PS1070 POLICY SARASOTA MEMORIAL HOSPITAL (SMH) PATIENT FLOW AND OVER EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: PAGE #: 12/1/05 06/15/18 Clinical Non-Clinical 1 of 12 Job Title of Responsible Owner: Director Clinical Logistics, Patient Flow, Observation Services and Discharge Services PURPOSE: POLICY STATEMENT: To identify and address the barriers to efficient patient flow throughout the organization and to ensure the immediate mobilization of all appropriate hospital resources; to heighten the awareness of the entire organization collectively to respond to the need to place patients; to institute a plan to address the needs of patients, ensuring safe and efficient delivery of quality patient care. Variables considered for each patient care area are: capacity, throughput, patient experience and patient acuity. A coordinated plan throughout the hospital will be activated when the placement of patients becomes delayed due to bed availability volume of admissions specific placement needs or the need to decompress the Emergency Care Center (ECC), PACU, Cath Lab, ICU or Radiology patient acuity EXCEPTIONS: DEFINITIONS: None ECC Pre-Code Lavender Alert: Initiated when ECC approaches maximum functional capacity of Internal ECC beds. ECC huddles with the for assessment purposes and department level actions taken to improve flow. The Logistics Center will send a situational alert to directors, clinical managers or designees of appropriate downstream units and support areas. House wide Code Lavender Alert: Alerts and initiates a collaborative approach that includes all patient care directors, administrative supervisors, Chief Nursing Officer, Chief Medical Officer, COO, and Integrated Case Management clinical supervisor that a significant house-wide patient flow problem exists that has not been corrected by department level mitigation efforts. Implemented when high census AND a sufficient number of discharges are not anticipated in the needed time frame or the number of patients awaiting placement exceeds the ability to meet the needs. 6/29/2018
2 of 12 Purple Alert: An alert called after the House-wide Code Lavender Alert has been activated and in place and a patient flow problem is still present. Patients are placed in any appropriate overflow bed that has been made available. Patients will not be placed in locations that would impair corridor access. Actions include mobilization of additional equipment, priority cleaning and transport. Over Capacity Situation where a house-wide alert is needed to decompress the ECC, Cath Lab, PACU, ICU or Radiology. Overfow Beds Additional beds that can be made functional by using strategic overflow areas. Decompress Alleviate high census in any area by opening additional beds to allow safe efficient patient flow. Patient Care Units Units delineated on Daily Census Worksheet as such (Med/Surg., Cardiac, Observation, and Critical Care) RTM- Patient is clinically Ready to Move in Teletracking system Targeted Unit - Unit notified by that they are likely to get a specific patient TBADM Acronym on ECC Status Board indicating to be admitted PROCEDURE: 1. When patient flow is restricted and admits/transfers exceed the ability to place patients or the ECC approaches maximum functional capacity, the administrative supervisor/nursing Administration director (NAD) and/or the director is notified by the. An ECC Pre- Lavender Alert may be initiated. 2. The Administrative Supervisor/Nursing Administration director (NAD) and/or the director actively assesses patient flow situation and notifies departments that discharges/transfers need to be expedited. 3. If bed placement continues to be restricted, the administrative supervisor/nad and/or director notifies the directors/clinical managers and sends out global message to physicians that a House-wide Code Lavender Alert has been called and the need to immediately assess and expedite potential discharges.
3 of 12 4. Patient care leadership will initiate an active assessment of the bed availability and staffing. The need for a STAT bed meeting is assessed and called by NAD/administrative supervisor and/or the director. All clinical managers/directors are asked for: potential discharges and any identified barriers to discharge staffing (current shift and following shift). 5. A plan of action is established to decompress flow restricted areas and move patients quickly. 6. After initiation of the House-wide Code Lavender Alert, all pertinent staff is alerted via various messaging systems in order to ensure that key staff and departments are actively supporting the Capacity Alert Plan. 7. If there is no improvement of the patient flow the administrative supervisor/nad and/or the director alerts all of Administration that a Purple Alert needs to be called. After discussion with CNO, CMO, COO, CEO a Purple Alert is called. This includes mobilizing any equipment needs (beds, overbed tables) priority cleaning bed assignments, and coordination of which patients are placed in purple beds as well as patient transport. 8. When a Purple Alert is called all staff assigned to units will return to the unit if elsewhere. Routine classes/meetings will be cancelled except for Nursing Orientation. During a Purple Alert staff may be assigned temporarily outside their unit once competency is assessed. 9. During a Purple Alert, staff with clinical expertise but not currently assigned to patient care, will report availability to the. 10. The administrative supervisor/nad and/or director will continue to act as coordinator/liaison of all activities. 11. All overflow beds will be open. Guidelines for overflow bed placement are based on ensuring that each patient s care needs can be met. (Appendix B) 12. Departure Lounge will be open to help facilitate potential discharges.
4 of 12 13. All key departments will be expected to review their procedure and initiate scalable departmental plans for Lavender/Purple Alert. (Appendix C) 14. The president/ceo, or designee, in cooperation with the and administrative supervisor/nad on duty and/or director collaborates to monitor or discontinues the Purple Alert when the situation no longer exists. Hospital diversion (see Trauma Diversion Plan, Policy #560.573) will be considered as circumstances warrant. The president/ceo, or designee, directs the announcement of Purple Alert All Clear. Departments facilitate the return of equipment to assigned storage areas. Refer to Department Plan for specific responsibilities. RESPONSIBILITY: REFERENCE(S): Department Directors Clinical Manager Administrative Supervisors Nursing Staff (HUC s, HUC Designee, Primary Care Nurses) ECC Registration (7p-7a, Weekends) Environmental Services Central Transport Integrated Case Management ANCC Magnet List Serve Dynamic Capacity Management for Healthcare; Advanced Methods and Tools for Optimization, 2011 Piece Story, MPHM, DSHS AUTHOR(S): Janet Steves, Executive Director, Organizational Capacity and Patient Throughput Division Susan Grimwood, Director Clinical Logistics, Patient Flow, Observation Services and Discharge Services REVIEWER(S): Connie Anderson, Chief Nursing Officer Lisa Collins-Brown, Director of Emergency Services ATTACHMENT(S): Appendix A Appendix B Appendix C
5 of 12 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: Date Director/Responsible Owner: Executive Director: Vice President: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Susan Grimwood, MSN, ARNP-C 5/21/18 Janet Steves, MBA, BSN, RN, CPAN 5/16/18 Connie Anderson, CNO 5/31/18 James Fiorica, MD 6/6/18 Medical Executive Committee: (if clinical and review requested by CMO and COS) Chief Executive Officer: David Verinder, CEO 6/8/18
6 of 12 Appendix A Triggers for Activation of Pre-Code Lavender/Code Lavender Status Department Trigger Primary Action Responsible Party ECC >8 patients in main waiting area (triage) Patients waiting >1 hour after triage Unable to place arriving EMS timely due to ECC room availability >5 RTM patients without bed assignments Any mass casualty or influx of trauma/stroke patients Conduct internal ECC huddle with Charge RN, management staff, and Logistics Center; create plan based on identified bottle necks Review staffing and reallocate based on current needs Initiate triage protocol orders for waiting patients Expedite ECC discharges Expedite admissions Identify patients awaiting radiology tests/results Utilize ECC staff to transport Move patients internally to create occupancy (i.e. subwaiting, departure ECC Charge Nurse ECC Leadership Team Medical Director or Lead attending on staff ICM *If covering ECC and MAC, triggers must be tightened when MAC with >5 unstatused patients) >5 TBADM unstatused ECC patients >10 RTM unstatused ECC patients >5 ECC patients RTM without assignment > 1 hr. PACU patient RTM >45 mins. and # PACU Holds lounge) Contact OBS ICM person for assistance Alert Logistics Center and Nursing Supervision to send patients to nursing units w/o Statusing Contact Logistics Center director and Nursing Supervision Prioritize bed requests to prevent procedural area cancellations Consult CNO/ ICM Clinical Manager Director
7 of 12 Nursing Supervision Cath Lab, PACU, Interventional Radiology > 3 Medical Administrator on Call to consider closing to incoming transfers (outside of those at risk for EMTALA) > 8 ECC Triage patients > 8 ECC patients RTM w/o assignments Number of patients threatens to exceed the ability to maintain departmental flow When flow impacts the ability of an area to perform procedures Transport > 5 pending transports with assignments, with average response times >15 minutes EVS House > 3 assigned to dirty beds Go to ECC to evaluate situation Assist with cardiac transports or Contact Intervention/Facilit ator RNs Consider overflow areas to place patients Notify and/or Nursing Supervision Prioritize placement for impacted areas Logistics Center will notify executive leadership Work with team and Nursing Supervision to garner additional resources Logistics Center to use Clean Next and Stat prioritizations Alert Logistics Center director and EVS leadership Consider Nursing Supervisor on duty director Cath Lab, PACU, Interventional Radiology leadership director and/or Transport Lead director and/or EVS leadership
8 of 12 Inpatient Nursing Units (Individual) >3 patients RTM with assignments per unit transporting patients to rooms in progress Send floor staff or other resource to pull patients up. Clinical Coordinators/Clinical Managers Critical Care Units >2 ICU patients in ECC and > 5 patients in Triage >3 ICU patients in ECC or single Hypothermia ICU patient in ECC >5 ICU patients awaiting placement from all avenues (PACU, ECC, Cath Lab, Transfers, etc.) Radiology >3 CT tests ordered from ECC >2 MRI tests ordered from ECC > 2 Stroke Alerts and/or Trauma Alerts Provide patient assignment w/in 5 minutes of RTM ICU Intervention RN to ECC Medical Director to triage all current ICU patients to determine which are appropriate to transfer out Work with ECC Charge Nurse and Medical Director to determine priority ICU Clinical Manager, Director and Medical Director Radiology Leadership Appendix B Overflow Bed List - Maximum Capacity by Unit (and alternative locations as listed) Other Areas
9 of 12 Radiology Pre/Post 8 Endoscopy 6 PACU 4 OB ECC 7 Total 25
10 of 12 Appendix C Departmental Roles in Lavender/Purple Alert Each department is to review their procedure and initiate their scalable department plans. Biomedical: Assess the need for additional telemetry needs and be available for urgent repair need or the need to increase staffing. Assist with RTLS for essential supplies. Blood Bank: To be aware of alert status and potential need of blood products. Cath Lab: Prepare to hold patients in post-cath recovery area as needed. Central Transport: The designated Central Transport supervisor will report to the Administrative supervisor/nad and/or director to assess the situation and dispatch transport staff to the most appropriate areas. Additional staff/volunteers will also be called per department plan which includes Environmental Services (EVS), Dietary and Hospitality Management Team. Consider assigning designated transporters to specific areas in need. Clinical Managers/Designee: Identify discharges/transfers and facilitate timely patient transportation to Departure Lounge. Obtain additional staff to open all beds on unit. Clinical Systems: Staff will be needed to assist with SCM documentation in areas where purple beds are being activated. Departure Lounge: Plan for additional staffing, consider need to expand service hours. Education, Clinical Practice and Research Department: Qualified nursing staff to be assigned through as helping hands to clinical areas or to assist with RN transports. Environmental Services (EVS): Designated EVS supervisor will report to with Administrative supervisor/nad to coordinate priority bed cleaning and also the availability of beds to place on identified traditional and overflow units. Food & Nutrition: Assess needs of staffing to support increased volume of patients and to increase food deliveries to traditional and overflow units. Infection Control: Activate an immediate review of isolation list and help to cohort infectious patients allowing closed/blocked beds to be opened. Information Systems: Assess the need for additional staff being called in to assist with increase in patient census. Integrated Case Management (ICM): Admissions: ICM staff will status patients as OBS/IP as best possible. When departmental triggers are met, additional staff will be assigned to assist with statusing patients (OBS, ICM and ICM management team).
11 of 12 Discharges: ICM staff will identify and expedite all discharges for that day, as well as identify discharges for the following day. The ICM staff will also act as liaison to physician staff and explain the need to discharge appropriate patients. Laboratory: Assess test ready status for instrumentation, staffing, and stat/asap priorities. Linen Services: Ensure linen availability and notify Bay Linen of census increase. Prepare to provide linen carts to overflow locations. : Assess the necessity to open all available beds for incoming patients. Medical Staff: The medical staff will be notified by a global message identifying the types of beds currently needed and requesting their assistance in expediting discharges. The medical directors and CMO also will be notified. Operation of Plant: Assess the need for additional staff being called in for priority repairs or closed beds that are impending patient placement. Other Departments: Awareness of alert status and need for help with transport or other duties. Pharmacy: Heightened awareness of potential increase of new medication orders and increase in census that may affect staffing. Prepare to provide stocked Pyxis to overflow locations. Post Acute Services: Will immediately identify all consults, expedite assessment and notify ICM of acceptance or denial based on criteria. PACU: Prepare to hold ICU/floor patients post recovery as needed. Procedural Recovery Areas: Will need to assess the need to remain open during alert status and hold current patients needing bed placement Radiology Services/Cardiovascular Services: Prioritize tests/studies/reading based on throughput needs. Assess ability to move tests to Outpatient sites. Respiratory Therapy: Reallocate staff as needed per patient population. Security: Security supervisor to communicate with ECC leadership and Director to assess security services needs during the Purple Alert. Supply Chain Management: Be alert to sudden need for additional patient care supplies in traditional and overflow locations. Valet Services: Assessment of need for valet service or increase of service during alert status.