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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Given the complexity of the ED- and hospital-wide nature of the surge protocol, implementation was done over multiple phases and Plan-Do-Study-Act (PDSA) improvement cycles:

Phase I (Apr 2013 - Jun 2013)

The initial proposed ED surge level metrics were measured at a single ED campus. Care facilitators were trained and asked to measure surge levels in the ED every 2 hours. This served as a testing period to gauge the sensitivity and reliability of our proposed surge level metrics, and no actual action items were triggered during this period. Stakeholder meetings were held to determine feasibility of the plan, validate the proposed metrics, and develop “standard work” action plans for each stakeholder group in response to the metrics. This first phase also allowed care facilitators to objectively reflect on ED surge patterns throughout the day, and provided everyone in the ED team a frequent global snapshot of how “busy” the department was at any time. Finally, surge level data during this phase confirmed previous suspicions that the Output component was the biggest driver behind overall ED surge level.

Throughout this phase, the ED clinical manager recorded all the usual actions taken in response to the different level of surges as felt appropriate by the individual care facilitator on duty. The variety of actions and types of escalations were collected and fed back to weekly workgroup meetings to help further refine crafting of standardized action plans for implementation of the surge protocol.

Phase II (June - Aug 2013)

An initial trial of a limited ED surge protocol was rolled out at both ED campuses, with actual action items being triggered in response to specific surge level metrics. The main focus of this PDSA cycle was to collect data on how the care facilitator groups at the 2 campuses utilized the surge protocol, as well as feedback on usability, barriers, and effectiveness. Regular audits were performed to ensure surge measurement and compliance rates. Educational sessions were provided regarding rationale and purpose of the plan so that all team members had a better understanding of ED surges. Frequent meetings with stakeholders to share updates continued throughout Phase II, allowing further engagement as well as fine-tuning of stakeholder action plans based on real-time experiences.

Phase III (Aug 2013 - Dec 2013)

The next phase of implementation expanded beyond the ED and included the hospital’s off-hours and off-service management group. This in effect was the official corporate roll-out of the ED surge protocol including full action plans for all stakeholders, including off-service clinical administrators, inpatient flow managers, and the director of emergency and critical care. Regular audits were performed to ensure compliance of measurement every 2 hours as well as performance of specified action items related to each surge level, with the actual surge level measurement completion rates of 98%.

Data Collection and Analysis

Over the study period April 2013 to December 2013 at the Civic campus and June 2013 to December 2013 at the General campus, ED surge levels were measured every 2 hours by the care facilitators and manually recorded in standardized ED surge protocol booklets. These were subsequently entered into Excel database for tracking and data analysis. Patient volumes and hospital occupancy levels were recorded daily. Perceptions of the primary users of the surge protocol (ie, care facilitators) were obtained via standardized interviews and polls. We present descriptive statistics and statistical process control (SPC) charts. Chi-squared test was performed for comparison of pre- and post-intervention frequencies of outcome measures.