Every system has surges in volume, whether they are predictable or unpredictable surges. Most facilities were not designed to handle either type of surge – it’s simply not cost effective. But staff can make the best of their inflexible facilities by knowing what to do in case of a surge in volume.
In the previous post in this series, we discussed bed shortages caused by predictable surges in patient volume. In this post, we describe how to increase capacity in an unexpected surge.
Sometimes, a bolus of patients arrives suddenly that you could not predict through historic arrival patterns. If you didn’t see it coming, how do you manage?
How to Increase Capacity in an Unexpected Inpatient Unit Surge?
Even though emergency departments (EDs) are acutely aware of the need to plan for the next pandemic, they can’t manage a tidal wave alone. Receiving units must admit patients faster as subsequent waves of new patients arrive.
We suggest that case managers, attending (PCP) physicians, and hospitalists regularly convene to plan for each patient’s discharge process. This team should tally patients who are ready to go home, nearly ready to go home, or not ready to go home. During surge periods, evaluate patients who may medically qualify for home discharge with immediate follow-up evaluations and/or continued diagnostic testing. Identify the last possible time a patient should move out of a bed and work toward beating that time. These measures help free up inpatient capacity to accept new patients from the ED.
Consider the development of a discharge lounge. Here, co-locate patients who are not prepared for home discharge with Care Managers who can assist in getting them home safely.
Evaluate the need to call in extra staff, or call in original staff early for duty. Extra staff can help increase the speed of preparing patients for discharge and accepting newly admitted patients. Adjust the nurse to patient ratio as needed.
Only when absolutely necessary, stage admitted patients in the inpatient hallway until a bed becomes available. Although not a preferred solution, this action enables ED staff to evaluate all presenting patients to the department in a safe and timely manner.
Bigger Picture Ideas
Real-time ED, surgery, and inpatient unit census data tracking is the best predictor of available inpatient capacity. With it, you can proactively develop a plan that will accommodate all anticipated admitted patients for that day. Doing this before the ED begins to board admitted patients is preferable to reacting to the problem as it snowballs.
EDs admit a known range of patients every day. Therefore, it should not be a surprise that ED patients require a certain number of inpatient beds per day. Hospitals must predict this number just as accurately as they predict the number of admitted surgery patients.
Department managers and directors should meet 2-3 times per day as they problem-solve inpatient capacity concerns and plan for the next 24 hours. With practice this effort can take less than thirty minutes. Huddles should yield a process for alerting downstream inpatient and outpatient departments of coming surges so they can actively prepare. The reverse is also true. If inpatient units are full with few discharges over the next 24 hours, the ED and OR can prepare accordingly.
While a team huddle can be a productive tool, it shouldn’t look like this:
ED: “We have 10 admitted patients in the ED waiting for beds.”
Inpatient units: “We are full and expecting 4 discharges.”
Surgery: “10 patients will need to be admitted following surgery.”
CU: “We are not full but we can’t take another patient because we don’t have enough staff to support a 1:2 ratios. We have two patients who can be downgraded to telemetry but telemetry is full.”
The typical outcome of this scenario is that patients stay in the ED where they do not have a 1 RN:2 patient ratio. It takes several hours for nursing supervisors to call in staff to staff the licensed operating capacity and get expected discharges out of the hospital in a timely manner. This happens because huddle meetings are used to report current activity and the anticipated day’s progress.
Instead, a huddle meeting with a proactive approach and shared ownership looks like this:
ED: “10 patients will need beds next Monday and every Monday thereafter until kingdom come, what’s the plan?”
Inpatient units: "We have 3 patients who are expected to be discharged Monday morning and can plan for at least two of those to go home.”
Surgery: "The surgery schedule accounts for 5 admissions to the ortho unit and 3 to med/surg. We don’t expect any to need monitoring.”
ICU: "Our intensivists and respiratory therapists suggest that two patients will pass their swallow tests and can step down out of the ICU.”
A surge is everyone’s responsibility. The ED should not be the only unit with a plan for a surge in patient volume. The admitted patient process is a concern for the entire hospital – not just the ED, OR, or Cath Lab. Planning for surges enables all patients to receive the level of care they need and deserve.
