Disaster management in Hospital: sizing

critical resources
I. Nouaouri, J-Ch. Nicolas, and D. Jolly
Abstract Disaster like terrorist attack, earthquake, and hurricane, often cause a high degree of damage. Hundreds of people
may be affected. In such situations, hospitals must be able to receive all injured persons for medical and surgical treatments.
Therefore, the involved health care facilities have to be well sized to prevent hospitals from becoming overwhelmed. In this
paper, we deal with the preparation phase of the disaster management plan. We focus on the sizing activity of emergency
resources and more precisely operating rooms and associated medical staffs. Therefore, we propose two integer linear
programming models. The first model provides the optimal number of operating rooms which allows the treatment of all the
victims. Taking into account this optimal number, the second model enables to determine the latest ready dates of surgical
staffs. The obtained results show that a substantial aid is proposed by using these models as decision tools for disaster
management in hospital.
Index Terms Integer programming, Disaster preparedness, Sizing, critical resources

1 INTRODUCTION
disaster situation is defined as a serious disruption
of a society that involves a big number of victims.
Such an incident, affects hospitals of all sizes and
geographic locations. The annual report of the Interna-
tional Federation of Red Cross and Red Crescent Societies
proves that the national societies were impacted by 429
different disasters or crises in 2006. This shows an in-
crease of 22% from 2005 and 47% from 2003 [5]. In such
cases, the needs for medical and surgical treatments
overwhelm hospitals capacities planned for standard
operating procedures. For that reason different contries
have plans for emergency preparation and disaster pre-
paredness. For example, in the USA, the Joint Commis-
sion on the Accreditation of Healthcare Organizations
requires hospitals to have a disaster management plan
(DMP). In other countries, like France and Tunisia, state
requirements or laws impose each hospital to have a dis-
aster plan called white plan [23] [24].
Any emergency management plan must address the
following phases: preparation, response, and recovery
[16]. The preparation phase is considered as the driving
force for a successful response. Indeed, it is vital to have a
strong framework to activate in case of a disaster [20]. It
includes all emergency preparedness activities such as
defining medical and technical supplies, maintaining ac-
curate contact lists of the involved actors and conducting
regular exercises with various disaster scenarios. In fact,
during the preparation phase, hospitals should consider
several scenarios of disasters in order to size its resources
according to the number of victims. This is not an easy
undertaking in any hospital setting [16] [20]. This phase
allows the hospital to be able to estimate the additional
resources that may be needed in a given disaster situa-
tion, to keep adequate supplies on hand and to establish
employees emergency planning.
In normal situation, [9] shows that sizing problem in
hospital system is a difficult task for two reasons: the
multiplicity of care flows [11], and the stochastic lengths
of activities composing these flows [11]. In the literature,
many optimization approaches address sizing problems
in hospitals. Most of them focus on critical resources in
normal working times such as hospitalisation beds [7]
[12] [13] [21] and nurses [29] [31]. These last years, the
dimensioning in emergency departments or activities has
become an important issue [1] [8] [22] [32]. Indeed, during
busy times, these departments face operational crisis due
to overloading that stresses staffs and puts patients at
increased risks [26]. Unfortunately, all these works do not
consider disaster situations, which necessitate urgent sur-
gical cares to be performed, while using critical resources
such as operating rooms.
In this paper, we deal with resources optimisation for
disaster management plan or white plan. Emphasis is
placed on critical resources and more precisely on operat-
ing rooms and surgical staffs. Our purpose here is to find
the optimal schedule of surgical cares that minimises the
number of operating rooms needed to treat all persons
injured by the disaster, while satisfying the early ready
dates of surgical staffs (given by emergency planning).
However, the obtained optimal solution can be affected if
staffs have difficulties to access to the hospital. Conse-
quently, we propose to assess the latest ready dates of
surgical staffs that maintain the optimal sizing. This as-
sessment enables hospitals to update the necessary staffs
and to adapt their pre-established emergency planning.
To achieve this, we propose a two-stage integer pro-
gramming model.

- I. Nouaouri, J-Christophe Nicolas and D-Jolly are with the Laboratoire de
Gnie Informatique et Automatque de lArtois, Faccult des Sciences Ap-
pliques, Technoparc Furura, 62400, Bthune.




A
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In section 2 of this paper, we present a literature re-
view about sizing problems in hospital. Section 3 de-
scribes the sizing problem we address in a disaster case.
Section 4 details the two-stage integer programming
model we propose. Section 5 discusses the obtained nu-
merical results given by the integer programs. Finally,
section 6 concludes the paper and presents possible ex-
tensions of this work.
2 RELATED WORKS
Sizing problems are frequently encountered in hospitals,
in order to optimize critical resources (operating rooms,
medical staffs, beds, etc.) [17] [32] and to satisfy health
care requirements. Different works exist in the literature.
They are based on four solving approaches: Markov
chains, mathematical programming, queuing theory and
simulation.
Markov chains have been used by [12] to analyse the
flows of patients among the different care units and there-
fore to assess their stay time in the hospital. The require-
ment on resources such as nurses staff and hospital beds
are then determined.
Several works based on mathematical programming
models have been also proposed [30]. In [31] a three-stage
programming model has been developed. The first stage
of optimization yields the optimal numbers of hospital
beds, nurses and operating rooms. In the second stage,
these resources are assigned to different specialties. Fi-
nally, the other facilities are allocated to specialties con-
sidering the critical resources already sized. [28] presents
a two-stage programming model. The first stage involves
the sizing of beds by room configurations while the sec-
ond stage assigns beds to physical locations with respect
to operational considerations such as physical spanning
and nurses training. [19] and [25] deal with bed sizing
and planning according to the number of admitted pa-
tients. [17] uses the dynamic programming for the sizing
of hospital beds while taking into account the operating
room planning, the availability of nurses staff, the arrival
and exit patterns of patients.
[7] [13] and [21] address the bed sizing problem with
respect to different room configurations. The authors use
queuing theory. The developed models are based on the
flows of patients, their waiting times and their stay times
in the hospital. [1] proposes a model based on a split pa-
tient flow to size different areas of the urgency depart-
ment according to desired performance indexes.
Simulation has been employed in health care systems
[4] [10] [14] [27] in order to better understand and analyse
care activities and, to evaluate impact of decisions.. In this
context, some works deal with the dimensioning of oper-
ating rooms and recovery beds [3] as well as beds in in-
tensive care units [15]. Considering emergency depart-
ments, simulation is also used to adjust medical staffs [32]
and to optimize the configuration of the department by
dimensioning both medical staffs and required beds [22].
In order to decrease the waiting time in the emergency
department, [32] improves the efficiency of the physicians
when eliminating the acts that can be delegated to the
paramedical staff. Also, [32] identifies a "fast" way for the
patients who don't require complementary tests and spe-
cialists opinion. Taking into account materials and pa-
tients constraints, [32] sizes the number of medical staffs
ensuring a normal working.
The literature review shows that few works address
sizing resources in emergency departments [1] [22] [32].
These works focus on daily or seasonal arrivals that ne-
cessitate medical cares and do not take into account sur-
gical cares. In disaster situations, a big number of victims
require urgent surgical treatments thus leading to an
overloading of the operating theatre.
3 PROBLEM DESCRIPTION
Following a disaster, an immediate established pre-
hospital and triage structure is set up near damage zone.
This structure routes victims to the nearby admitting
hospital. The triage allows classifying victims according
to the urgency of the medical and/or surgical cares they
need. In this paper, we consider victims that require sur-
gical cares. Each of them is characterized by an emer-
gency degree which is defined by the latest starting time
of its surgical care and a predefined processing time.
Therefore, the surgical care must be planned before the
vital prognosis of the victim is being overtaken [2] [23].
Each hospital has a maximum of human resources that
should be requested in a disaster situation. Therefore, the
number, configurations and ready dates of surgical staffs
in the operating theatre are detailed in a pre-established
emergency planning. Each surgical staff (composed by a
surgeon, an anaesthetist and nurses) is assigned to an
operating room. In such a situation, all operating rooms
are considered to be polyvalent. The hospital needs to
forecast the minimal number of operating rooms in order
to be able to face a given disaster situation, that is treat
all the sent victims. It has also to identify whether its hu-
man resources are sufficient enough.
Therefore, decision tools need to be developed in order
to optimise human and material resources in disaster
management plan. In this frame, we propose a two stage
programming model. The first stage, named sizing prob-
lem (H
1
), is stated as follows: given a set of victims and a
set of surgical staffs, find an optimal schedule of surgical
cares to be realized, so as all victims are treated. In this
case we minimize the number of required operating
rooms while satisfying some given constraints such as the
ready dates of victims and the establish employees
emergency planning: (ready dates of surgical staffs).
The obtained optimal sizing can be affected when
staffs have difficulties to access to the hospital. Our pur-
pose is to determine the latest ready dates and so slack
times of surgical staffs without altering the optimal num-
ber of operating rooms already obtained. Indeed, accord-
ing to their durations, these slacks can limit the effect of
the tardiness of staffs so as the disruption is absorbed [6]
Therefore, we consider, in a second stage, the following
optimization problem (H
2
): given the minimal number of
operating rooms, find the optimal latest ready dates of
surgical staffs, so as all victims are treated, while maxi-
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mizing the total slacks and satisfying some given con-
straints in (H
1
).
4 PROBLEM MODELLING
We propose a two-stage mathematical model. For each
stage, an integer linear programming model is developed
using ILOG OPL 6.1 Studio.
Before presenting our models, we will first introduce
the following notations:
N number of victims; C number of staffs; T time horizon;
i
p processing time of surgical care of the victim i;
i
dl lat-
est starting date for surgical care of the victim i;
i
dar ready date of victim i;
c
r ready date of surgical staff c
with respect to the hospital emergency planning; M very
big positive number.
Besides, we define the following decision variables:
i
t starting time of surgical care of victim i;
cl
r latest ready
date of surgical staff c;
c
St slack time of surgical staff c
( )
c cl c
St r r = ;







4.1 Model 1: Optimization of the number of
operating rooms
In the first stage, we address the optimization problem
(H
1
). Thus, using the notations listed above, we propose
the following integer linear programming:
The objective function (1) minimizes the number of
operating rooms used in a given disaster situation.

C
c
c
Minimize NO

(1)
Under the following contraints :
1
T C
itc
t c
X =

{ } 1 i ..N e
(2)
1
N
itc
i
X s

{ } 0 t ..T e
{ } 1 c ..C e
(3)
i i
t dl s
{ } 1 i ..N e
(4)
i i
t dar >
{ } 1 i ..N e
(5)
1 0
T T
i c itc itc
t t
t r X M X
| |
>
|
|
\ .


{ } 1 i ..N e
{ } 1 c ..C e
(6)
1
N
ijc
j i
y
=
s

{ } 1 i ..N e

{ } 1 c ..C e
(7a)
1
N
jic
j i
y
=
s

{ } 1 i ..N e

{ } 1 c ..C e
(7b)
1
N N N T
ijc itc
i j i i t
y X
=
=



{ } 1 c ..C e
(8)
T C
i itc
t c
t t X =

{ } 1 i ..N e
(9)
1
j i ijc i ijc
t t y p M( y ) > +

{ } 1 i, j ..N e

{ } 1 c ..C e
(10)
itc c
X NO s

{ } 1 i ..N e

{ } 1 c ..C e

{ } 0 t ..T e
(11)
{ } 0 1
ijc
y , e
{ } 1 i, j ..N e
{ } 1 c ..C e
(12)
{ } 0 1
itc
X , e
{ } 1 i, j ..N e { } 0 t ..T e
{ } 1 c ..C e
(13)
{ } 0 1
c
NO , e
{ } 1 c ..C e
(14)

Constraints (2) ensure that each victim is treated at
least and only once during the horizon T. If the available
human resources are not sufficient these constraints may
not be satisfied.. The hospital is then aware of this im-
portant information and should reinforce its staffs. Con-
straints (3) grantee that every staff makes one surgical
care at most at each time t. Constraints (4) impose to satis-
fy the emergency degree of each victim. Equations (5) and
(6) verify the respect of the availability dates of respec-
tively victims and staffs to begin surgical cares. Con-
straints (7a), (7b) and (8) are disjunctive precedence con-
straints. Equations (9) give the starting times of surgical
cares. Constraints (10) impose no overlapping between
two successive cares made by the same staff. Equations
(11) guarantee that an operating room is used by one
staff; at least one surgical care is assigned to this staff.

4.2 Model 2: Optimization of the latest ready dates
of surgical staffs
In the second stage of optimization, our purpose is to de-
termine the latest ready date of surgical staffs so as to
maintain the optimal sizing given by the model 1. The
mathematical formulation of this combinatorial optimiza-
tion problem (H
2
) is given by the following linear 0-1 in-
teger program.
The objective function (15) expresses the maximiza-
tion of the total slack times of staffs. The slack time of one
staff is defined as the difference between its proposed
latest ready date and its initial ready date with respect to
the hospital emergency planning.

C
c
c
Maximize St

(15)
Under constraints (2), (3), (4), (5), (7a), (7b), (8), (9), (10),
(12), (13), (14) and (16).

Constraints (16) grantee that the surgical cares respect the
latest ready dates of staffs:
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1 0
T T
i cl itc itc
t t
t r X M X
| |
>
|
|
\ .


{ } 1 i ..N e
{ } 1 c ..C e
(16)
5 COMPUTATIONAL EXPERIMENTS
In this section, we present the computational experiments
that are performed using the Cplex solver. We run pro-
grams on a Cluster composed of 6 workstations Bixeon
of 3.00 GHz processor and 2-4 Go RAM. We assess the
performances of the proposed two-stage optimization
model in different situations described on the following.

5.1 Problem tests
Different disaster situations (scenarios) are considered by
making vary the number of victims (N=25, 50 and 70) and
the duration of surgical cares (given between 1 hour and
2.5 hours). Moreover, 11 staffs are available with different
ready dates (R = (r
1
,r
C
), C = 11) according to the hospital
emergency planning. The instance label PN.R means the
problem P involves N victims and ready dates R of staffs.
For example P50.R
5
denotes a problem of 50 victims and
11 staffs among which ready dates in minutes are given
by R
5
, with r
1
= 0, r
2
= 0, r
3
= 30, r
4
= 30, r
5
= 60, r
6
= 60, r
7
=
60, r
8
= 120, r
9
= 120, r
10
= 120, r
11
= 120.
The computational experiments are performed while fix-
ing the time horizon
( )
1
i i
i ,..., N
T max dl p
=
= + . Indeed, after
this date, no victim can be treated. T is decomposed in
elementary periods of 15 minutes.

5.2 Results
The results presented in Tables 1 and 2 are obtained by
solving respectively Model 1 (H
1
) and Model 2 (H
2
). For
each instance, we report the CPU time, the number of
constraints (N.Cont.), the number of variables (N.Var.), the
number of iterations (N.Iter.) and the optimal values of
the objective function denoted by
*
c
NO (H
1
) and
*
ST (H
2
) . C
max
(h) is the Makespan, TM (%) the mean
occupancy rate of operating rooms and NS(%) the rate of
use of the available operating rooms (surgical staffs).

1
N
i
i
*
max c
d
TM(%)
C .NO
=
=



(I)
*
c
NO
NS(%)
C
=

(II)










Table 1 shows the minimal number of operating rooms
needed to treat all victims requiring surgical cares with
respect to staffs ready dates given by the hospital emer-
gency planning. This sizing allows an optimal use of
available resources. For example, to treat 25 victims in
time with different staffs ready dates R
3
, we need five
operating rooms. Therefore, if the hospital possesses a
greater number of operating rooms, only 5 rooms will be
used. Consequently, the remaining rooms can be kept on
hand as safety rooms more particularly in case the disas-
ter became more important than foreseen. Otherwise, the
minimal number of needed operating rooms may exceed
the maximal number of operating rooms. In this case; the
proposed model allows the hospital to estimate how
many modulated operating rooms [23] are needed and to
forecast the associated needed staffs. As a result, the hos-
pital can extend its resources, to avoid the evacuation of
victims to farther hospitals, thus decreasing the risk of
loss of lives.
The number of operating rooms varies according to the
number of victims and the ready dates of surgical staffs.
Some victims, notably those who have a high emergency
level (low latest starting time), are very sensitive to theses
ready dates of surgical staffs. This explains, in some cases,
the increase of the number of operating rooms when we
change the ready dates of surgical staffs (example:
*
c
NO =
5 in case of P25.R
3
and
*
c
NO = 7 in case of P25.R
4
).








TABLE 1
RESULTS OF MODEL 1

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According to table 2, we note that the slacks vary from
one surgical staff to another. Indeed, they depend of ur-
gency of the cares which are assigned to the staff. The
knowledge of the slacks allows to determine the sensitivi-
ty of the optimal sizing toward to the tardiness of staffs.
So that the vital forecast is not engaged, each staff must
have to respect its latest ready date.
The obtained slacks allow the hospital to identify staffs
that must be ready in time (St
i
=0). Without any slack
these staffs need to be requested in a priority way. Slacks
illustrates the various alternatives offered by the optimal
sizing. It might be useful if some surgeons, had difficul-
ties to access to the hospital. Furthermore, these slacks
can absorb disruptions that can occur during operating
schedule such as the overtaking of assessment processing
time. Consequently, if slacks appear insufficient, the hos-
pital can revise the emergency planning of its surgical
staffs. To illustrate this, consider the results obtained for
the instance P50.R
1
(figure 1). Staffs C
5
, C
6
and C
7
have
slacks of respectively 30, 120 and 120 minutes. However,
staffs C
1
, C
2
, C
3
and C
4
(St
1
=0, St
2
=0, St
3
=0 and St
4
=0) must
be available at ready dates indicated by the emergency
planning. The obligatory presence of some staffs in the
hospital at the initial instant, does not raise any problem
since it is always ensured by emergency units. Assume
now, that the surgical staff C
7
cannot be ready to operate
due to an access problem. In this case, the hospital has
other alternatives with non affected staffs C
8
to C
11
.

Another observation stemming from Tables 1 and 2 is
that the computational time increases (the maximum CPU
time is of 21 h 51 mn) with the number of victims. Our
work deal with resources optimisation for disaster man-
agement plan (white plan). So, these high execution times
may be considered compatible with this preparation peri-
od.
6 CONCLUSION
In this paper, we have addressed an emergency prepar-
edness activity tied to the sizing the number of operating
rooms and medical staffs. The suggested approach is
based on a two-stage integer linear programming model.
The first model yields the minimal number of operat-
ing rooms needed to treat all injured persons, while satis-
fying the availability of surgical staffs in the operating
theatre. The second model enables to assess the slack for
each staff, and thus their latest ready dates so as the op-
timal number of operating rooms is maintained. These
slacks aid to identify during the preparedness phase the
different alternatives offered by the optimal solution, thus
assessing the emergency preparedness of the hospital.
The proposed approach allows the hospital to optimal-
ly defines the critical resources, to estimate the additional
supplies to be kept on hand and to revise the emergency
planning of staffs by updating their number, configura-
tion and their ready dates. Another interesting advantage
of this approach is that it proposes a scheduling program
for the involved surgical cares with respect to the ob-
tained optimal number of operating rooms. Nevertheless,
occupation rate of operating rooms is not optimized be-
cause the program can use a new room in order to treat
(save a life) of one or several victim (s). This program is
very useful for the hospital employees training which is
essential for a successful response of a disaster manage-
ment plan.
This approach has been tested on various disaster sce-
narios for which we have shown that we can find the op-
TABLE 2
RESULTS OF MODEL 2
rl
1
=r
1
=0 r
5
=30
r
6
=30
rl
5
=60
C
4
C
5
St
3
= 30
Surgical staffs
Ready dates (mn)
St
1
= 0
St
2
= 0
C
3
C
2
C
1
rl
2
=r
2
=0
rl
3
=r
3
=0
rl
4
=r
4
=30
St
4
= 120
St
4
= 120
rl
6
=150
rc
7
=60
rl
7
=180
C
6
C
7
C
c
: surgical staffc
r
c
: readydate ofsurgical
staffc
rl
c
: latest readydate of
surgical staffc
St
c
:slacktime ofsurgical
staffc

Fig. 1. Slacks of staffs in case of P50.R
5
.
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timal solutions. Further research works should consider
this important issue and deal with auxiliary services (re-
covery room, post anaesthesia care unit, etc.) as well as
sharing critical resources.

ACKNOWLEDGMENT
The authors thank the university group and medical
partners of the project ARC-IR (France) as well as pro-
fessionals of the university hospital Charles Nicole
(Tunisia) and the General Direction of the military
health (Tunisia). We are particularly grateful to Dr.
Mondher Gabouj, Dr. Naoufel Somrani, Dr Henda
Chebbi, Pr. Eric Wiel and Dr. Cdric Goz.
The authors also want to thank the Nord Pas-de-Calais
region, the European Regional Development Fund
(ERDF) and The European Doctoral College that sustain
these works financially.
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