). The impact of the pandemic at the community level varies depending on the contagiousness of the microorganism, its virulence, the immune status of the individuals in the society, the contact among the individuals and transportation characteristics among societies, the presence of risk factors, the health services provided and the climate. Throughout human history, many important pandemics such as smallpox, cholera, plague, dengue, AIDS, influenza, SARS have been recorded (13).

1. COVID-19

The first coronavirus case was reported as a common cold in 1960. In a study conducted in Canada in 2001, a flu-like disease was observed in approximately 500 patients. It was confirmed by polymerase chain reaction method that 17-18 cases were infected by coronavirus during this pandemic. Corona was considered a simple non-fatal virus until 2002. In 2003, various reports were published with evidence that the coronavirus spread to many countries such as the United States of America, Hong Kong, Singapore, Thailand, Vietnam and Taiwan. In 2003, more than 1,000 cases of SARS were reported in coronavirus-infected patients who experienced the fatal syndrome (14).

The acute respiratory infection pandemic that we are currently experiencing, caused by COVID-19, occurred on December 12, 2019 in Wuhan, China, possibly caused by bats in a seafood market. Studies have suggested that the bat may be a potential reservoir of SARS-Coronavirus-2 (15). On January 7, 2020, it was announced that the causative virus was a new coronavirus (2019-nCoV) that was not previously detected in humans. Then, the name of the 2019-nCoV disease was accepted as COVID-19 (16). It is the seventh coronavirus causing disease in humans. The virus is named this way because of its crown-shaped (corona) protrusions (17).

Surge Capacity in Pandemics

Planning an unpredictable, effective, long-term and widespread health emergency is difficult, but imperative. It requires a “social integration” and a coordinated effort in which all public stakeholders collaborate (18). Significant assessments should be made when public health decisions are needed to be useful. For this purpose, a serious risk assessment should provide as much information as possible about an emerging outbreak to answer the following key questions.

- How fast do new cases occur?

- What types of diseases and complications are observed?

- Which groups of people (eg. age groups or groups at risk of serious consequences) will become severely ill and die?

- Is the microorganism sensitive to antimicrobial agents?

- How many people will get sick?

- How will it th affect the health sector, including factors such as healthcare use and impact on the health workforce?

Operationally, these questions will help guide decisions regarding vaccine production and strategy for its use, antimicrobial use, mobilization of health resources, school closures, and other social distancing strategies (19).

In the occurrence of a complex emergency pandemic, it is very important to detect and verify the outbreak from the beginning so that resources can be scaled correctly and used efficiently. In addition to all factors, patient surveillance in a hospital and communication infrastructure against risks are vital for controlling and struggling epidemics (7). It is recommended that hospital management move to a team that can provide clinical surge capacity and deploy quickly during the outbreak (20).

In pandemics, the primary care system is always needed to be sensitive and high-capacity. Pre-hospital screening and pre-hospital and post-hospital care are crucial to patient survival. Since there will be an intense increase in patients in the event of an epidemic, it is unthinkable for the emergency department to provide healthcare services to all patients or for hospitals to accept patients and provide care without evaluating the status of alternative facilities (21).

Epidemic and pandemic planning offers the opportunity to integrate the primary, secondary and tertiary levels by using the rules of public health and the public administrative resource infrastructure in increasing the health capacity in primary care and in the care service. With this planning, patients are helped to receive health care services at home with primary care under the supervision of a doctor (21).

It is difficult to respond to the need for healthcare services that will arise with the occurrence of excessive capacity increase in infectious disease epidemics and similar emergency health situations. There may be problems in meeting the need for extra bed (2).

Healthcare professionals have a responsibility to treat as many patients as possible to survive in a disaster or emergency. Responsible personnel evaluate patients under limited conditions and resources in the field of triage and rank them for treatment priority. Correct triage management is achieved by ensuring medical success with scarce resources. Triage is valid for all disasters regardless of their size (2).

In the event of a pandemic, home care may not be provided for pandemic influenza patients with complex respiratory management needs. Instead, some patients who need hospital-level care but do not need 24-hour supervision are provided care at home. By providing home care for these patients, hospital beds can be used for severe pandemic patients (22).

1. COVID-19 Surge Capacity Strategies

When designing health systems, the study is done according to the average patient load, not the number of patients that will arise in the presence of the epidemic. With the occurrence of COVID-19, it is seen that countries with a high number of patients are faced with a patient burden far above the capacity of health centers. For example, a study by Imperial College suggested an 8 to 30-fold increase in health system capacities for the UK and the USA (23).

The high rates of serious and critical cases in the development of the evolution of the epidemic in some countries have shown that the surge capacity must be increased rapidly in order to prevent the rapid depletion of medical supplies and the shortage of health personnel. It has been observed that the increase in cases has doubled or become more in three days in some countries. According to the largest cohort of COVID-19 patients, it has been observed that this disease is a mild disease that is symptomatic but does not require inpatient care in 40% of patients; a moderate disease that will require inpatient care in 40% of them; a disease requiring oxygen therapy or serious patient intervention in 15% of the patients; and a critical disease requiring mechanical ventilation in 5% of cases (24). This shows that 55% of patients need inpatient treatment. Considering the number of cases here, the available hospitalization areas may not be sufficient for the number of patients that will arise as a result of the surge capacity. A 4-item strategy has been considered to increase capacity (25).

a. Trying to reduce the number of COVID-19 cases in order to increase capacity: Explaining the ways of protection against the virus to the society, directing non-emergency patients to alternative health centers instead of emergency services, urgently discharging patients who need to be discharged, and postponing all unnecessary health services.

b. Establishment of alternative health facilities: Foundation of alternative medical centers (underground hospitals, field hospitals, activation of non-used/closed hospitals, use of nursing homes as health centers). Using places that do not provide medical services as health centers (public spaces, hotels, dormitories).

c. Minimizing the resource consumption of admitted patients: Giving patients only the health care they need. Patients should not be admitted to the isolation room except when necessary.

d. Increasing bed capacity: Taking low-risk patients into non-used areas for regular health care provides more space for high-risk patients who need ICU. Any area that provides a room standard and isolated environment can be used.

The Monroe State Administrator of the United States, Adam Bello, and health officials, which has been most affected by the COVID-19 virus, explained the stages of the plan for the surge capacity as follows (26);

Stage one: Make existing beds available and delay any non-emergency surgery.

Stage two: Transform the busy or outpatient clinics of the hospital into areas that can provide patient care.

Stage three: Expand into unconventional physical spaces, transform spaces such as corridors into patient care rooms, double the number of non-COVID-19 patients in private rooms.

Stage four: Create a field hospital.

2. Surge Capacity Strategies Against COVID-19 Pandemic in Turkey

With the occurrence of the COVID-19 crisis, countries have taken some measures to reduce the effects of the emerging crises. Forty-six of the 214 world countries (21.5%) announced at least 97 measures in response to the COVID-19 outbreak in the first periods of the pandemic (between February 1 and March 22, 2020). Thirteen countries (28.9% of the countries in the region) in the Asia and Pacific region, where the epidemic originated, announced the measures they took against the crisis. Later, 11 countries in Europe and Central Asia (36.2%), 11 countries in the American continents (24.4%) and 1 country in Arab countries (8.3%) explained the measures they took (Figure 3) (27).

The first COVID-19 case in Turkey was a patient who was detected to catch the virus as a result of a contact in Europe on March 11, 2020. In order to minimize the negative effects of the virus after the occurrence of the first case, the government of the Republic of Turkey started to work urgently for taking precautions with the guidance of the WHO and the Republic of Turkey Ministry of Health. The measures emerging as a result of these studies were put under a heading and published by the Ministry of Health (28);

1. Precautions to be Taken in Blood Centers

2. Measures to be Taken for Protection from COVID-19 in the Provinces where Seasonal Agricultural Workers will Go to Work

3. Measures to be Taken for Morgue and Burial Services

4. Precautions to be Taken at Airports

5. Recommendations for Security Control and Passport Officers at Airports

6. Precautions to be Taken in Accommodation Facilities

7. Cleaning Measures for Public Transportation Vehicles

8. Protection and Control Measures in Bank Branches

9. Measures to be Taken in Food Markets

10. Precautions to be Taken in Restaurants

11. Precautions to be Taken in Nursing Homes and Elderly Care Centers

12. Precautions to be Taken in Traditional and Complementary Medicine Units & Centers and Beauty & Medical Aesthetic Centers

13. Measures to be Taken in Penal Institutions of the Republic of Turkey Ministry of Justice.

Turkey has brought some rules for social measures in the context of determined struggle with COVID-19 pandemic;

- Airway transportation to 20 countries was stopped.

- A 14-day home quarantine obligation was imposed for citizens from abroad.

- Primary schools, high schools and universities were closed, and education activities were initiated on the internet from home.

- Administrative leave was given to pregnant women working in the public sector, those on breastfeeding leave, the disabled, those with chronic illnesses and personnel over 60 years of age until a second decision.

- A decision was made to work in turns for personnel in public sector.

- In order to raise the awareness of the public, public service announcements were started in all social media areas on the issues of virus protection and providing social distance.

- In all metropolitan cities (31 provinces) in the country, a curfew was imposed on weekends.

- The permissions of the soldiers in the barracks were stopped.

- Visits and transfers in penal institutions were suspended.

- Non-urgent trials and other judicial proceedings were postponed.

- Cultural and artistic activities were postponed.

- Mosques and masjids were closed to worship.

- Restrictions for going out were imposed first for citizens over the age of 65 years and then for those under the age of 20 years in Turkey.

- All scheduled national and international scientific activities, open and closed meetings, congresses, conferences, military exercises, paid military service calls were postponed.

- Activities where people come together, such as general assemblies and training activities, were postponed.

- Football, basketball, handball and volleyball competitions were postponed due to the COVID-19 outbreak until a new decision.

- The activities of places such as coffee houses, cafes, cinemas, theaters, concert halls, wedding halls, Turkish baths, sports halls, internet cafes, indoor children’s playgrounds, condolence houses were temporarily suspended.

- Activities of entertainment places such as bars, casinos, and nightclubs, anf of museums and libraries were stopped.

- Production of protective equipment was increased in the public and private sector. Support was provided to many textile companies for the production of protective equipment. The sale and export of all protective equipment produced was prohibited.

- A local ventilator was designed and its production was started.

- Free masks were distributed to all citizens by the state.

- The number of laboratories for the detection of COVID-19 cases was increased to 36 within the country.

In addition, in order to prevent surge capacity in hospitals;

- At the hospital entrances, the pre-triage area was determined and the patients with suspected covid were identified.

- Non-urgent surgeries were stopped in order to minimize the density in health institutions and alleviate the burden on health personnel.

- All public and private hospitals were accepted as pandemic hospitals and started to serve free of charge for epidemic treatment.

- The number of hospital ICU beds was increased.

- Planning and preparations were made to transform normal patient rooms and operating rooms into ICU beds in case of need.

- In order to use the existing beds for COVID-19 infected patients, inpatients who did not have an emergency situation were discharged and followed up at their homes.

- When the symptoms of COVID-19 positive patients were improved, their treatment was planned and their quarantine processes were completed at their homes.

The COVID-19 pandemic has shown that the world may face an epidemic that will be devastating at any moment. As can be seen from the number of cases and deaths around the world, the health system in the world is not prepared for such big epidemic risks. Turkey has revealed a health care system that will be an example to the world in terms of the rates of cases and mortality, with the measures taken after the occurrence of the first case and strong infrastructure of the health system.

According to the COVID-19 Status Report published by the Ministry of Health on 30.06.2020, the total number of hospitalizations due to COVID-19 in Turkey is 105,416 (29). Currently, hospital capacities are sufficient; however, against future epidemic risks that may arise at any time, the construction of two pandemic hospitals with a capacity of 1000 beds has been started in the district of Sancaktepe in Istanbul and in the Atatürk Airport area, which is closed to use, in Yeşilköy district. While each room of the hospitals is prepared for a single person, each room can be converted into an ICU room if needed, and both will have a fully-fledged hospital infrastructure.

Investigation of Surge Capacity in the COVID-19 Pandemic with SWOT Analysis Matrix

By conducting a SWOT analysis of the surge capacity in the COVID-19 pandemic, the strengths, weaknesses, opportunities and threats to be encountered were evaluated.

1. SWOT Analysis

The SWOT analysis applied is shown in the table below (Table 1).

For strengths, the strongest part emerging in the pandemic is the database on viruses. Knowing the viruses that have been seen before, their sources and treatment methods have created an important source of information in the fight against COVID-19. Despite the speed of the virus spreading, the ability to instantly share scientific studies on treatment in various parts of the world with the technological infrastructure is another strength, even if they are not approved. It is very important to use the press and social media correctly in order to slow the spread of the virus and to raise the awareness of the society. The rapid adaptation of the society to the pandemic process is effective in reducing the rate of spread of the virus.

For weaknesses, first of all, we can accept that the components of the virus are unknown and there is no vaccine to be used in treatment and prevention, as they negatively affect the treatment process. This not only delays the application of treatment methods against the virus, but also negatively affects the process of finding a vaccine that will be effective against the virus. The late detection of the source of the virus is one of the most important weaknesses for this process, because it directly affects the treatment process. Insufficient number of patient beds during the treatment process may prevent patients to access treatment. It can prevent the treatment of patients who need to be kept under surveillance at the hospital. Another important weakness is the insufficient number of health personnel to take part in the pandemic. A small number of personnel working at a busy pace can negatively affect the treatment process, and may cause transmission by reducing the resistance of the personnel to the virus. Also, the insufficient stocking of the drugs used in the treatment process is another important weakness. In case of pandemic risks that may arise at any time, not having enough medicine stock may negatively affect the treatment process. One of the most important weaknesses that directly affect the spread of the virus is the insensitivity and misconsciousness of the society to protection methods against the virus.

For opportunities, it is important to obtain new data in order to take precaution in advance against new types of viruses that may emerge. Making new plans for increasing the number of healthcare personnel in the occurrence of the pandemic, designing alternative physical places for hospitalization, facilitating the supply of drugs to be used in the treatment process, and providing protection materials (such as respirator, mask, gloves) can be considered as important opportunities.

For threats, the lack of information about the virus is a major threat that delays the availability of the vaccine. The insufficient number of healthcare professionals involved in the treatment process is an important factor that negatively affects patient treatment. Insufficient treatment areas and patient beds are among the biggest threats to patients’ access to treatment. Incomplete or incorrect stocking of drugs to be used in the treatment process will negatively affect the treatment. Failure to raise the awareness of the society correctly and in time poses a serious threat to the rapid spread of the disease.

2. SWOT Matrix

The SWOT Matrix was applied to make a decision by focusing on strategically important elements with the data obtained through SWOT analysis. The SWOT Matrix applied is shown in the table below (Table 2).

Conclusion

The occurrence of pandemics is not limited to the winter season, and unlike seasonal flu, they can occur at any time of the year. In addition, they are not limited to a specific time and place, unlike an epidemic. Planning and measures to be taken before the epidemic occurs determine the level of economic and social impacts of the epidemic. The course of a pandemic can be reduced by effective infection control measures. The first of these control methods is to be prepared. Rapidly increasing urbanization also increases the patient burden in the health system. In parallel with this increase, in addition to strengthening the health system, planning should be made against possible outbreaks. Experiences have shown that no matter how advanced the health systems and technology in the countries are, there may be an epidemic situation beyond predictions. At this point, the resistance of existing health systems and technology cannot be a savior. It is necessary to make alternative plans and produce solutions against the worst scenario that may arise. The excessive resource need arising in the surge capacity experienced in a pandemic should be evaluated correctly and planning should be done accordingly. The pandemics that caused great losses have shown that one of the biggest resource demands is in physical areas. For this reason, it is necessary to create alternative areas. It is necessary to design underground parking lots of hospitals as underground hospitals and evaluate other closed areas within this scope, and to plan parks and reserve areas in cities for the establishment of field hospitals in case of any disaster. With these plannings, the physical space demands that will arise in response to the surge capacity can be met.

Peer-review: Externally and internally peer-reviewed.

Authorship Contributions

Concept: M.N.K., Ö.E., Design: M.N.K., Ö.E., Data Collection or Processing: M.N.K., Ö.E., Analysis or Interpretation: M.N.K., Ö.E., Literature Search: M.N.K., Ö.E., Writing: M.N.K., Ö.E.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.