Daily Pearl

What is the new surge policy?

Policy Statement: There are three levels of patient care management strategies for over-census control: ED Overcrowding, Hospital Surge, Emergency Preparedness/HICS Activation.
ED Overcrowding Plan:

Definition: ED overcrowding exists when 55 adult patients are undergoing evaluation and care within the Emergency Department and 12 patients are admitted to the Hospital without a ready bed assignment.

Standard Operating Procedure:
ED Leadership will provide communication via email of current status and needs to a pre-defined administrative distribution list ED Clinical Coordinators review ED Admission Bed Board at regular intervals and look for opportunities to facilitate patient throughput. ED Medical and Nursing Leadership huddle with Bed Management in the Emergency Department to forecast bed availability. Admitted non-monitored patients assigned to “to be cleaned beds” by Bed Management will be transferred from the Emergency Department to assigned inpatient units. Reassessment of ED overcrowding conditions will continue until conditions improve or activation of next level.

Hospital Surge Plan:
Hospital Surge Plan will be activated when both of the following conditions are met:
Greater than 70 adult patients undergoing evaluation and care within the ED and 24 admitted patients without ready bed assignments
Hospital Surge Plan addresses high hospital occupancy with reduced capacity.
Implement rapid inpatient evaluation and rapid discharge procedures. Inpatient units will create surge capacity using their unit-specific procedures outlined in an appendix. Transfer patients who meet surge criteria.


Internal Communication:
ED Leadership (Medical and Nursing) will communicate with the Hospital President or designee to request activation of the Hospital Surge Plan when criteria are met.
During the off-hours, ED Leadership (Medical and Nursing) will communicate with the Hospital and Nursing Administrators-on-Duty requesting the activation of the Hospital Surge Plan. The Hospital and Nursing Administrators-on-Duty will communicate with the Hospital President or designee for approval.
Depending on day/time of day, the Hospital President or the Hospital and Nursing-Administrators-on-Duty will communicate the activation decision to the surge plan distribution list.
Surge Procedure:
Patients who meet surge inclusion criteria will be assigned to inpatient units by Bed Management in collaboration with Nursing, and regardless of assigned bed status (whether beds are clean or dirty), will be transferred from the Emergency Department to inpatient units. They will remain in unit common areas or hallways until rooms become available. An inpatient unit may be assigned over-census patients by Bed Management up to 2 patients over their normal maximum census.
All transfers of over census patients during activation of surge procedure must follow hospital policies on hand-off communication (i.e. SBAR).
To increase inpatient bed assignment flexibility and capacity during Hospital Surge: Identified patients will be reviewed by Nursing and Medical Leadership prior to acceptance for unit common areas or hallways. Patients may be assigned off-service beds. Private rooms, treatment/procedure rooms, or lounges may be used to accommodate additional patients, if possible, to go over census. *Note: Use of CRC beds to be approved by CRC program administrator or designee.
Patients meeting exclusion criteria shall include: Patients on telemetry Patients with acute pulmonary disease requiring oxygen or ventilation support Patients with diarrhea (defined as greater than two episodes in 12 hours)
o Patients with a history of c.difficile who do not have active diarrhea may be placed in the hall if approved by Infection Control. Selected patients with isolation status (i.e. mrsa or vre) – which will be determined by Infection Control on a case-by-case basis. Patients with abnormal vitals defined as HR>110 or SBP<90 Patients on one-to-one observation who are combative
o Patients on one-to-one observation for elopement risk will be evaluated on a case-by-case basis.
The CMO or designee will coordinate decision-making for those cases where there is disagreement about exclusion or inclusion.
These immediate actions will be carried out to accommodate over-census patients: These patients will be assigned to patient care units in a virtual over-census location (“99” bed). This is an over-census designation in the IT clinical systems, such as Cerner, EPIC, and Agiletrac. Call bells, privacy screens, beds/stretchers will be provided by Building Services.


Surge Reassessment:
ED and Hospital bed capacity will be reassessed every four hours by reviewing the following:
ED census and inpatient bed census Available patient care staff resources and patient-to-provider ratios for patient care areas Available supply needs for patient care (i.e., stretchers/beds, privacy curtains) Available ancillary staff to provide patient services (i.e., transport, patient observation).
The Hospital Surge plan will be concluded when Hospital Surge criteria are no longer met.
The ED leadership will communicate with the Hospital President or designee during regular business hours or the Hospital and Nursing Administrators-on-duty when Surge criteria no longer exist and communicate the conclusion via email distribution list.
Emergency Preparedness – Activation of Hospital Incident Command System (HICS)
Any situation with a significant impact to hospital operations generating a large number of patients or in preparation for a large number of patients, including events such as mass casualty incidents, public health emergencies, or emergency evacuations to the medical center.
The activation of this plan is outlined in The Mount Sinai Hospital Emergency Management Plan.

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