MANUAL St. Mary's Hspital Camrse, Alberta PURPOSE Initiated by: Number: ER-7290 Apprved by: Date First Issued: May 24, 2016 Date f Last Revisin: Nv 5, 2008 Categry: Emergency Ref Plicy #: Tpic: SURGE CAPACITY PROTOCOL Surge Capacity activities are initiated: I. In the event that vercrwding and cngestin and/r unusually high acuity in an Emergency Department have the ptential t cmprmise client safety. II. In the event that a number f staff is unable t reprt t wrk due t illness/ ther, This prtcl des nt replace Emergency Preparedness measures. APPLICABILITY This plicy and prcedure applies t all Cvenant Health facilities, staff, members f the medical staff, vlunteer, students and any ther persn acting n behalf f Cvenant Health. PROCEDURE I. Initiatin Criteria II. The can nly be initiated by the Site Administratr r Admin n Call Prcedure ER physician, ER Manager/ Charge Nurse cntact Admin n Call t activate upn cmpletin f the criteria check list and determinatin that n ther strategies will reslve the cngestin in ER at that time. The reasns fr initiatin (criteria chsen) are dcumented n the wrksheet and signed by the ER physician and the ER Manager/ Charge Nurse. This is the fficial START TIME fr the Surge Capacity Event.
Camrse, Alberta Page 2 f 8 DEFINITIONS Hspital Capacity: The day t day availability f peple, prcesses, equipment, and pathways that supprt the effective management f hw clients mve thrugh the health system. By and large, hspital capacity is abut the number f available beds n a daily basis, the ccupancy rate, and the peple, the supplies and the infrastructure required in rder t efficiently delivering care. Hspital Surge Capacity: The ability f a hspital t expand capacity during peaks in demand; particularly in an Emergency Department. Hspital Surge Capacity may be the state that a hspital is functining within at any given time based n average ccupancy rates and length f stay. : A series f activities that are initiated t ffer strategies and decisin supprt tward managing episdes when the system is experiencing a surge f clients beynd manageable levels. RELATED DOCUMENTS Admin On-Call The Site Administratr r the designated Admin-n-Call persn fr the site. Cvenant Health Rural Acute Surge Plan
Camrse, Alberta Page 3 f 8 Wrksheet A) The Emergency Department must meet triggers fr acuity, vlume and staffing. 0700-2300: Must meet any 3 f the fllwing triggers t initiate Surge Capacity 2300-0700: Must meet any 2 f the fllwing triggers t initiate Surge Capacity Triggers Acuity Triggers 2 r mre CTAS 1 r 2 patients in the department with n expectatin f transferring ut within the next hur 2 r mre patients in the department requiring physician rdered cntinuus cardiac mnitring 2 r mre patients requiring clse bservatin (examples are altered LOC, c-spine pts, disruptive mental health patients) Vlume Triggers 5 admitted and/r hld patients in ER 2 r mre transfer patients currently in the ER (waiting transfer t a higher level facility) Staffing Triggers Staffing challenges are affecting ability t see new patients Unable t arrange fr additinal physician supprt B) The Hspital may be triggered t initiate the when there is: Increase in vlume f patients at the site Increase in acuity f patients at the site Number f staff unable t attend wrk due t illness r ther circumstances SIGNATURES: ER MANAGER/ CHARGE NURSE ER PHYSICIAN Date: Time:
Camrse, Alberta Page 4 f 8 Appendix A Admin-On-Call Checklist 1. Ensure Triggers have been met, Activate. 2. Cntact Site Administratr/ designate 76 funded beds 4 ver capacity 4 unfunded in the Ambulatry Care Unit (fr stable patients awaiting discharge require supervisin f regulated health care prfessinal) 3. Site Administratr/Designate Ntify Senir Directr Operatins (SDO) Ntify IPC Practitiner, if applicable Ntify Site Medical Directr Wrk with Unit Managers, Charge Nurses, CLC t: Identify ptential discharges. Create phantm spaces fr discharged patients t wait. Determine if unfunded bed spaces are required. Determine if elective surgical cases shuld be cancelled (required SDO ntificatin). Meet with Stakehlders every 30-60 min until reslved.
Camrse, Alberta Page 5 f 8 Appendix B St. Mary s Hspital Date: Time n: Time ff: Nurse in Charge: ER Physician: CHARGE NURSE CHECKLIST: Time & Initial PRE-SURGE TASKS Cnsult with Admitting staff t determine: Number f currently available empty inpatient beds, (unit 2, 3, 4, & 5) Number f patients scheduled fr the next day same day surgery If all pprtunities t c-ed patients n inpatients units have been implemented Instruct Admitting Clerk t call all acute care inpatient unit nurse in charge t immediately Cmmunicate urgency f situatin in ER and ensure all discharge patients and rm transfers are in the cmputer Determine the number f patients wh are expected t be discharged shrtly and can (nt want ) wait in lunge Determine the number f beds ptentially available thrugh discharge within the next 24 hurs, and reprted back t the ER Nurse in charge Instruct ER Attendant (during ffice hurs) t: Phne all physician clinics, t alert them f immediate need fr inpatient beds and the pending initiatin f. State: Attentin all Physicians. The ER urgently requires inpatient beds. Please cntact inpatient units as sn as pssible, if yu have patients that can be safely discharged. When abve infrmatin is gathered, if n inpatient beds can be made available within 30 minutes, and required ER SCP triggers still exist with n imprvement in sight, cnsult with ER Physician & Admin n Call fr hspital t INITIATE SCP. Cmmunicate cnfirmed inpatient bed situatin t ER physician n call fr Hspital, and cnfirm that trigger criteria are still met. Initiate Critical Supprt Team; Attempt t cntact ER staff t reprt t wrk. Time & Initial SURGE CAPACITY TASKS TO BE COMPLETED Initiate Surge Capacity & sign ff dcument with ER Physician n Call, nting time f day. Annunce verhead; Surge Capacity in effect. Speak with Admitting and request immediate activatin f the Surge Capacity Prtcl accrding t their checklist. Instruct ER attendant t cntact ambulance service t ntify them we have activated the Surge Capacity Prtcl. Phne # Wrk with Admitting t mve patients frm ER, within apprpriate guidelines. Start reassessment f SCP (in discussin with ER physician) within 90 minutes f initiatin t determine if cngestin has imprved.
Camrse, Alberta Page 6 f 8 ADMITTING CLERK CHECKLIST: Date & Initial SURGE CAPACITY TASKS TO BE COMPLETED 0700-1500: Make verhead annuncement Attentin physicians and hspital staff. We are nw initiating surge capacity prtcl. All acute care nursing units begin t prepare fr ne ver capacity admissins. Cntact the 2828 Mnday Friday. Weekends & After hurs: Telephne all acute care nursing units. Request t speak with Nurse in Charge. Infrm Nurse in Charge f SCP, and request they begin t prepare fr ver capacity admissins. Frward this cmpleted checklist t ER Nurse Manager/ER Charge Nurse. Once SCP has been discntinued, pririty f receiving apprpriate inpatient beds will be given t patients wh have been placed in ver capacity beds, r c-ed situatin.
Camrse, Alberta Page 7 f 8 St. Mary s Hspital ER- Original signed cpy must be frwarded t the ER Manager upn cmpletin f Surge Capacity Event ER Charge Nurse Data Cllectin Original signed cpy must be frwarded t the ER Manager upn cmpletin f Surge Capacity Event
Camrse, Alberta Page 8 f 8 SURGE CAPACITY EVALUATION TOOL Date Situatin: Were yu able t enact pre-surge activities Yes N If yes, what did yu d t try & alleviate vercrwding in the ER? If n, explain factrs cntributing. Backgrund: Cmment n the triggers that necessitated Surge Capacity. Recmmendatin/ Initiated at hrs by Actin Re-assessed at hr Discntinued at hrs by Were yu able t reassess in a timely manner? Yes N If yes, what did yu d t try & alleviate vercrwding in the ER? If n, explain factrs cntributing. Were there any difficulties / areas fr imprvement in the prblem? Please prvide feedback. Feedback frm Units/EMS/ Other Departments (t be cmpleted ER Manager)