Harbor:Surge plan: Difference between revisions

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==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)


===INTERNAL/EXTERNAL DISASTERS===
'''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


====Closing to EMS (ALS) Ambulances====
* '''Indicators to consider''':
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.
** 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'''<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:
** 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


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


==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


====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=====
'''Guidelines for BLS Diversion triggers''': Requires hospital administration approval
*Level 1
*Above ALS diversion triggers AND
**Ambulance Diversion (Diversion is for ALS only, never BLS)
*'''3 patients in ambulance triage waiting >60 min''' AND one of the following:
**Four RME Rooms should be converted to Fast Track if not already done
**At least 2 #ESI 2’s in waiting room
**Assign residents as available to staff the extra Fast Track rooms
**WR #s = 50-60
**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)
**WR LOS = >12hrs
**Charge nurse facilitates full staffing of Gold Unit by reallocating staff as available
**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


*Level 2
Schlesinger/Chappell/Wu  5/5/22
**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
==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. 
**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.
* 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.  


* 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, you no longer need a majority)=====
** Triage
*Level 1
*** NA/router to help take vitals before triage
**NEDOCS >140
*** Second RN to help check in patients into WR
**> 50 Patients in Triage/Waiting Room
*** FT provider to help triage catch up - get wait to MSE <30 min and review WR lab/imaging results
**> 11 OBS/CORE/Boarders in AED
**Inpatient census > 320
**Low inpatient bed count (<16 Ward '''AND''' <5 ICU/PCU beds)


*Level 2
** ED
**NEDOCS >180
*** 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
** Maximize use of all available rooms
**> 14 OBS/CORE/Boarders in AED
*** Can see AED patients in PED - thoughtfully select patients
**Inpatient census > 330
*** 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
**Lower inpatient bed count (<11 Ward '''AND''' <3 ICU/PCU beds '''AND''' No "Bump Bed" for Trauma or STEMI)
** '''Flex to hall space''' - if > 4 hours wait for definitive care
**4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU
*** '''Disaster (X-hall) chairs'''
*** '''PWR overflow treatment chairs'''
*** '''Admitted ward patients to hall'''


*Level 3
** Inpatient pre-surge:
**NEDOCS 200
*** Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending
**> 75 Patients in Triage/Waiting Room
*** Maximize use of discharge lounge
**> 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)
** 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


=====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)  
===Resource Utilization Indicators (Need any 3)===
*2. If surge criteria met (see above), call Patient Flow Facilitator to check if surge plan has been initiated.
* Policy updated on 4/2022 [[:File:337 - Surge Capacity Plan.pdf]]
*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.)
* ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5 and ambulance triage (ATri)
*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=====
* Level 1 Criteria: near max capacity for ED and inpatient with demand expected to increase
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:
** 50 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
*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.
** 16 or more boarders in ED (hospital icon for admission orders up)
*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.
** 5 or more ESI2s and Amb Tri waiting to be seen
*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.
** PACU at capacity (PFF will know)
** ED staffing in yellow (no breakers)
** 2 or more inpatient units' staffing in yellow


EXCEPTION: Regardless of empanelment - patients perceived to have a high likelihood of needing placement will ALWAYS be placed/kept on Observation.
*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)
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"
** 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


Peterson 8/15/  18
*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


====DISASTER INSTRUCTIONS====
===What Happens at Different Surge Levels===
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.
* 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


=====General Instructions=====
* Level 2
#Everbridge System notification for callbacks if at home - Call to clerk's phone to report if available and receive assignment.
** Above and:
#Activate the DEM Emergency Operations Plan (EOP) based on info from EMS/Reddinet: Criteria:
** Close to ALS for 1-2 hours to decompress
##5 or more "Immediate/Red" patients,
** Evaluate patients to see if they can be moved out of ED monitored rooms into hallways or chairs to free up monitored rooms
##10 or more "Immediate/Red" or "Delayed/Yellow" patients from the same incident.
** Utilization Management (UM) request transfer to capitated hospitals, and transfer for decompression or lower level of care
##Multiple patients arriving from incident involving Hazmat exposure.
** Reschedule end of day Tier 2 procedures/surgeries (care needed w/in 2-4 weeks) and above inpatients
##Directive from hospital administration, via activation of Hospital Code Triage.
*** Surgery/Procedure Acuity Tiers
#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.
**** Tier 0 - needs immediate care
#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.
**** Tier 1 - care needed w/in 2 weeks
#The DEM Organizational Chart contains all ED roles during a disaster event.
**** Tier 2 - may need care w/in 2-4 weeks
#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).
**** 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


=====Disaster Triage=====
* Level 3
#ADULT AND YOUNG ADULT  Triage Category Definitions
** Above and:
#*Minor - Ambulates without assistance OR minor lower extremity injury
** Consider closure to BLS (needs MAC approval) - typically related to number of ATri >60min
#*Expectant - No spontaneous breathing after airway positioned
** Consider closure to STEMI (needs approval by Interventional Cardiologist on duty)
#*Immediate
** Consider closure to Trauma (needs approval by Trauma Division Chief and CEO/designee)
#**Apnea responds to positioning
** Notify DEM AOD to consult hospital leaders if need to open command center.
#**RR >30
** ED attending/OCN identify staff to safely monitor patients in WR
#**No palpable Radial Pulse/Cap refill > 2sec
** ED attending/OCN to adjust staffing assignments as needed
#**AMS
** CNO to evaluate need to implement alternate staffing plan
#*Delayed - Needs gurney but not immediate
** Inpatient attendings to see patients and decide dispositions


#CHILD Triage Category Definitions
(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)
#*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=====
==See Also==
*Airway Cart –
*[[Harbor:Main]]
*Atropine - use ED supplies first- Mark I antidote stock in basement - requires MAC approval (see Code Triage Manual for Phone number)
*[[Harbor:Disaster plan]]
*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
==References==
<references/>


==See Also==
[[Category:Admin]]
*[[Harbor:Operations manual]]

Latest revision as of 17:34, 17 October 2025

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 - if > 4 hours wait for definitive care
      • 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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