Space, staff key concerns in ED surge capacity plans

Emphasize adequate pharmaceuticals, equipment 

One of the key challenges for ED managers when faced with a communitywide health crisis — be it terrorism, infectious disease, or natural disaster — is surge capacity.

While such events affect the entire community, "I think it’s fair to say the main concern [of the ED manager] should be focused on health care facility surge," says Dan Hanfling, MD, FACEP, director of emergency management and disaster medicine at Inova Health System in Falls Church, VA. "In this day and age with EDs teeming to the brim, [the challenge is] how they can make space available for more patients coming in or an onslaught of patients that just keep coming."

ED managers must ask themselves what actions they should take if they become overloaded, says John L. Hick, MD, medical director for emergency preparedness at Hennepin County Medical Center in Minneapolis. "Do we have an agreement in place for transfer plans to put triage in the cafeteria?" he asks. "Are our clinics available to handle additional patients?"

Making space available is the No. 1 priority, adds Hanfling. "ED overcrowding is more a function of hospital overcrowding, so the hospitals needs to do a better job of expediting discharge," he says.

In the past, Hanfling has used a large patient lobby area as a discharge center, and he is engaged in discussions to use a large corporate building that is across from his hospital because it has a huge cafeteria.

Adjusting triage protocols also can help free more space, he says. "If you canvass your existing ED population and apply a re-triage of patients, you probably will be able to delay or offset a number of those patients presenting for care in anticipation of victims coming from the disaster," Hanfling explains. "You also can cancel elective surgeries, which will make beds available to move ED patients up and out."

Work on life-threatening situations, Hick advises, likening the situation to having to treat a patient in the back of a pickup truck — where an entirely different kind of triage is required. "Ask yourself, Do I really need to do this right now?’" he advises.

These situations make clinicians think hard, Hick continues. Ask, "Is this somebody I would normally do, but maybe not now?" he says. You may alter your assessment protocols, Hick says. "With a wound patient, you may watch them with hourly clinical exams rather than doing a [CT] scan," he notes.

To help make these decisions, he adds, there should be a triage gatekeeper — usually the ED manager or head physician.

To make more staff available, you must figure out how to become more flexible and to draw on existing staff or other professionals in the community, Hanfling advises. "You need to get a good sense of what available personnel resources you have; how many docs and nurses can you call back to assist, and how many off-service or subspecialty providers you can rely on," he adds.

Larger facilities will have an easier time filling this staffing need, Hanfling notes, but in any event, it should be addressed in pre-planning. "Concomitant with this is how to alert and notify these people that they may be required," he explains.

In the pre-event planning phase, Hanfling advises, work hard to obtain buy-in for participation, making it clear you will need more doctors and nurses to meet the surge in demand. "Once the event has occurred, your request for support can be done electronically — for example, using page alert phone systems and through local media requests on public channels."

Adequate supplies also should be a major concern, Hick says. "The ER is pretty unique; it’s at the hub of lot of different spokes," he explains. "You need to plan with central supply and other units."

For example, he adds, if you have five chest tube trays, which is an adequate supply under normal circumstances, it would be inadequate in terms of surge capacity. "We had eight handy in central supply, but we upped it to over 25 trays, and 100 suture trays," Hick says. "This is the kind of thing you should worry about."

In terms of the pharmacy, "It’s guaranteed you are going to need more morphine," he says, adding that many hospitals do not have enough, even though it is relatively inexpensive. Hick also recommends stocking up on tetanus boosters, midazolam, penicillin, and lorazepam.

Finally, Hanfling advises, be sure to focus on protecting your facility and your staff. "Don’t get to where you are so overrun that you put your staff or the patients in your charge at risk," he warns. Personal protective equipment, if required for infection control, is critical. "If you lose the protection required, you can forget about taking care of patients," Hanfling concludes.