Harbor:Surge plan

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Closing to EMS (ALS) Ambulances

The decision to close to ALS ambulances should be made as a joint decision by the AED charge nurse and the ED attending. Although looking at the NEDOCS score can be a helpful indicator of the level of congestion, it does not need to be the only factor that goes into determining the need to close to ALS ambulances. With our recent adjustment of the equation to calculate the NEDOCS score (we now have the accurate ED bed count in the equation) - you may find at times that you need to close at lower NEDOCS scores.

As always, the decision to close should be carefully considered, as it results in longer transport times for potentially critically ill patients.

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, 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 x3434 or on Beeper x0939.

What Happens in the ED at Different Surge Levels

  • 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 Gold Unit by reallocating staff as available
  • Level 2
    • Above and:
    • When beds are available upstairs, 4 OBS/CORE patients each hour are admitted and moved to inpatient beds. Hospitalist or CORE Cardiologist writes orders.
  • Level 3
    • Above and:
    • CMO or designee makes determination to go on Diversion to Trauma
    • When beds are available upstairs, 6 OBS/CORE patients each hour are admitted and moved to inpatient beds. Hospitalist or CORE Cardiologist writes orders.


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

Resource Utilization Indicators (Need any 3, you no longer need a majority)

  • Level 1
    • NEDOCS >140
    • > 50 Patients in Triage/Waiting Room
    • > 11 OBS/CORE/Boarders in AED
    • Inpatient census > 320
    • Low inpatient bed count (<16 Ward AND <5 ICU/PCU beds)
  • Level 2
    • NEDOCS >180
    • > 50 Patients in Triage/Waiting Room
    • > 14 OBS/CORE/Boarders in AED
    • Inpatient census > 330
    • Lower inpatient bed count (<11 Ward AND <3 ICU/PCU beds AND No "Bump Bed" for Trauma or STEMI)
    • 4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU
  • Level 3
    • NEDOCS 200
    • > 75 Patients in Triage/Waiting Room
    • > 17 OBS/CORE/Boarders in AED
    • No available gurneys, chairs or monitors for new patients in ED
    • Inpatient census > 345
    • Low inpatient bed count (<5 ward AND 0 ICU/PCU beds with no "Bumps")
    • 5 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU

(Hosp Policy 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. (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

DISASTER INSTRUCTIONS

Detailed Instructions are in the Harbor-UCLA DEM Emergency Operations Plan Binder on the shelves next to the clerk's desk in the AAED A-side.

General Instructions

  1. Everbridge System notification for callbacks if at home - Call to clerk's phone to report if available and receive assignment.
  2. Activate the DEM Emergency Operations Plan (EOP) based on info from EMS/Reddinet: Criteria:
    1. 5 or more "Immediate/Red" patients,
    2. 10 or more "Immediate/Red" or "Delayed/Yellow" patients from the same incident.
    3. Multiple patients arriving from incident involving Hazmat exposure.
    4. Directive from hospital administration, via activation of Hospital Code Triage.
  3. Step-by-step instructions for activating the ED EOP are located in the "Checklist: Activating the ED EOP" document posted behind each console in the Base Station Radio Room, and in the ED EOP binder by the AED Clerk's desk.
  4. The ED Nurse Manager, or Overall Charge Nurse on weekends/evenings, assumes the role of ED/Casualty Care Unit Leader, and coordinates all role assignments and/or other activity in the ED during the Disaster period.
  5. The DEM Organizational Chart contains all ED roles during a disaster event.
  6. Roles that may be assigned to physicians include: Immediate Unit Leader (Purple Attending), Delayed Unit Leader (Green Attending), Minor Unit Leader (Fast Track NP or MD), Pediatric Unit Leader (PED Attending), Triage Unit Leader (Screening MD or NP), Decon Unit Leader (Any Decon-Trained MD/NP/RN).

Disaster Triage

  1. ADULT AND YOUNG ADULT Triage Category Definitions
    • Minor - Ambulates without assistance OR minor lower extremity injury
    • Expectant - No spontaneous breathing after airway positioned
    • Immediate
      • Apnea responds to positioning
      • RR >30
      • No palpable Radial Pulse/Cap refill > 2sec
      • AMS
    • Delayed - Needs gurney but not immediate
  1. CHILD Triage Category Definitions
    • Minor - Ambulates without assistance OR minor lower extremity injury
    • Expectant - No spontaneous breathing after airway positioned and 5 rescue breaths
    • Immediate
      • Apnea responds to positioning or rescue breaths
      • RR <15 or >45
      • No palpable Radial Pulse/Cap refill > 2sec
      • Posturing or unresponsive
    • Delayed - Needs gurney but not immediate

Supplies

  • Airway Cart –
  • Atropine - use ED supplies first- Mark I antidote stock in basement - requires MAC approval (see Code Triage Manual for Phone number)
  • Cones - Triage Color Coded - Wheelchair Storage Closet
  • Decon Team Supplies (PAPRs, Level C PPE) - Storage Closet under Helipad
  • Decon Trailer - Trailer Lot
  • Disaster Cart - Central Supply and Linen Room SE BF09 - keys on big ring in Command Post (1L1) cupboard
  • Disaster Packets/Clipboards - Shelving unit next to clerk's desk, AED A-side
  • Disaster Tags - (Pedestrian spine storage by Router desk)
  • Dosimeters - Radiation Safety Office Building N32
  • Geiger Counters
    • 3 in ED Charge Nurses Office
    • 6 in Radiation Safety Office Building N32
  • Gurneys, disaster – Trailer #3 - Give keys to housekeeping - they will open trailer and assemble gurneys
  • Keys - AAED Pyxis (SE 1J25)
    • For instructions see disaster manual
  • Privacy Kits for Patients - Decon Trailer
  • Signs - Triage Station - Wheelchair Storage Closet
  • Trailers 1-5 - keys in Pyxis AAED
  • Additional Vests - Wheelchair Storage Closet
  • Wheelchairs - (SE1A04) - NA7 Key

Dir OPS 9/14/16

See Also