Reports From the Field

A Novel Emergency Department Surge Protocol: Implementation of a Targeted Response Plan

Journal of Clinical Outcomes Management. 2015 November;22(11)

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Responding to ED Surges

An effective surge plan should ensure the delivery of safe, effective care in response to various input/throughput/output surges in a coordinated and standardized manner. The ideal ED surge plan should include (1) a prospective continuous tool/method that accurately gauges the surge level (based on objective measures) in various components of the Input-Throughput-Output model of the department, (2) standardized targeted actions that are tied to specific triggers identified within that model to ensure effective solutions, and (3) built-in contingency plans for escalation in the face of sustained/worsening surges. Few studies have been published describing successful implementation of ED surge protocols, with the majority being linked to global ED crowding measures such as the NEDOCS score [10]. As a result, it is difficult to tease out the specific targeted actions that are most effective in dealing with the root causes of a surge.

Local Problem

Prior to the quality improvement initiative we describe below, the Ottawa Hospital ED had no formal process or method of measuring daily surges nor any standardized action plan to respond effectively to those surges. The state of “busy-ness” was often defined by gut feelings of frontline workers, which was quite variable depending on the individuals in charge of departmental patient flow. Often, actions to try and mitigate rising ED surges were triggered too late, resulting in consistent gridlock in the ED that lasted many hours. Several near-misses as well as actual critical incidences had occurred as a result of ineffective management of ED surges, and the authors of this initiative were tasked by senior hospital leadership with designing and implementing a novel solution.

Objectives

We describe our approach to the development, implementation, and evaluation of a novel ED surge protocol at a tertiary care academic hospital based on the principles cited above. Specifically, we sought to:

define various levels of ED surge and to provide a common language for better communication between all stakeholders
incorporate the validated Input-Throughput-Output model of ED flow to provide a conceptual framework for measuring surges in real-time and developing targeted action plans
standardize ED and organizational responses to various ED surges based on identified bottlenecks
measure and evaluate the effectiveness of the ED surge plan implementation
continuously modify and improve the ED surge protocol using quality improvement strategies

Methods

Setting

The Ottawa Hospital is an academic tertiary care center with 3 campuses (Civic, General, and Riverside), with the ED providing coverage at 2 physical emergency rooms. The hospital is the regional trauma center as well as referral destination for many subspecialties such as cardiac, vascular and neurosurgical emergencies. This 1163-bed facility handles over 160,000 emergency visits a year, over 1 million ambulatory care visits a year, and roughly 35,000 surgical cases annually. The ED is staffed by 78 staff physicians, approximately 250 registered nurses (RNs), and ~50 emergency medicine residents/trainees.

The EDs are supported by a computerized tracking system that provides real-time metrics. This information is displayed by ED-specific geographical area on electronic whiteboards, which can be accessed on overhead monitors, desktop computers, and personal iPads. Information available to ED physicians and staff at any time includes individual-level data such as location, demographics, Canadian Triage Acuity Score (CTAS), and presenting complaint as well as departmental-level data such as patient volumes, wait times, length of stay (LOS), pending/completed diagnostics, consultation status and final dispositions.