Anyone in a leadership role at a hospital has seen what happens on days with a very high census. Critical patients wait hours in the emergency department because there aren’t any ICU beds. Patients in the ICU have had discharge orders for two days but there are no telemetry beds for them to move out to. There are anxious calls to make sure the PACU remains open overnight. Patients start to walk out before they are seen in the emergency department, and even without official diversion, ambulance dispatch is sending patients elsewhere.
As the magnitude of a surge in census becomes clear, leadership scrambles to respond. Calls go out asking nurses for extra shifts or calling in agency nurses. The COO opens a closed unit. Case management, social workers and physician leaders work frantically to find a few extra discharges and find post-acute placements. Admitted patients are routed to other hospitals in the system.
The problem for a hospital experiencing a surge is that more often than not hours go by before everyone recognizes and agrees that this is not a normal day. And once action is taken to mitigate the problems, it takes considerable time to get a variety of moving parts into place. There are phone calls to be made, requests and negotiations, and significant delays as people find childcare and change plans to come in to work. These actions must be renegotiated every time there is a bed crisis. Then there is the financial impact. Surges take key personnel away from patient care and important administrative work. At the same time, costs are driven up through expensive unplanned extra staffing, and revenue from external transfers and ambulance arrivals is lost and ambulatory ED patients walk out. It’s a triple-whammy to the bottom line. There has to be a better way.
To address this problem, many hospitals are implementing “surge plans” to formalize and improve the ad hoc responses that have been developed over time. Most surge plans standardize the triggers for action, which dramatically improves reaction time, and cuts through the debate that delays a response. Surge plans also tie specific actions to those triggers, formalizing the consensus around necessary responses and avoiding the need for making the case and negotiating in real time.
Having structure and detail in a surge plan help avoid missing steps, or leaving out groups and departments whose involvement is necessary. Surge plans can also help focus efforts on specific bottleneck areas so that if, for instance, the ICU is the most gridlocked point in the hospital, efforts can be concentrated effectively at that point.
Surge plans lend themselves to measurement, analysis, refinement and improvement over time. The final element that technology enables is census forecasting, giving hospitals precious extra hours or even days in which to recognize impending census surges and to deploy their response proactively.
Surges are a fact of life in hospitals, but new technology is allowing us to more quickly anticipate and respond to surges, and keep the focus on patient care. In future posts, I will discuss surge plans in greater depth, including triggers for action, scaled responses, actions in various disciplines, units and departments, messaging, building agreement and participation, and advanced warning systems.