UAMS MEDICAL CENTER POLICIES & PROCEDURES Number: MS.5.16 Source: Hospital Administration Approved By: Hospital Medical Board Date Approved: Review/Revised Date: Replaces Policy: PURPOSE To define the process for notification of local Emergency Medical Services (EMS) providers and other agencies when there is a change in status of the Emergency Department s capacity. DEFINITIONS I. Emergency Department Overload The patient volume in the Emergency Department has exceeded the threshold of normal available resources, and the ED is following usual accommodation processes to provide necessary care. II. III. IV. Delayed Status A status implemented with EMS agencies when patient volume in the Emergency Department is at or approaching overload status but necessary care is being provided through usual accommodation processes and relief is expected within a reasonable period of time. During periods of Delayed Status, patients will receive care as required by the severity of their illness but may experience delays due to diminished capacity, and EMS agencies will be informed so they may offer other destination alternatives to patients. Open Status Normal operations without restrictions or limitations. Trauma Medical Director The Trauma Medical Director, Associate Trauma Medical Director or the On-Call Trauma Surgeon if neither of the above are available. POLICY UAMS is committed to providing care to critically ill or injured patients who are in need of highly specialized or advanced medical care that is not generally available in other areas of the state. Occasions may arise when one or more essential hospital resources are functioning at maximum capacity or otherwise unavailable and it is in the best interests of patient care to initiate a Delayed Status to allow 1
EMS to inform patients that they may experience delays at UAMS due to diminished capacity and offer them the opportunity to choose another facility, if appropriate based on the EMS provider s clinical judgment. This policy describes the processes for notifying EMS agencies of times of limited availability and delays due to diminished capacity. Delayed Status applies only to incoming ambulance patients and not to walk-in patients or ambulance patients that have arrived on hospital property. Such patients will be evaluated and treated or transferred regardless of the hospital s status. Delayed Status may be implemented at the discretion of the ED Attending with concurrence of the On- Call Chief Medical Officer (CMO) and ADON. During times of Delayed Status, patients en route via ambulance who are experiencing a condition such that transport to any other facility could reasonably be expected to result in increased morbidity or death may be prioritized over other patients who are already present in the Emergency Department or en route via another ambulance provider. PROCEDURES I. The ED Attending and ED Charge Nurse will continually monitor the ED for Overload status and will confer with the ADON and On-Call CMO when appropriate to assess the need for Delayed Status. II. III. IV. When it is determined that the ED has reached Overload status and Delayed Status is warranted, the ADON will notify the On-Call CMO or the On-Call Administrator of the requested change in status of the facility. The Emergency Department Delayed Status Worksheet (Appendix A) will be activated and completed by the ED Charge Nurse. Telephone notifications to all of the agencies listed on the Delayed Status Worksheet will be performed by the ED Charge Nurse with documentation of contact name and time for Delayed notification and Open notification. Any changes to the Trauma Dashboard and Trauma Status require the concurrence of the Trauma Medical Director and will be governed by the Trauma Diversion Policy. V. After initiation of Delayed status, ED status will be re-evaluated internally by the ED Attending, ED Charge Nurse and the ADON at least every two hours. VI. VII. When the ED Attending, ADON and On-Call CMO determine that ED Overload Status is resolved and normal services can be resumed, the ED Charge Nurse will contact all agencies to revert back to an OPEN status. Individual Specialties may be placed on Delayed Status at the discretion of the ED Attending in circumstances where a single specialty or resource is not immediately available. 2
APPENDIX A. UAMS Emergency Department Delayed Status Worksheet REFERENCES Arkansas Trauma System Rules and Regulations (Sept. 6, 2014). Trauma Diversion Policy 42 C.F.R. 489.24 3
APPENDIX A UAMS Emergency Department Delayed Status Worksheet Notification ED Attending: ADON: On-Call CMO: Trauma: Required for Trauma Delay Delayed Status Authorization Name Official DELAYED/OPEN Times: Date/Time DELAYED Status Date/Time OPEN Status Reason for DELAYED Status Patients Holding in ED ICU Floor Nurse Staffing Issues OTHER Comments: 4
ED Charge Nurse will: 1. Call the following agencies in the order listed when possible. 2. Provide the following information for notification of DELAYED STATUS: This is (your name), RN at UAMS Emergency Department. I am calling to notify you that we need to be placed in DELAYED STATUS for all ambulance traffic [except for Major and Moderate trauma (or any other service as determined by the CMO/ADON/ED Attending/Trauma Director)]. We will call back to notify you when we are no longer in DELAYED STATUS. 3. At the conclusion of DELAYED STATUS, notify the same agencies of the return to OPEN STATUS. This is (your name), RN at UAMS Emergency Department. I am calling to notify you that we are now OPEN to all traffic and are no longer in a DELAYED STATUS. 4. If the status change is a change to the Trauma Status, update the Trauma dashboard and notify the dispatchers on the phone of the change in the Trauma dashboard. Any status changes to the Trauma dashboard require approval of the Trauma Medical Director. Agency Phone Number MEMS 301-1407 OR Desk 614-2900 Central RCC 661-2136 EASI 870-226-3793 Southern Paramedic 870-672-4595 Jacksonville Fire 985-2802 Allied 501-941-5651 MEDTRAN 501-303-5648 Air Evac 800-247-3822 Med Flight 202-1000 DELAYED STATUS OPEN STATUS Date Time Date Time Life Net Survival Flight 903-831-2061 877-581-5558 5
This form shall be maintained for a minimum of 5 years. 6