Welcome back to The Frontline Review, a newsletter written by the Institute for Disaster Mental Health in partnership with the New York State Department of Health. This bi-annual newsletter will cover topics such as responder wellness, burnout, best practices for providing assistance to frontline workers, self-care strategies, and other topics relating to frontline work. If you have topics that you would like to see covered in future issues of The Frontline Review, send us your ideas with the subject line “Frontline Review Topic” at IDMH@newpaltz.edu.
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Staffing for Surge Events: Meeting Unforeseen Demands
Following an acute crisis or mass casualty incident, it can be a challenge to balance the delivery of high-quality care with the significant logistical demands that these events create. These situations often overwhelm the standard operating practices and procedures that hospitals and health systems have in place, as the number of patients needing care - often with a high severity of injuries - overwhelms operating capacity. These crises can involve anticipated events, such as hurricanes or winter storms, as well as “no-notice” events that occur without warning, such as mass shootings, explosions, or transportation disasters (ASPR TRACIE, 2025a). Adequate staffing of health systems is critical to ensure effective care for everyone who may seek services in these instances. Thus, disaster-planning for health systems often includes “surge plans,” which break temporarily from standard operating practices in staffing, in order to meet the increased demands of the situation.
Surge is defined as “the ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system; the ability of the health care system to manage patients who require specialized evaluation or intervention” (Missouri Dept. of Mental Health, 2013). There are four major elements identified in surge planning, often referred to as the “four S’s of surge capacity;” space, staff, stuff, and systems (ASPR TRACIE, 2025a). Of these elements, staffing during these critical surge periods can be especially difficult to manage. This edition of The Frontline Review will examine staff-related challenges during surge events and highlight techniques provided by the US Department of Health and Human Services, Administration for Strategic Preparedness tegic Preparedness and Response, Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) as well as outside research that have been shown effective in meeting the needs that arise in this time of intense demand.
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Four S's of surge capacity: space, staff, stuff, and systems
-ASPR TRACIE, 2025a
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Planning for surge
One of the primary factors that affects planning for staff management during surge events is how much advance notice the hospital system has before the event occurs (ASPR TRACIE (2025a). For anticipated events, such as forecasted storms, administrators can begin surge planning in advance. This can include changing staff schedules in the days leading up to the event to ensure adequate staffing levels during peak surge periods, as well as obtaining necessary equipment and medication that may be in limited supply before the forecast event occurs. Planned events also provide staff themselves with advance warning, allowing them to prepare for the anticipated surge and to make necessary arrangements in their personal and home lives.
Reminder – it is important to ensure the continuity of conventional operations in addition to meeting the surge capacity, as there will be patients that still require care outside of the major incident causing the surge.
However, during no-notice events, hospital systems and staff alike have little, or even no, time to engage in any pre-planning, and instead must act quickly to meet the immediate demands of the situation. These events can be quite chaotic, with little time to ensure that there are enough staff or supplies to meet the surge demand. These challenges can be compounded by any pre-existing shortages of staff or supplies, as the increased surge demand may outpace the readily available supply (ASPR TRACIE, 2024). Especially during events which have broad reach or that continue for extended periods of time, such as infectious disease outbreaks, shortages of personnel, equipment, and medication can be enduring and widespread, since demand may be high across multiple hospitals and it is not clear when additional resources may be available.
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Staffing the surge: call back, step up, and step over
There are three staffing mechanisms that have been found effective during surge events: callback increases the number of staff available, step up increases clinical capacity, and step over redistributes existing staff to where they are most needed. Of course, planning for these staffing mechanisms is critical; staff must be trained in the tasks that they will be required to perform during a surge event (ASPR TRACIE, 2022). It is also critically important that training is provided on a regular basis, to ensure that skills remain current.
Staff callbacks are particularly useful during no-notice events where staffing concerns may be immediate (ASPR TRACIE, 2025a). This method helps to increase the number of staff members available in vital areas, while also allowing extra staff to assist with additional surge-specific tasks. Some tasks that are often required of called-back staff during surge operations include, but are not limited to, conducting patient triage, working with families to identify missing family members, or providing information or reassurance to patients (ASPR TRACIE, 2022). Assigning staff to these non-traditional tasks can free other critical staff to engage in specialty tasks, such as critical surgeries.
If staff cannot be called back, it is then recommended for staff to “step up” or “step over” their normal work duties. These methods are especially useful during no-notice events. ASPR TRACIE (2025a) defines “step up” as providing care for patients at a higher acuity than a staff member may typically manage, such as performing blood transfusions, medication drips, or other processes that can be performed with proper prior or just-in-time training (Jarrett et al., 2022). By comparison, “stepping over” involves applying one’s usual skills in a different setting, such as a NICU nurse assisting in an ICU. In some cases, specialty personnel such as HAZMAT, CBRN teams, and surgical units will also be required to perform specialized tasks (ASPR TRACIE, 2024).
These strategies can also work hierarchically, allowing for staff to function as “extenders” for staff with more specialized roles. For instance, when NICU nurses step over to the ICU, ICU nurses can step up to triage, treat critically injured patients, or staff other specialty jobs like assisting with surgeries. This extends staffing capacity, helping to maintain continuity of conventional care and ensure that all patients receive needed care. Due to the unique needs of surge events, plans for these types of staffing should remain flexible. It can be helpful to have staff trained in multiple secondary roles and skills so that they can be utilized to step up or step over into different roles as the circumstances necessitate. Given that staff will likely be working outside of their normal scope, it is vital to provide regular trainings and practice opportunities, to ensure readiness and confidence when those skills are needed.
Related Resource:
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Staffing to address non-medical needs
Because surge events, especially no-notice events, create such intense operational and clinical exigencies, they often consume all available attention, leaving the emotional, behavioral, and cognitive impacts on patients and family members unattended. Even as most patients will require immediate medical attention, some will present with non-critical issues and still others will be seeking information about the incident, reassurance (such as examination to ensure that they were not contaminated), or information about missing loved ones (ASPR TRACIE 2025a). All will likely have emotional needs that require attention, if only to enable delivery of proper medical care. It is vital to consider the immense staffing needs that are required to triage this large influx of people with such diverse need. Mental health professionals or those trained in early intervention models such as Psychological First Aid may be uniquely suited to support this endeavor.
Planning for adequate, and staffing, physical space is another important operational consideration in surge events. To manage patient influx, health systems may set up auxiliary spaces, such as tents in the parking lot, to complete this triage process or to render non-critical aid (Peterson & Muckey, 2022). This space can also accommodate staff who have been called-back or are assisting through mutual aid agreements (ASPR TRACIE, 2024).
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Supporting staff during surge events
Given the heightened workload, rapid pace, and often traumatic nature of surge events, it’s essential to recognize and address the mental health impact these situations can have on staff themselves (ASPR TRACIE, 2025b). Having mental or behavioral health professionals check-in on other staff members, especially those serving in critical care or stepped-up roles, can mitigate the potential negative behavioral health impacts on staff serving in those capacities. Post-incident debriefings can provide opportunities for staff to learn about the incident and ask lingering questions. Connecting staff who were involved in the surge event with available resources, such as an Employee Assistance Program (EAP), and providing psychoeducational materials about common stress reactions and resilience strategies can assist them in navigating post-event reactions (ASPR TRACIE, 2025b; Gaiser et al, 2023). Ideally, support needs should be anticipated prior to the event, to allow for the creation of a flexible staff wellness and support plan, prior to the overwhelming demand and uncertainty of the event itself.
During surge events, attention to staff mental health and wellbeing is critical to reducing the risk of burnout and compassion fatigue, and to mitigate staff turnover (ASPR TRACIE, 2025b). Recommended strategies include providing staff with a quiet space where they can step away to decompress and reenergize (ASPR TRACIE, 2025b). Peer support services, information about common stress reactions, EAP resources, or self-help strategies, can be offered in this space. Staff trained in Psychological First Aid (PFA) can be available to those who are experiencing stress reactions; some programs even offer support groups to staff members who have worked through the surge event (ASPR TRACIE, 2025b; Missouri Department of Mental Health, 2013). As it is part of the surge, staffing for wellness efforts must be considered too; for example, it is important to ensure that personnel trained to deliver PFA or other mental health supports are available to support staff while maintaining overall operational capacity. Healthcare systems can also assist by providing direct assistance to impacted staff, facilitating referrals to internal and external resources, and providing reassurance about the continuity of employment (ASPR TRACIE, 2025b).
In addition, it is important to recognize the possibility that staff themselves may be directly affected by the disaster event. In these instances, staff may experience related emotional, physical, and financial impacts which can have negative personal impact and can also, in turn, impact their ability to perform their professional duties (Meredith et al., 2010). It is vital to consider what workforce support and resilience strategies can be implemented to help support the needs of staff in this instance.
If possible, consider assigning disaster-affected staff their own "disaster concierge," such as a social worker on your staff, to assist them in their disaster recovery processes.
ASPR TRACIE (2025b) recommends that healthcare systems consider both the immediate and short-term needs of their staff after a major event. Following Maslow’s Hierarchy of Needs (1943), access to food, water, and shelter are primary. This includes things like working with your healthcare system’s cafeteria or food service department before a major incident to ensure availability of food and water for staff (and their families if possible) on site and to take home, if possible. Ensuring that staff members and their families have adequate access to showers, restrooms, and other personal care facilities is also a vital piece to taking care of staff and has the added benefit of reducing the spread of illnesses or contaminants. Access to clothing appropriate to the season is another important consideration, as is access to laundry services. Hosting a donation drive to secure clothing or other necessities to assist impacted staff members and their families can be helpful.
Surge events place extraordinary demands on healthcare systems and working through them successfully depends on the capacity and well-being of the healthcare workforce. Recommendations highlight the importance of anticipating, and planning for, staffing challenges, supporting role flexibility, and anticipating ways that staff will need to be supported as healthcare providers through a surge event and if they are directly impacted. With the increase in patient volume and workforce strain during and immediately following surge events, proactive staffing plans are essential to ensure adequate coverage, role clarity, and continuity of care. In addition, as surge events affect every operational aspect of healthcare delivery, it is especially critical to address impacts on staff by supporting their emotional and physical wellbeing and mitigating burnout for their own wellness and for maintaining a workforce capable of sustaining high-quality patient care.
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Contact Us
Institute for Disaster Mental Health
Science Hall 148
1 Hawk Drive, New Paltz, NY 12561-2440
Phone: (845) 257-3477
Email: idmh@newpaltz.edu
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Watch our Most Recent Webcast!
Click below to watch a recording of our 2026 webcast, Coordinating Care in Crisis: Addressing Administrative and Logistic Demands.
Edward Wurster, a nationally recognized emergency management expert and former Chief Physical Security Officer for PPL Corporation, offers practical insights drawn from his extensive work in the U.S. and abroad. In this webcast, he explores how the greatest challenges in emergency response often arise not from the hazards themselves but from the administrative and logistical barriers that impede effective operations. Drawing on his work Wurster highlights common obstacles such as funding, staffing, and resource access—even during blue‑sky periods. The session offers practical insights to help responders strengthen readiness and improve outcomes for affected individuals and communities.
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Mental Health Resources to Check Out!
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