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Preparations enable children's EDs to effectively handle H1N1 surge
Meetings began in early summer to be ready by the fall
If the term "be prepared" works for the Boy Scouts, it works even better for EDs facing potential surge situations. Tabletop exercises during the summer of 2009 were among the strategies used by the Minneapolis and St. Paul EDs of Children's Hospitals and Clinics of Minnesota to prepare themselves for a fall surge of H1N1 patients. Apparently, they did their job. Although the EDs' staffs saw 50%-60% more patients in the peak month of October, the average length of stay remained unchanged.
In early summer, before the first formal tabletop meeting, "The entire group — physicians from the ED, management from the pediatrics clinic, anesthesia inpatient services, radiology, environmental services, and resource management — all gathered in a big room, and we discussed what it was that we needed to do to see a potentially unexpectedly large number of patients," recalls David Hirschman, MD, FACEP, FAAP, medical co-director for the group's emergency departments.
The actual tabletop exercise involved "everyone who might have an effect on the patient visit through the ED: registration people, environmental services, nurses, physicians, security, materials management, and IT," he says. The exercise involved thinking about all the possible scenarios where varying numbers of patients would have to be seen, and how to create processes that would handle those increasing numbers. "It covered everything from having adequate scanning machines for registering people and enough forms for them and places for them to be, to computer access, including computers on wheels or laptops, and so on," says Hirschman. "We talked about nursing — how to get adequate numbers of nurses involved; where the patients would sit if we had overwhelming numbers; having a party tent type of setup that needed to be heated; supervision of the patients; who would do the vital signs, and how often they should get done."
Although there was not a designated leader, all the participants agreed that for homework, they would think about how each of their departments could contribute to seeing exceedingly large and unusual numbers of patients. "We did not know how sick they would be or what their needs could be," he says.
The physicians came up with threshold numbers of patient that would trigger additional staffing and additional space requirements. "We used our standard staffing for up to 160 patients in a 24-hour period," says Hirschman. "If the hourly numbers appeared to be heading in the wrong direction, we'd activate additional space and staffing." Alternatively, he says, if the number of patients reached 150 for two days or more, because it was difficult to sustain care for a long time, additional resources also would be triggered.
If the first threshold was reached, one physician and two nurses would be added on both campuses. "If we went up to around 200, we'd increase again," adds Hirschman. Staff members signed up for additional shifts with the potential of being called, and "there were few days when they weren't called," he says. However, only the first part of the plan was exercised, Hirschman says. "We did exceed 200 patients for a short period of time, but we just managed with the staffing we had," he notes.
As one subset of the tabletop exercise, the entire group went physically to each of the proposed overflow locations to look, measure, and see what needed to be changed. "They considered functionality like code buttons, airway cards, and resuscitation equipment," says Hirschman. "We designed the [overflow] space so it was truly an extension of the ED." For example, the spaces involved areas that typically were used as clinics, he says.
The tabletop exercises for the Minneapolis facility didn't take place until early October, notes Claudia Hines, RN, BSN, patient care manager of the ED there. The group in Minneapolis had a double challenge, Hines says.
"[The tabletop exercises] happened right before we were about to move into new space," she says. In previous exercises, they had identified three satellite areas where patients could be seen when volumes increased, Hines says. "We already had mechanisms in place. In our tabletop discussion, we talked about expanding to another area in the clinics, so we would have four different areas we could expand to," she says.
Thus, that tabletop exercise was highly focused on processing needs. "In the ED, we have patients coming in with various presentations of symptoms," Hines says. "We tried to walk through what these patients would need and what each next step would be."
The day the new ED opened, "We had the largest volume of patients we had ever had. It was an absolutely crazy period of time," recalls Hines. "Minneapolis saw 54% greater volume than last year at the same time, and St. Paul saw a 66% increase in volume."
The additional spaces enabled the ED to expand its capacity from 16 beds to 26, she says. "We had a lot of patients coming in during that huge surge, and they were mostly worried well," says Hines, "But they still needed to go through triage." On the weekends, she says, there was an extra provider (a doctor or a nurse practitioner) available to see the patients, and one or two RNs were added, depending on the time of day.
Prior to the new ED opening, an orientation program was held, which also helped processes move more smoothly when it opened. "Each member of the RN staff and support staff had to come to orient on the unit," says Hines. A new phone system had to be learned. The new configuration of the department meant that locations changed for important areas such as the ambulance entrance. "Orientation also consisted of different scenarios," says Hines. "We have a results room where patients go when critically ill or injured, and we had people go through the room to make sure they knew where supplies were."
Wait times were easy to track, because "we've been working on process improvement for the ED over the last nine months using Lean principles," she says. The ED saw 1,000 more patients in October 2009 than it did in October 2008, yet length of stay was the same, Hines says. "In 2008, in October, the fall surge length of stay was 158 minutes compared to 138 minutes in 2009," Hines recalls. Without our preparations, "it would have been over 200 minutes," she says.
For more information on using tabletop exercises to prepare for pandemic surge, contact:
Surges always bring surprises
While ED managers can make elaborate preparations for possible surge situations, it's virtually impossible to cover all possibilities, says David Hirschman, MD, FACEP, FAAP, medical co-director for the Minneapolis and St. Paul EDs of Children's Hospitals and Clinics of Minnesota.
Despite holding very complex tabletop exercises to prepare for the fall 2009 H1N1 outbreak, Hirschman says, "we discovered things we had not foreseen." For example, he notes, "In our overflow area, which was typically used as a clinic, the air handlers and elevator access had been turned off, and cleaning had been discontinued." The air handlers, he notes, are on timers, and his staff discovered on the first day of the surge that there was inadequate ventilation. The hospital quickly remedied the situation. "You may think all of the details are covered, but there's always something missing," says Hirschman.
Nonetheless, the preparations were invaluable, he says. "It would have been a completely different experience had we not been prepared; this way, as the numbers of patients increased we had a contingency plan, and things worked." The facility was not taxed beyond its limits, he says, "and we continued to practice more or less along the same lines as we had been up until then."
In addition to learning that "it could be done," Hirschman also learned the value of the tabletop exercises. "It's not enough to write a plan down on a piece of paper saying what you intend to do," he says. "There has to be a unified effort from administration, nursing, security, physicians, environmental services, and so on. Otherwise things break down."
Healthy staff mean healthier patients
One of the key elements of a successful response to last fall's H1N1 surge in the EDs at Children's Hospitals and Clinics of Minnesota was ensuring the health of the staff, says David Hirschman, MD, FACEP, FAAP, medical co-director for the group's Minneapolis and St. Paul EDs.
"You can ensure you will not be taxed beyond capacity by providing encouragement and adequate resources for hand-washing and personal protective equipment," he says. "Had we experienced a significant lack of providers, our experience would have been vastly different. This is a key to the success of managing a pandemic."