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


Schlesinger/Chappell/Wu  5/5/22


===Resource Utilization Indicators (Need any 3)===
==Surge Plan==
* Policy 337
* 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. 
* ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5
 
*Pre-Surge
* 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.
** 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
* Things to consider in ED for pre-surge with OCN:
**NEDOCS >140
**> 50 Patients in Triage/Waiting Room (WR+R5)
**> 11 boarders in AED (if beds are assigned, get them moved upstairs)
**Inpatient census > 320
**Low inpatient bed count (<16 Ward '''''OR''''' <5 ICU/PCU beds)
***'''Based on current conditions, not beds that will be coming''' (will go off surge when conditions are no longer met)
*** Ward should include unstaffed ward beds as they can be utilized in surge conditions per CEO


*Level 2
** EMS
**NEDOCS >180
*** Consider closure to ALS to decompress rooms for next sick patient
**> 50 Patients in Triage/Waiting Room (not including RME/tasking/internal WR like R5,R6,or R12)
*** If prolonged APOT times, BLS agency may call MAC and have us placed on "BLS Sat"
**> 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
** Triage
**NEDOCS 200
*** NA/router to help take vitals before triage
**> 75 Patients in Triage/Waiting Room (not including RME/tasking/internal WR like R5,R6,or R12)
*** Second RN to help check in patients into WR
**> 17 boarders in AED
*** FT provider to help triage catch up - get wait to MSE <30 min and review WR lab/imaging results
** 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)
** 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


* '''DRAFT COVID CHANGES'''
** Inpatient pre-surge:
** '''NEDOCS updated to reflect current 43 rooms'''
*** Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending
** '''WR max for social distancing is ~40 patients'''
*** Maximize use of discharge lounge
** '''Boarder:  after request for admit + psych patients pending bed in Psych ED'''
** Max inpatient capacity variable based on staffing


*Level 1
** Prolonged Surge
**NEDOCS >140
*** Consider Urgent Care Clinic (UCC) expanding scope to include Out of Plan (OOP) patients (CMO approval required)
** >40 Patients in Triage/Waiting Room ('''AWR + R1-R5 + AmbTri''') '''or >5 ESI 2 in WR'''
*** Consider adding additional ED physicians if nursing available to help with completion of care
** '''>4 ambulance triage'''
** >14 boarders in AED for > 2 hours (OCN to provide numbers to PFF - '''includes psych boarders''')
** Inpatient census > 90% staffed capacity ('''PFF report: census/capacity''' for critical care, PCU/SDU, tele, & med/surg - excludes specialty areas) ... '''delete this and just use individual level of care numbers OR a fixed number like 10 open staffed beds which is ~4%)'''
** Low inpatient bed count (<7 Ward '''''OR''''' <5 ICU/PCU beds'''/tele''')
***'''Based on current conditions, not beds that will be coming''' (will go off surge when conditions are no longer met)
*** If beds are assigned, get them moved upstairs
*** CNO can authorize use of unstaffed ward beds as they can be utilized in surge conditions in compliance with AB 394


*Level 2
**NEDOCS >180
** >50 Patients in Triage/Waiting Room ('''AWR + R1-R5 + AmbTri''')
** >18 boarders in AED for > 2 hours (OCN to provide numbers to PFF - '''includes psych boarders''')
** Inpatient census > 95% staffed capacity ('''PFF report: census/capacity''' for critical care, PCU/SDU, tele, & med/surg - excludes specialty areas)
** Low inpatient bed count: <4 Ward '''''OR''''' <2 ICU/PCU beds (should always have a trauma ICU bed)
** 4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU


*Level 3
===Resource Utilization Indicators (Need any 3)===
**NEDOCS 200
* Policy updated on 4/2022 [[:File:337 - Surge Capacity Plan.pdf]]
** >60 Patients in Triage/Waiting Room ('''AWR + R1-R5 + AmbTri''')
* ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5 and ambulance triage (ATri)
** >21 boarders in AED for > 2 hours (OCN to provide numbers to PFF - '''includes psych boarders''')
** Inpatient census at 100% staffed capacity ('''PFF report: census/capacity''' for critical care, PCU/SDU, tele, & med/surg - excludes specialty areas)
**Low inpatient bed count: 0 Ward '''''OR''''' <2 ICU/PCU beds (should always have a trauma ICU bed)
**4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU


===What Happens at Different Surge Levels===
* Level 1 Criteria: near max capacity for ED and inpatient with demand expected to increase
*Level 1
** 50 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
**Ambulance Diversion (Diversion is for ALS only, never BLS)
** 16 or more boarders in ED (hospital icon for admission orders up)
**Four RME Rooms should be converted to Fast Track if not already done
** 5 or more ESI2s and Amb Tri waiting to be seen
**Assign residents as available to staff the extra Fast Track rooms
** PACU at capacity (PFF will know)
**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)
** ED staffing in yellow (no breakers)
**Charge nurse facilitates full staffing of all areas by reallocating staff as available
** 2 or more inpatient units' staffing in yellow
**PFF communicates to Nurse Managers to get timely discharge/transfer orders from inpatient teams


*Level 2
*Level 2: max capacity for ED and patient and additional resourced needed to meet demand
**Above and:
** 60 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
**Identify 1 or more stable/not newly admitted ICU patients for transfer to LAC-USC or Rancho.
** 8 or more ESI2s and Amb Tri waiting to be seen
**CMO or designee determines if need to cancel scheduled admissions, elective surgeries; requests department chairs to provide list of pending downgrades and discharges
** 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
*Level 3
**Above and:
** 75 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
**CMO or designee makes determination to go on Diversion to Trauma
** 10 or more ESI2s and Amb Tri waiting to be seen
**AOD consult hospital leaders if need to open command center.
** 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


'''DRAFT COVID CHANGES'''
===What Happens at Different Surge Levels===
*Level 1
* Level 1
** PFF & OCN huddle to review current numbers (NEDOCS, WR, boarders)
** Actions from pre-surge (see above)
** Ambulance Diversion (Diversion is for ALS only, never BLS)
** Consider ambulance diversion (ALS only)
** Utilize available area in PED
** Discharge patients to the WR to wait for transportation when appropriate
** Charge nurse facilitates full staffing of all areas by reallocating staff as available
** UCC to see all ESI4/5s (no exclusions) --> RME Director and UCC Director to coordinate
** SEVEN RME Rooms (R6-12) should be converted to Fast Track and EIGHT RME rooms (R13-20) to AED if not already done
** OR/PACU: Hold patients in OR and procedural areas if PACU full
*** Assign residents as available to staff the extra Fast Track rooms
** ED Charge RN communicate with boarder admitting team for downgrades/discharges
** PFF communicates to Nurse Managers to get timely discharge/transfer orders from inpatient teams
** ICU identifies stable patients to transfer to Rancho Los Amigos or LAC+USC
** Inpatient rounding at least 2x/day and coordinate expedited outpt workups
** Transfer female patients to open 7W rooms
** Inpatient attending IM attending make right level of care decision on each patient
** Inpatient charge RN identify potential downgrades/discharges w/in 2 hours of Surge 1 being declared
** CNO can authorize use of unstaffed ward beds as they can be utilized in surge conditions in compliance with AB 394
** Get additional nursing to work in ED and inpatient areas
*** waiver until 12/31 (Law was passed Jan 2020 - creates financial penalty)
** 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)


*Level 2
* Level 2
** Above and:
** Above and:
** Prioritize DC from ED
** Close to ALS for 1-2 hours to decompress
** Facilitate home O2 & home health f/ups
** Evaluate patients to see if they can be moved out of ED monitored rooms into hallways or chairs to free up monitored rooms
** Identify 1 or more stable/not newly admitted ICU patients for transfer to LAC-USC or Rancho.
** Utilization Management (UM) request transfer to capitated hospitals, and transfer for decompression or lower level of care
** CMO or designee determines if need to cancel scheduled admissions, elective surgeries; requests department chairs to provide list of pending downgrades and discharges
** 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
* Level 3
**Above and:
** Above and:
** Utilize 8 hallway chairs
** Consider closure to BLS (needs MAC approval) - typically related to number of ATri >60min
** Consider activating backup ED team
** Consider closure to STEMI (needs approval by Interventional Cardiologist on duty)
**CMO or designee makes determination to go on Diversion to Trauma  
** Consider closure to Trauma (needs approval by Trauma Division Chief and CEO/designee)
**AOD consult hospital leaders if need to open command center.  
** 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)
(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)
===Adult ED Attending Standard Work During Severe ED Overcrowding===
*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)
*2. If surge criteria met (see above), call Patient Flow Facilitator to check if surge plan has been initiated.
*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.)
*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.
*3. If time allows, go through patient charts on the admissions track and contact admitting inpatient teams of patients that might be downgradable.
(Director OPS, 3/22/18)
===Observation Surge Plan===
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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