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)

Author(s):

Edmund S.H. Kwok, MD, MHA, MSc, FRCPC

Cheryl Geymonat, RN, BScN, MBA

Kevin Peters, RN

Kathryn Bickerton, RN, BScN

Taryn Mackenzie, RN, BScN, ENC(C)

Rosa Lamothe, RN, BScN

Aline Mayer-Lalonde, RN, BScN

Mathieu Gatien, MD, CCFP(EM)

References

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From the Ottawa Hospital, Ottawa, ON Canada.

Abstract

Objective: Fluctuations in emergency department (ED) visits occur frequently, and traditional global measures of ED crowding do not allow for targeted responses to address root causes. We sought to develop, implement, and evaluate a novel ED surge protocol based on the input-throughput-output (ITO) model of ED flow.
Methods: This initiative took place at a tertiary care academic teaching hospital. An inter-professional group developed and validated metrics for various levels of surge in relation to the ITO model, measured every 2 hours, which directly linked to specific actions targeting root causes within those components. Main outcome measure was defined as the frequency of sustained (≥ 6 hours) high surges, a marker of inability to respond effectively.
Results: During the 6-month study period, average daily hospital occupancy levels rose above 100% (pre 99.5%, post 101.2%; P = 0.01) and frequency of high surges in the output component increased (pre 7.7%, post 10.8%; P = 0.002). Despite this, frequency of sustained high surges remained stable for input (pre 4.5%, post 0.0%; P = 0.13) and throughput (pre 3.5%, post 2.7%; P = 0.54), while improvement in output reached statistical significance (pre 7.7%, post 2.0%, P = 0.01).
Conclusions: The ED surge protocol led to effective containment of daily high surges despite significant increase in hospital occupancy levels. This is the first study to describe an ED surge plan capable of identifying within which ITO component surge is happening and linking actions to address specific causes. We believe this protocol can be adapted for any ED.

Emergency department (ED) crowding has been defined as “a situation where the demand for emergency services exceeds the ability to provide care in a reasonable amount of time” [1]. Crowding is an increasingly common occurrence in hospital-based EDs, and overcrowding of EDs has been shown to adversely affect the delivery of emergency care and results in increased patient morbidity and mortality [2,3]. Furthermore, the nature of medical emergencies dictates that rapid daily changes (or surges) in patient volume and acuity occur frequently and unpredictably, contributing to the difficulty of matching resources to demands. Accurate understanding and continuous measurement of where bottlenecks may be occurring within an ED are critical to an effective response to ED surges.

While it is now widely accepted that hospital inpatient overcapacity greatly contributes to crowding in the ED, there are many other factors related to overcrowding that are within the control of the ED. A conceptual model proposed by Asplin partitions ED crowding into 3 interdependent components: input, throughput, and output ( Figure 1 ); this model has recently been accepted as the standard theoretical model for discussing patient flow through the ED by national professional groups such as the Canadian Association of Emergency Physicians [4,5]. Surges can arise from rapid demands in any of these areas, resulting in overall net ED crowding; however, depending on the model component affected, different approaches to solution design may be required. For example, a sudden massive influx of new patients arriving to an ED would cause a surge in the “input” aspect of the model, and response plans should address the issue with actions such as increasing triage capacity, or perhaps calling in additional physician resources in anticipation of looming “throughput” surge. Activating inpatient hospital responses may be premature and ineffective, wasting valuable resources that can be utilized elsewhere. In contrast, ED surges related to “output” factors may be best tackled with hospital-wide responses and resource reallocation.

Many of the widely used measurement tools for overcrowding produce one final overall net value on a one-dimensional scale, failing to capture the complexity of the root causes of surges. For example, the National ED Overcrowding Study (NEDOCS) scoring system, validated at various centers and widely used and studied [5–7] utilizes a number of institutional and situational variables to calculate a final NEDOCS score, which translates to “Not Busy,” “Busy,” “Overcrowded,” “Severely Overcrowded,” or “Dangerously Overcrowded” as a global state. Other published scoring systems such as the Emergency Department Work Index (EDWIN), while performing well in comparison to subjective impressions of physicians and nurses, also suffers from computation of a single final score, which makes it difficult to tie to specific actions or solutions [8]. Other surrogate markers quantifying ED crowding have also been used, such as left-without-being-seen rates, ambulance diversions, and total number of boarded patients in the ED; yet they too only measure consequences of crowding and provide little diagnostic information on when and where specific ED surges are actually happening throughout the day [9].

A Novel Emergency Department Surge Protocol: Implementation of a Targeted Response Plan

References

Abstract

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