Hospitals’ preparation for surge of patients helps with new Joint Commission standards
With new surge capacity standards from the Joint Commission on Accreditation of Healthcare Organizations, EDs are finding that their preparation for any type of patient surge translates into preparation for the infectious patients specifically targeted in the new standard (IC.6.10), which says, "As part of emergency management activities, the organization prepares to respond to an influx, or the risk of an influx, of infectious patients."
Baptist Hospital of Miami has developed guidelines for surge of any type of patients, including infectious patients, that allow it to decompress the excess volume in the ED or empty the ED.
Baptist has had to decompress twice, due to the volume of flu cases and other patients, about two weeks apart in March 2005. In each of two situations, more than 20 patients in the ED were admitted and awaiting inpatient beds.
Baptist Hospital identified rooms that were slightly larger than the standard ones, says Becky Montesino, RN, MS, assistant vice president at Baptist. Two patients at a time are moved temporarily to one of these single rooms, Montesino says.
Patients are carefully selected to be temporary roommates in one of these rooms, she says. "We matched for age group, diagnosis, preferred language — general compatibility," Montesino says.
Both patients had to be agreeable, she explains. "Those two patients are just happy to be in a room with a bathroom. Their care is progressing in a safer, much more private environment for them."
As private rooms open on the floors, ED patients are put on stretchers and admitted. "We happened to have electric stretchers in storage for outpatient areas," Montesino says. "We put them into use."
Baptist administrators learned lessons to prepare them for future ED surges. One was that they needed to adjust their computerized billing system so that it could bill for two patients in a private room, as well as scan orders and order meals.
"A surge still requires the same standard of care for everyone," says Montesino, referring to a Joint Commission leadership standard.
Baptist created imaginary room numbers for the patients who were doubled up in a room. For example, if the last actual room on a floor was 2235, a patient admitted to a room with two stretchers would be assigned the room number of 2236.
Other hospitals address this problem by adding "A" or "B," or "Bed 1" or "Bed 2" to the room number.
Baptist also arranged to have second call lights for those rooms. "Now we have them stored and ready to go," Montesino explains. The hospital put tracks in the room to hang curtains as dividers, and they also are stored.
"Planning it before we ever tried it didn’t work," she notes. "We learned by experience."
Communicate with all departments
How you communicate changes made during a surge is significantly important, Montesino says. For example, pharmacy needs to know where to deliver drugs to patients who aren’t listed with their actual room number, she says.
E-mails are sent to the directors of every department when implementation of the surge capacity plan seems imminent, Montesino says. Every department has a role, she adds. A meeting is called for the director of every department. The directors are told that the patients are surging, and the changes to normal policies are explained. Directors are asked whether they need anything to help them handle the surge. "From that point out, every department knows how to handle it," Montesino says. For example, the dietary department staff understand that there would be two trays going to some rooms.
Additionally, signs are posted on every unit informing physicians that due to high patient volume, some patients are being admitted on stretchers. They are informed to check with the charge nurse at the desk to find out where their patients are located. "We knew they would get confused," Montesino notes.
Baptist learned an immediate good lesson. "You need to communicate with the patients before they go into that setting," she says. "Be direct and honest about the situation."
Undo the double rooms as soon as you can, she advises. "You don’t want to get stuck," she says. "It’s an emergency."
After weathering the two surges earlier this year, the administrators realized that these changes would help address the new surge capacity standards.
"After we debriefed on these guidelines, we determined with our infection control director that we could use this same method and expand on it as need be" if there was a surge of infectious patients, Montesino says. "We had developed a system that worked already," she adds. "Every nursing care unit understood it."
One area that isn’t addressed in the current surge guidelines is the additional staff that would be needed in the event of a disaster or an infection. "We have a pool, and we have some ways to do that because we have to stretch staff in disasters, like Hurricane Andrew in 1992," Montesino explains.
Hospital drafts response policy
St. Joseph Medical Center in Towson, MD, has drafted a surge capacity response policy that could be used in the event of a surge of patients, infectious or otherwise.
"When the Joint Commission was here, they were informed of the draft and what we were doing for surge and how functionalities change as we need to for census management," says Carole Mays, MS, RN, CEN, director of emergency services.
The ED has experienced surges during flu seasons and at other times, Mays says.
"We decided to be proactive this next year," she says. The policy involves all departments, Mays emphasizes. For example, housekeeping is involved in cleaning beds in the ED and on the floor, she says.
"We make sure we decrease and increase staffing, as we need to switch capacity changes," Mays notes.
The ED already has a clinical placement nurse to address capacity issues, she says. Bed meetings are held twice at day, at 8:30 a.m. and 4 p.m., every day, regardless of the census, Mays says.
All the patient care coordinators/clinical leaders attend, plus housekeeping. The ED is represented by the patient care coordinators, the manager, or Mays. "We say, Were on diversion’ or not, so we let whole hospitals know at that time what our needs are," she adds.
The leaders discuss how many patients in the ED are admitted and don’t have beds, Mays says. "Also, we let them know what our potential admissions are. In essence, the hospital helps respond to us by pulling patients from the ED."
When facing surges, the hospital expects physicians to make their rounds differently, Mays notes. Case managers call them, she says.
Also, "They are notified at some of their ground rounds and in the physician lounge that we’re in a surge time and we need beds for admissions," Mays explains.
Physicians are asked to assist by rounding earlier and by helping patients understand when they’ll be discharged. Case managers are asked to help with the transportation needs of discharged patients, Mays says. "It’s a whole effort," she points out.
Other ideas that aren’t yet part of the written surge capacity plan include bringing a phlebotomist from the lab to the ED and having physicians at triage to help plan care, May says.
"It’s important to us to keep our doors open — our ambulatory doors and our ambulance doors," she says.
Sources
For more information on the new surge capacity standards, contact:
- Carole Mays, MS, RN, CEN, Director of Emergency Services. St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204. Phone: (410) 337-1543. E-mail: carolemays@chi-east.org.
- Becky Montesino, RN, MS, Assistant Vice President, Baptist Hospital of Miami, 8900 N. Kendall Drive, Miami, FL 33176. Phone: (786) 596-6556. E-mail: beckym@baptisthealth.net.