Preparation and creativity help EDs beat the heat’

Parallel processing lessens added burdens

Perhaps the most challenging aspect of this summer’s heat wave was that it not only affected areas that were accustomed to extreme heat, such as Phoenix, but many that were not, including northern states such as Pennsylvania and Michigan. In areas such as these, creative protocols and processes, along with a healthy dose of preparation, can help you through these crises with a minimal impact on throughput and patient care, ED managers say.

In Detroit, it was very hot in May and "up and down" all summer, which required ED managers to be on constant alert, in ongoing contact with weather resources, and above all, well prepared, says Frank McGeorge, MD, a metro Detroit emergency physician and member of the board of directors for the Michigan chapter of the American College of Emergency Physicians.

In Hershey, PA, where temperatures reached 100 and humidity was in the high 90s, Penn State Hershey Medical Center saw a 1% to 2% increase in volume this summer related to the heat, says Christopher DeFlitch, MD, FACEP, director and vice chairman of the department of emergency medicine. He credits advanced nursing protocols and "parallel processing," as opposed to the more traditional model of "serial processing," with enabling his ED to meet this challenge.

The parallel processing model is ideal for times when EDs experience an unexpected surge of patients, DeFlitch adds. In traditional serial processing, the patients present, they tell someone what’s wrong, they are registered, and they tell another someone the same information, he says. "They get taken to triage and say the same thing, then labs are taken, then an intervention may be done, then the primary nurse asks the same questions Results come back; a disposition is made," DeFlitch adds. "We in medicine have traditionally looked at processes of care as linear functions."

In reality, when you have good information systems and process design, you can have different people doing their jobs parallel to each other so the care is seamless to the patient, he explains.

When dealing with heat-injured patients, they often require a longer ED evaluation, DeFlitch notes. "Patients who present with heat-related problems may require IV [intravenous] access, IV fluid resuscitation, some lab studies — all of which in combination require a longer LOS [length of stay] than, say, a sprained ankle, so not only does your volume increase, but your LOS per patient is more than average," he says.

From the ED manager’s perspective, this situation poses another challenge: It takes a nurse extra time to start lines, and lab times can be a problem if you already have a long turnaround time. That’s where parallel processing and advance nursing protocols come in. The response to heat-related illnesses begins by cooling the patient, and that process can be initiated by all ED staff. Place the patient in a care space, have him or her disrobe, and initiate simple cooling methods such as cool towers to the vascular areas of the body. That can be accomplished before physician evaluation.

The most important thing ED managers can do is as simple as paying attention to the heat index, McGeorge says. "We do watch the weather, and sometimes the media even comes to with us with warnings or requests for interviews about upcoming heat waves," he says.

Targeted communication with pre-hospital providers also is incredibly important, as symptoms of heat injury and infection, for example, can be similar, McGeorge notes. "Get them into providing the home circumstances [of patients]," he advises.

Elderly and chronically debilitated patients who present with high body temperatures may be unconscious or less responsive, McGeorge notes.

"They can’t tell us what happened," he says. If they lived in a well air-conditioned apartment, staff aren’t worried about a heat problem, he continues. "If the apartment was 110 degrees, that’s another story."

McGeorge also pre-stocks extra cooling blankets before the summer, which blow cooled air onto the patient. At another facility that didn’t have cooling blankets, he had patients stripped to their underwear and sprayed with fine-mist water, which required having extra bottles available. (Since the patients usually are unconscious or semiconscious, either from medications they are given to prevent shivering or because of hyperthermia, they are lying on stretchers when this is done.)

"We then went to environmental services to get their giant industrial fans that they use to dry floors," he recalls. "You turn them on, and you can cool several patients at once and mist them. It’s very effective."

You must arrange for the fans early, McGeorge stresses. "If you do not prearrange to have the fans, trust me, when you need them, you will have trouble finding them," he warns.

DeFlitch says he’s also learned an important lesson from this summer: Educate the public by writing articles for the local press about how to handle heat, and do it early.

"All the articles are coming out now; we should tickle the papers sooner so they come out in early summer," he says. Have pre-written articles ready early, DeFlitch suggests.

You do know it will be hot, McGeorge notes. "We don’t know precisely when, but every year, we do know in summer, we have to prepare for heat."

Sources

For more information on heat wave preparation, contact:

  • Christopher DeFlitch, MD, FACEP, Director and Vice Chairman, Department of Emergency Medicine, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA 17003. Phone: (800) 243-1455. E-mail: cdeflitch@psu.edu.
  • Frank McGeorge, MD, Board of Directors, American College of Emergency Physicians, Michigan Chapter, Detroit. Phone: (248) 898-1944. E-mail: mcgmd@comcast.net.