Harbor:Surge plan: Difference between revisions
 
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==Closing to EMS (ALS) Ambulances "ED Sat"(uration)==
==ALS Diversion==
* Joint decision by the AED charge nurse and AED attending
* The goal of diversion is to ensure safety of current ED patients and of patients being transported by EMS by:
** Allowing staff time to move patients within or through the ED to free up space/staff resources.
** Allowing the ED time to prepare for next round of sick patients.
* ED Saturation (aka Diversion) is a process of marking the ED in the countywide ReddiNet system as “closed” to adult Advanced Life Support (ALS) arrivals.
** “ALS ED Sat” does NOT redirect BLS arrivals or specialty center patients arriving to Harbor (e.g. Trauma, STEMI, Perinatal).
** ALS ED Sat” lasts for two hours but can be ended earlier.  At the end of the two-hour diversion, ReddiNet will automatically re-open the hospital to ALS.
** If the nearest alternative ED is also noted as “ALS ED Sat”, ALS ambulances will be directed to the closest ED, regardless of “ED Sat” status on ReddiNet.
** “ALS ED Sat” is not a command, but a suggestion. EMS can still bring the patient to the MAR if it is considered to be the safest decision (e.g. patients in extremis)
 
'''Guidelines for ALS Diversion triggers''':
* Consider when not enough space to care for the next critical patient coming by ambulance
** Not enough treatment spaces despite decompress patients to other beds/hallway
** Not enough staff (RN, RT, provider, etc.) or supplies (vents, blood, etc.)
* Diversion is a joint decision by the MICN, AED charge nurse, AED attending(s), Overall Charge Nurse (OCN)
** Consider carefully as it results in longer transport times for potentially critically ill patients
** Consider carefully as it results in longer transport times for potentially critically ill patients
** Indicators to consider:
** OCN & Attending names are recorded in the ReddiNet as the Authorizing personnel
*** NEDOCS>140 (must be done hourly while on diversion status) '''and''' Hospital Surge level
 
*** EMS closure criteria
* '''Indicators to consider''':
*** Surrounding hospital status  
** NEDOCS>140 (must be done hourly while on diversion status) '''and''' Hospital Surge level
*** All ED rooms are full (Peds=18, AED=34 [Tr 1-5, AED 1-23, RME 6-9, 13-20]) and 30% or greater of the ED patients are ESI1, ESI2, or admit boarders
** EMS closure criteria
** '''If group decision is to close, proceed with the 1 hour ED closure;  must reevaluate the department before going on ED ALS diversion again'''<ref>Harbor ED Policy 20.4, LA County EMS policies 503, 506, & 513</ref>  
** Surrounding hospital status  
***Closure to ED saturation should always be accompanied by closure to interfacility, ED to ED, and other transfers through the Medical Alert Center (MAC). All MAC closures are discussed with the Patient Flow Facilitator (PFF) or Administrative Officer of the Day (AOD).
** All ED rooms are full (Peds=18, AED=55 [Tr 5 beds, AED 22 beds, RME 6-9, 13-20, Gold 16 beds]) and 30% or greater of the ED patients are ESI1, ESI2, or admit boarders
* '''If group decision is to close, proceed with the 1 hour ED closure;  must reevaluate the department before going on ED ALS diversion again'''<ref>Harbor ED Policy 20.4, LA County EMS policies 503, 506, & 513</ref>  
**Closure to ED saturation should always be accompanied by closure to interfacility, ED to ED, and other transfers through the Medical Alert Center (MAC). All MAC closures are discussed with the House Supervisor/Patient Flow Facilitator (PFF) or Administrative Officer of the Day (AOD).
* Other potential reasons for ambulance diversion:
* Other potential reasons for ambulance diversion:
**CT:  based on the availability of alternate scanners;  AED Attending will notify the ED Overall Charge for Reddinet entry
** CT:  based on the availability of alternate scanners;  AED Attending will notify the ED Overall Charge for Reddinet entry
**Trauma:  joint decision by Trauma and ED Attendings;  based on equipment issues, OR unavailability, primary and backup trauma team encumbrance  
** Trauma:  joint decision by Trauma and ED Attendings;  based on equipment issues, OR unavailability, primary and backup trauma team encumbrance  
**Peds:  PED Attending contacts ED Overall Charge RN to close via Reddinet;  PICU beds have no influence on PED diversion status
** Peds:  PED Attending contacts ED Overall Charge RN to close via Reddinet;  PICU beds have no influence on PED diversion status
** STEMI: Joint decision amongst Interventional Cardiologist, AED Attending, House Supervisor, and ED Overall Charge Nurse;  due to cath lab team encumbrance, mechanical failures, or internal disaster;  automatically re-open after 3 hours unless further diversion is deemed necessary  
** STEMI: Joint decision amongst Interventional Cardiologist, AED Attending, House Supervisor, and ED Overall Charge Nurse;  due to cath lab team encumbrance, mechanical failures, or internal disaster;  automatically re-open after 3 hours unless further diversion is deemed necessary  
** Internal Disaster (see https://www.wikem.org/wiki/Harbor:Disaster_plan)
** Internal Disaster (see https://www.wikem.org/wiki/Harbor:Disaster_plan)
** Helipad: due to unsafe landing conditions, damage to the helipad, current helicopter on the pad, deployment of the decon trailers for a large Hazmat incident; MAC must immediately be notified of closure
** Helipad: due to unsafe landing conditions, damage to the helipad, current helicopter on the pad, deployment of the decon trailers for a large Hazmat incident; MAC must immediately be notified of closure


Schlesinger/Chappell  2/14/19


==Surge Plan==
==BLS Diversion==
*There are three levels of surge.  The surge level is determined by meeting the "Resource Utilization Indicators" (see below). When a surge level is met, the patient flow facilitator, in consultation with the ED attending, will enact the surge plan. Alerts go out to all hospital departments. If you think criteria have been met to activate the Surge Plan - contact the Patient Flow Facilitator at '''68647''', x3434, or pager x0939.
* “BLS ED Sat” is added to ALS ED Sat and marks the ED in the countywide ReddiNet system as “closed” to all ALS and BLS arrivals.
* “BLS ED Sat” does NOT redirect specialty center patients arriving to Harbor (e.g. Trauma, STEMI, Perinatal).
* Very serious decision given consequences to community. Only to be used when situation in ED is felt to be truly unsafe for patients.  
* '''Requires hospital administration approval'''
* If MAC closes us to BLS due to prolonged APOT times, the closure is for 4 hours;  if this occurs, please notify ED AOD


*Refer to [https://wikem.org/wiki/Harbor:Infectious_Disease_Threats#Covid_Surge_Plan|ED_Surge_Plan]  for things we can do internally to maximize use of ED space and when to escalate to DEM admin on call and Clinical Nursing Director.


'''Guidelines for BLS Diversion triggers''': Requires hospital administration approval
*Above ALS diversion triggers AND
*'''3 patients in ambulance triage waiting >60 min''' AND one of the following:
**At least 2 #ESI 2’s in waiting room
**WR #s = 50-60
**WR LOS = >12hrs
**No trauma bays open
*ED request for “BLS ED Sat” must come from the Clinical Nursing Director and ED AOD via the OCN and Attending. Hospital approval by CMO/CEO or designee.
*Request is made by phone to the MAC on behalf of the CMO. Cannot be done via ReddiNet


===What Happens at Different Surge Levels===
Schlesinger/Chappell/Wu  5/5/22
*Level 1
**Ambulance Diversion (Diversion is for ALS only, never BLS)
**Four RME Rooms should be converted to Fast Track if not already done
**Assign residents as available to staff the extra Fast Track rooms
**UR Nurse works with Hospitalist and Admitting Residents to identify 2.76 Transfers (Hospitalist and Nurse Analysts look for patients to transfer that County will find special funding for)
**Charge nurse facilitates full staffing of all areas by reallocating staff as available
**PFF communicates to Nurse Managers to get timely discharge/transfer orders from inpatient teams


*Level 2
==Surge Plan==
**Above and:
* There are three levels of surge.  The surge level is determined by meeting the "Resource Utilization Indicators" (see below). When a surge level is met, the patient flow facilitator (PFF), in consultation with the ED attending and OCN will enact the surge plan. Alerts go out to all hospital leadership. If you think criteria have been met to activate the Surge Plan - contact the PFF at '''68647''', pager x0939. It is based on current criteria, NOT what may happen in a few hours. 
**Identify 1 or more stable/not newly admitted ICU patients for transfer to LAC-USC or Rancho.  
**CMO or designee determines if need to cancel scheduled admissions, elective surgeries; requests department chairs to provide list of pending downgrades and discharges


*Level 3
* Refer to [https://wikem.org/wiki/Harbor:Infectious_Disease_Threats#Covid_Surge_Plan|ED_Surge_Plan] for things we can do internally to maximize use of ED space and when to escalate to DEM admin on duty and Clinical Nursing Director.  
**Above and:
**CMO or designee makes determination to go on Diversion to Trauma
**AOD consult hospital leaders if need to open command center.  


* Things to consider in ED for pre-surge with OCN:


(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)
** EMS
*** Consider closure to ALS to decompress rooms for next sick patient
*** If prolonged APOT times, BLS agency may call MAC and have us placed on "BLS Sat"


===Resource Utilization Indicators (Need any 3)===
** Triage
* Policy 337
*** NA/router to help take vitals before triage
* ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5
*** Second RN to help check in patients into WR
*Pre-Surge
*** FT provider to help triage catch up - get wait to MSE <30 min and review WR lab/imaging results
** Hospital LEAN initiative to avoid overcrowding
** Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending


*Level 1
** ED
**NEDOCS >140
*** DC to chairs - chairs outside rooms or in waiting room (WR) for discharge for quicker room cleaning for next patient
**> 50 Patients in Triage/Waiting Room (WR+R5)
** Maximize use of all available rooms
**> 11 boarders in AED (if beds are assigned, get them moved upstairs)
*** Can see AED patients in PED - thoughtfully select patients
**Inpatient census > 320
*** If nursing available, utilize shared vertical room model (1 RN, 4 chairs to room, 2nd room next door to eval patients);  with 2 nurses, can see 8 patients in 4 rooms
**Low inpatient bed count (<16 Ward '''''OR''''' <5 ICU/PCU beds)
** Flex to hall space
***'''Based on current conditions, not beds that will be coming''' (will go off surge when conditions are no longer met)
*** Disaster (X-hall) chairs
*** Ward should include unstaffed ward beds as they can be utilized in surge conditions per CEO
*** PWR overflow treatment chairs
*** Admitted ward patients to hall


*Level 2
** Inpatient pre-surge:
**NEDOCS >180
*** Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending
**> 50 Patients in Triage/Waiting Room (not including RME/tasking/internal WR like R5,R6,or R12)
*** Maximize use of discharge lounge
**> 14 boarders in AED
**Inpatient census > 330
**Lower inpatient bed count ('''EITHER''' <11 Ward AND <3 ICU/PCU beds '''OR''' No "Bump Bed" for Trauma or STEMI)
**4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU


*Level 3
** Prolonged Surge
**NEDOCS 200
*** Consider Urgent Care Clinic (UCC) expanding scope to include Out of Plan (OOP) patients (CMO approval required)
**> 75 Patients in Triage/Waiting Room (not including RME/tasking/internal WR like R5,R6,or R12)
*** Consider adding additional ED physicians if nursing available to help with completion of care
**> 17 boarders in AED
** No available gurneys, chairs or monitors for new patients in ED
**Inpatient census > 345
**Low inpatient bed count (<5 ward '''OR''' 0 ICU/PCU beds with no "Bumps")
**5 or more patients in the Recovery Room (PAR - x65189) awaiting ICU/PCU/SDU


(Hosp Policy 337)


* '''DRAFT COVID CHANGES'''
===Resource Utilization Indicators (Need any 3)===
** '''NEDOCS updated to reflect current 43 rooms'''
* Policy updated on 4/2022 [[:File:337 - Surge Capacity Plan.pdf]]
** '''WR max for social distancing is ~40 patients'''
* ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5 and ambulance triage (ATri)
** Max inpatient capacity ~272?
** define boarder


* (Surge 1 criteria)
* Level 1 Criteria: near max capacity for ED and inpatient with demand expected to increase
** '''inpt 260 (95% staffed capacity)'''
** 50 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
** ''''40 in WR'''
** 16 or more boarders in ED (hospital icon for admission orders up)
** '''increase to 14 boarders (OCN to include the +2 psych boarders) for 2 hours''' (stays at 33%)
** 5 or more ESI2s and Amb Tri waiting to be seen
** PFF/OCN huddle - OCN provides the total numbers (psych boarders, WR=AWR+EMS+R1-5)
** PACU at capacity (PFF will know)
** Sue - add EMS wall patients ... '''include ATri as WR''' with time on wall ... currently counted as acute patients, not waiting room -> should be in WR
** ED staffing in yellow (no breakers)
** Sue wants time of boarding, level of boarding ... ICU heavier weight (RN out of ratio)
** 2 or more inpatient units' staffing in yellow
** Sue - remove the inpt bed capacity
** Sue - AED COVID ICU patients
** Nancy - can open 4th ward bed in room when we have nursing


* (Surge 1 response) 
*Level 2: max capacity for ED and patient and additional resourced needed to meet demand
** fully staff RME
** 60 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
** 8 RME rooms to FT
** 8 or more ESI2s and Amb Tri waiting to be seen
** maximize use of PED
** 20 or more boarders in ED (hospital icon for admission orders up)
** surge into unstaffed ward beds out of ratio - waiver until 12/31 (Law was passed Jan 2020 - creates financial penalty)  
** PACU at capacity (PFF will know)
** '''inpt rounding at least 2x/day'''
** ED staffing in red (charge RNs in ratio)
** IM attending make right level of care decision
** 2 or more inpatient units' staffing in red
** '''UM pressuring for outpt workouts'''
** '''use 95% staffed capacity'''


* (Surge 2 criteria):
*Level 3
** 16 boarders
** 75 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
** inpt 270)
** 10 or more ESI2s and Amb Tri waiting to be seen
* (Surge 2 response):
** 30 or more boarders in ED (hospital icon for admission orders up)
** delete obs/core admissions
** PACU at capacity (PFF will know)
** prioritize DC from ED
** ED staffing in red (charge RNs in ratio)
** facilitate home O2 & home health f/ups
** 3 or more inpatient units' staffing in red


* (Surge 3 criteria):
===What Happens at Different Surge Levels===
** 19 boarders
* Level 1
* (Surge 3 response):
** Actions from pre-surge (see above)
** delete obs/core admissions
** Consider ambulance diversion (ALS only)
** 8 hallway chairs
** Discharge patients to the WR to wait for transportation when appropriate
** backup ED team
** UCC to see all ESI4/5s (no exclusions) --> RME Director and UCC Director to coordinate
** OR/PACU: Hold patients in OR and procedural areas if PACU full
** ED Charge RN communicate with boarder admitting team for downgrades/discharges
** ICU identifies stable patients to transfer to Rancho Los Amigos or LAC+USC
** Transfer female patients to open 7W rooms
** Inpatient charge RN identify potential downgrades/discharges w/in 2 hours of Surge 1 being declared
** Get additional nursing to work in ED and inpatient areas


===Adult ED Attending Standard Work During Severe ED Overcrowding===
* Level 2
** Above and:
** Close to ALS for 1-2 hours to decompress
** Evaluate patients to see if they can be moved out of ED monitored rooms into hallways or chairs to free up monitored rooms
** Utilization Management (UM) request transfer to capitated hospitals, and transfer for decompression or lower level of care
** Reschedule end of day Tier 2 procedures/surgeries (care needed w/in 2-4 weeks) and above inpatients
*** Surgery/Procedure Acuity Tiers
**** Tier 0 - needs immediate care
**** Tier 1 - care needed w/in 2 weeks
**** Tier 2 - may need care w/in 2-4 weeks
**** Tier 3 - may need care w/in one to two months
**** Tier 4 - " " w/in two to three months
**** Tier 5 - can be posted greater than three months


*1. Ensure that the MICN / Charge RN has updated the NEDOCS score. (Click on the colored bar to see when the NEDOCS score was last updated - should be updated every 2-3 hours)
* Level 3
*2. If surge criteria met (see above), call Patient Flow Facilitator to check if surge plan has been initiated.
** Above and:
*3. If you have ward beds and ED is impacted by Observation and Boarders - admit stable patients to the ward rather than placing them on Observation. See "OBSERVATION SURGE PLAN" (EXCEPTION: Placement patients - always initially place on Observation.)  
** Consider closure to BLS (needs MAC approval) - typically related to number of ATri >60min
*4. Consider using the RME Fast Track rooms and/or Pediatric ED rooms to see patients who don't need to stay in a bed.  
** Consider closure to STEMI (needs approval by Interventional Cardiologist on duty)  
*3. If time allows, go through patient charts on the admissions track and contact admitting inpatient teams of patients that might be downgradable.
** Consider closure to Trauma (needs approval by Trauma Division Chief and CEO/designee)
(Director OPS, 3/22/18)
** Notify DEM AOD to consult hospital leaders if need to open command center.  
** ED attending/OCN identify staff to safely monitor patients in WR
** ED attending/OCN to adjust staffing assignments as needed
** CNO to evaluate need to implement alternate staffing plan
** Inpatient attendings to see patients and decide dispositions


===Observation Surge Plan===
(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)
Whenever the number of OBS/CORE patients that overflow in the AED due to lack of GOLD Unit available beds equals or exceeds 5 patients AND there are inpatient beds available at the appropriate level of care:
*1. Emergency Physicians will ADMIT any additional patients that are empanelled to the DHS network* to an inpatient bed rather than place the patient on Observation.
*2. The Observation hospitalist will ADMIT any patients already on observation that are in DHS network*, giving priority to WARD level patients, followed by TELEMETRY level patients for this activity.
*3. These two activities will only continue until we reduce the number of OBS/CORE patients in AED beds down to 5, after filling up all available GOLD beds.
 
EXCEPTION: Regardless of empanelment - patients perceived to have a high likelihood of needing placement will ALWAYS be placed/kept on Observation.
EMPANELLED TO DHS NETWORK = Provider name in the Empanelled Provider area of the Banner Bar in Cerner OR an insurance type that is listed as "DHS"
 
Peterson 8/15/  18


==See Also==
==See Also==

Latest revision as of 18:03, 19 December 2024

ALS Diversion

  • The goal of diversion is to ensure safety of current ED patients and of patients being transported by EMS by:
    • Allowing staff time to move patients within or through the ED to free up space/staff resources.
    • Allowing the ED time to prepare for next round of sick patients.
  • ED Saturation (aka Diversion) is a process of marking the ED in the countywide ReddiNet system as “closed” to adult Advanced Life Support (ALS) arrivals.
    • “ALS ED Sat” does NOT redirect BLS arrivals or specialty center patients arriving to Harbor (e.g. Trauma, STEMI, Perinatal).
    • ALS ED Sat” lasts for two hours but can be ended earlier. At the end of the two-hour diversion, ReddiNet will automatically re-open the hospital to ALS.
    • If the nearest alternative ED is also noted as “ALS ED Sat”, ALS ambulances will be directed to the closest ED, regardless of “ED Sat” status on ReddiNet.
    • “ALS ED Sat” is not a command, but a suggestion. EMS can still bring the patient to the MAR if it is considered to be the safest decision (e.g. patients in extremis)

Guidelines for ALS Diversion triggers:

  • Consider when not enough space to care for the next critical patient coming by ambulance
    • Not enough treatment spaces despite decompress patients to other beds/hallway
    • Not enough staff (RN, RT, provider, etc.) or supplies (vents, blood, etc.)
  • Diversion is a joint decision by the MICN, AED charge nurse, AED attending(s), Overall Charge Nurse (OCN)
    • Consider carefully as it results in longer transport times for potentially critically ill patients
    • OCN & Attending names are recorded in the ReddiNet as the Authorizing personnel
  • Indicators to consider:
    • NEDOCS>140 (must be done hourly while on diversion status) and Hospital Surge level
    • EMS closure criteria
    • Surrounding hospital status
    • All ED rooms are full (Peds=18, AED=55 [Tr 5 beds, AED 22 beds, RME 6-9, 13-20, Gold 16 beds]) and 30% or greater of the ED patients are ESI1, ESI2, or admit boarders
  • If group decision is to close, proceed with the 1 hour ED closure; must reevaluate the department before going on ED ALS diversion again[1]
    • Closure to ED saturation should always be accompanied by closure to interfacility, ED to ED, and other transfers through the Medical Alert Center (MAC). All MAC closures are discussed with the House Supervisor/Patient Flow Facilitator (PFF) or Administrative Officer of the Day (AOD).
  • Other potential reasons for ambulance diversion:
    • CT: based on the availability of alternate scanners; AED Attending will notify the ED Overall Charge for Reddinet entry
    • Trauma: joint decision by Trauma and ED Attendings; based on equipment issues, OR unavailability, primary and backup trauma team encumbrance
    • Peds: PED Attending contacts ED Overall Charge RN to close via Reddinet; PICU beds have no influence on PED diversion status
    • STEMI: Joint decision amongst Interventional Cardiologist, AED Attending, House Supervisor, and ED Overall Charge Nurse; due to cath lab team encumbrance, mechanical failures, or internal disaster; automatically re-open after 3 hours unless further diversion is deemed necessary
    • Internal Disaster (see https://www.wikem.org/wiki/Harbor:Disaster_plan)
    • Helipad: due to unsafe landing conditions, damage to the helipad, current helicopter on the pad, deployment of the decon trailers for a large Hazmat incident; MAC must immediately be notified of closure


BLS Diversion

  • “BLS ED Sat” is added to ALS ED Sat and marks the ED in the countywide ReddiNet system as “closed” to all ALS and BLS arrivals.
  • “BLS ED Sat” does NOT redirect specialty center patients arriving to Harbor (e.g. Trauma, STEMI, Perinatal).
  • Very serious decision given consequences to community. Only to be used when situation in ED is felt to be truly unsafe for patients.
  • Requires hospital administration approval
  • If MAC closes us to BLS due to prolonged APOT times, the closure is for 4 hours; if this occurs, please notify ED AOD


Guidelines for BLS Diversion triggers: Requires hospital administration approval

  • Above ALS diversion triggers AND
  • 3 patients in ambulance triage waiting >60 min AND one of the following:
    • At least 2 #ESI 2’s in waiting room
    • WR #s = 50-60
    • WR LOS = >12hrs
    • No trauma bays open
  • ED request for “BLS ED Sat” must come from the Clinical Nursing Director and ED AOD via the OCN and Attending. Hospital approval by CMO/CEO or designee.
  • Request is made by phone to the MAC on behalf of the CMO. Cannot be done via ReddiNet

Schlesinger/Chappell/Wu 5/5/22

Surge Plan

  • There are three levels of surge. The surge level is determined by meeting the "Resource Utilization Indicators" (see below). When a surge level is met, the patient flow facilitator (PFF), in consultation with the ED attending and OCN will enact the surge plan. Alerts go out to all hospital leadership. If you think criteria have been met to activate the Surge Plan - contact the PFF at 68647, pager x0939. It is based on current criteria, NOT what may happen in a few hours.
  • Refer to [1] for things we can do internally to maximize use of ED space and when to escalate to DEM admin on duty and Clinical Nursing Director.
  • Things to consider in ED for pre-surge with OCN:
    • EMS
      • Consider closure to ALS to decompress rooms for next sick patient
      • If prolonged APOT times, BLS agency may call MAC and have us placed on "BLS Sat"
    • Triage
      • NA/router to help take vitals before triage
      • Second RN to help check in patients into WR
      • FT provider to help triage catch up - get wait to MSE <30 min and review WR lab/imaging results
    • ED
      • DC to chairs - chairs outside rooms or in waiting room (WR) for discharge for quicker room cleaning for next patient
    • Maximize use of all available rooms
      • Can see AED patients in PED - thoughtfully select patients
      • If nursing available, utilize shared vertical room model (1 RN, 4 chairs to room, 2nd room next door to eval patients); with 2 nurses, can see 8 patients in 4 rooms
    • Flex to hall space
      • Disaster (X-hall) chairs
      • PWR overflow treatment chairs
      • Admitted ward patients to hall
    • Inpatient pre-surge:
      • Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending
      • Maximize use of discharge lounge
    • Prolonged Surge
      • Consider Urgent Care Clinic (UCC) expanding scope to include Out of Plan (OOP) patients (CMO approval required)
      • Consider adding additional ED physicians if nursing available to help with completion of care


Resource Utilization Indicators (Need any 3)

  • Policy updated on 4/2022 File:337 - Surge Capacity Plan.pdf
  • ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5 and ambulance triage (ATri)
  • Level 1 Criteria: near max capacity for ED and inpatient with demand expected to increase
    • 50 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
    • 16 or more boarders in ED (hospital icon for admission orders up)
    • 5 or more ESI2s and Amb Tri waiting to be seen
    • PACU at capacity (PFF will know)
    • ED staffing in yellow (no breakers)
    • 2 or more inpatient units' staffing in yellow
  • Level 2: max capacity for ED and patient and additional resourced needed to meet demand
    • 60 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
    • 8 or more ESI2s and Amb Tri waiting to be seen
    • 20 or more boarders in ED (hospital icon for admission orders up)
    • PACU at capacity (PFF will know)
    • ED staffing in red (charge RNs in ratio)
    • 2 or more inpatient units' staffing in red
  • Level 3
    • 75 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
    • 10 or more ESI2s and Amb Tri waiting to be seen
    • 30 or more boarders in ED (hospital icon for admission orders up)
    • PACU at capacity (PFF will know)
    • ED staffing in red (charge RNs in ratio)
    • 3 or more inpatient units' staffing in red

What Happens at Different Surge Levels

  • Level 1
    • Actions from pre-surge (see above)
    • Consider ambulance diversion (ALS only)
    • Discharge patients to the WR to wait for transportation when appropriate
    • UCC to see all ESI4/5s (no exclusions) --> RME Director and UCC Director to coordinate
    • OR/PACU: Hold patients in OR and procedural areas if PACU full
    • ED Charge RN communicate with boarder admitting team for downgrades/discharges
    • ICU identifies stable patients to transfer to Rancho Los Amigos or LAC+USC
    • Transfer female patients to open 7W rooms
    • Inpatient charge RN identify potential downgrades/discharges w/in 2 hours of Surge 1 being declared
    • Get additional nursing to work in ED and inpatient areas
  • Level 2
    • Above and:
    • Close to ALS for 1-2 hours to decompress
    • Evaluate patients to see if they can be moved out of ED monitored rooms into hallways or chairs to free up monitored rooms
    • Utilization Management (UM) request transfer to capitated hospitals, and transfer for decompression or lower level of care
    • Reschedule end of day Tier 2 procedures/surgeries (care needed w/in 2-4 weeks) and above inpatients
      • Surgery/Procedure Acuity Tiers
        • Tier 0 - needs immediate care
        • Tier 1 - care needed w/in 2 weeks
        • Tier 2 - may need care w/in 2-4 weeks
        • Tier 3 - may need care w/in one to two months
        • Tier 4 - " " w/in two to three months
        • Tier 5 - can be posted greater than three months
  • Level 3
    • Above and:
    • Consider closure to BLS (needs MAC approval) - typically related to number of ATri >60min
    • Consider closure to STEMI (needs approval by Interventional Cardiologist on duty)
    • Consider closure to Trauma (needs approval by Trauma Division Chief and CEO/designee)
    • Notify DEM AOD to consult hospital leaders if need to open command center.
    • ED attending/OCN identify staff to safely monitor patients in WR
    • ED attending/OCN to adjust staffing assignments as needed
    • CNO to evaluate need to implement alternate staffing plan
    • Inpatient attendings to see patients and decide dispositions

(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)

See Also

References

  1. ↑ Harbor ED Policy 20.4, LA County EMS policies 503, 506, & 513
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