Hospital Capacity Management II: The Surge

Surge is used when a hospital has reached the point of over-capacity, requiring the hospital to implement a unique processes to allow for decompression.

If surging becomes a frequent occurrence in any hospital organization, a sort of “surge fatigue” will occur, when activation means little if anything to associated staff. Meetings will be eliminated as meaningless and the entire concept of surge will become a routine with no real response from the system. This numbness from frequent surge activation will ultimately fail the organization and any meaningful process improvement to impact and avoid surge will be lost.

Truly, any time a hospital goes on surge, it is an indicator of a failed understanding of hospital capacity management and an inability to implement the necessary processes to reduce Length of Stay (LOS) and impact capacity management to manage the patients entering the organization.

Surge: An Emergency Department Phenomenon

I have never and likely will never see a hospital on surge because of the OR or Cath lab schedule, though these areas can impact the Emergency Department with high-scheduled volumes and may result in surge becoming a more likely phenomenon.

Other causes of a hospital surging include disease processes such as influenza or a raging gastrointestinal bug going through the community. On rare events, a major traumatic issue can occur such as a bus crash or a multi-car accident, but 99.9 percent of the time the cause is a significant rise in patients presenting to the Emergency Department who are deemed in need of hospitalization, while at the same time hospital beds are unavailable for them.

A primary goal of hospital capacity management is to never go on surge and always be one step ahead of the bed need. Accurate assessment of the status of the hospital at any given point is essential. Surge triggers must be clear and commonly agreed upon, and they must activate resources not normally in use. Surge must also include a regular (hourly) assessment of the surge status.

When to Determine If Surge Is Necessary

Prediction of potential surge can be generally accomplished by well seasoned bed-czars. They know the OR and Cath lab schedule, the anticipated discharges for the day, and the hourly admission rate through the ED and will see clear indicators that a surge activation is necessary.

Hospitals must first define the key indicators for activation. The when is extremely important since in many high volume Emergency Departments indicators for surge activation can be reached routinely at 3 or 4 pm. The ORs are packed as is the Cath lab, discharges come too late, and ED admission volume swells. At this point, the system needs a period of time to equilibrate. This also means that the standard bed-prep for the next-day list with beds held for OR and Cath lab patients will not occur. From a capacity perspective, the system has been overwhelmed and all resources require utilization.

I have found that the best time for surge determination is 8pm. If indicators hit suge criteria then it is highly unlikely that criteria to come-off surge will occur overnight. This is primarily because the last discharge leaves the hospital somewhere between 8 and 9pm. Ongoing admissions through the ED will continue to occur (though at a lower rate) all night long. The key is the indicators for activation.

Surge Activation Indicators

The following activation indicators should be reviewed every day at 8pm:

1. There are less than three hospital beds available, total. This does not include the Intensive Care Units.

2. Emergency Department admitted patients with an unassigned a bed is equal to or exceeds 30% of total ED adult bed capacity. So for a 30 bed ED there would have to be 12 or more ED admissions without a bed assignment at 8pm.

Once surge activation criteria have been met, communication must occur to a broad group of individuals, each of whom will have a responsibility to activate non-clinical space or provide extended service capability to manage the over-capacity.

It should be noted that surge does not change organizational priorities. Its purpose is to allow the system to continue to manage patients entering the system from all portals of entry – ED, OR, CATH lab, directs, and transfers.

The Surge Activation Process

Step 1: Text messages to surge team members to notify them of activation. The team should include the hospitalist director, and directors of the ED, Cath lab, OR/PACU, Med/Surg, Radiology, and Echo/Stress, as well as an administrative representative.

Step 2: Environmental service sets up hall-way beds in various med/surg units to flex capacity—This can be anywhere between 1 to 2 beds per unit.

Step 3: 7am team meeting for 5 minutes to determine anticipated bed needs for the day based on ED current state, OR, and Cath lab schedule; expected transfers into the organization; and anticipated discharge volume. This short meeting will determine what flex space beyond the anticipated hallway beds will be utilized.

Step 4: Determine Flex space to be used: Cath lab holding, boarding in PACU, or other identified hospital space suitable for patients. These numbers will vary by institution and availability but clarity around specific plans need to be established and put into action immediately. PACU holds for example should focus on patients who are considered extended recovery cases and have a high likelihood of discharge the next morning.

Step 5: Determine extended service capability. Limitations of available testing hours may inhibit anticipated discharges. These usually involve cardiac studies (nuclear stress tests, echos, other stress testing) and radiographic studies (MRI, CT, USN). These areas will need to implement extended hours to provide testing to all patients whose disposition status and potential discharge may be dependent on them. All disposition studies should be completed on all hospitalized patients by extending these service hours,  including the reading of these studies.

Step 6: Focus on discharges. Hospitalists should focus efforts on early discharges with environmental services focused on immediate room cleans and contact to bed assignment of cleaned available beds. Administrative representation is to concur and validate the need for overtime services and additional staff if necessary.

Step 7: Hourly assessment. The criteria to remain in Surge and to continue to utilize alternative clinical space and extended service hours is conducted hourly. Team members should reconvene at appropriate intervals – usually 12 noon and 4pm – to determine challenges and utilization of other strategies if necessary. Maintaining use of non-clinical space for patients such as hallways, cath-lab holding areas or the PACU in OR recovery need to be taken into account for additional staffing resources if required.

When to End the Surge

Only when the system has decompressed below the initiating surge criteria should surge activation be cancelled. Debriefs should occur with the team to determine if all components were activated as anticipated and what could be done in the future to avert surge activation or once initiated to cancel surge activation as quickly as possible.