Surge

When hospital capacity is exceeded, SURGE is implemented in order to allow for decompression. This involves the activation of unique processes across the entire hospital. This is always an ED phenomenon. I have and likely will never see a hospital on SURGE caused by the OR or Cath Lab schedule. Yet, these units often strain the ED with high scheduled volumes, sometimes increasing the likelihood of SURGE conditions occurring. The outbreak of influenza or a raging GI bug going through the community can also trigger a SURGE response. On rare events, a major traumatic issue can occur with a bus crash or multiple motor vehicle accidents, but almost always the cause is a significant rise in patients presenting to the ED who are deemed in need of hospitalization and beds are unavailable (Table 16.1).

The primary goal in capacity management is to never go on SURGE and always be one step ahead of the need for hospital beds. While designed to accommodate an influx of hospitalizations beyond the hospital’s normal operating capacity, SURGE is to be avoided whenever possible because it is expensive, highly stressful on both staff and patients, and is less than ideal for the proper provision of care for every

Table 16.1 Indicators for Hospital Flow and Triggers for SURGE

patient. Accurate assessment of the status of the hospital at any given point is imperative. Triggers for activation of SURGE must be clear and agreed upon by all. Activation should be in a series of steps and include regular (hourly) assessments of the SURGE status throughout.

Prediction of potential SURGE can be easily accomplished by knowledgeable 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 will result in SURGE activation. Hospitals must first define what the key indicators for activation are and when activation should occur. 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 OR’s are packed as is the Cath lab, discharges come too late and ED admission volume swells.

The best time we have found for SURGE determination is 8 pm at night. If indicators hit SURGE criteria then, it is highly unlikely that criteria to come off SURGE will occur overnight.

This is because the last discharge leaves the hospital somewhere between 8 pm and 9 pnt. Meanwhile, ongoing admissions through the ED will continue to occur (though at a lower rate) all night long. After 8 pm, things are unlikely to improve.

If, at 8 pm, the total hospital bed availability is less than three beds, not including ICUs and ED admissions with unassigned beds and, the overall ED admissions boarding exceeds 30% of ED adult bed capacity, then SURGE is activated. One issue that occurs with a late activation is that holding personnel longer or extending testing hours will be difficult to achieve since most of these individuals have left for the day. A compromise is to have necessary personnel start the next day earlier if the hospital is still in surge mode.

Once these criteria have been reached, communication must occur to a broad group of individuals. A domino effect is intended, activating non-clinical space and providing extended service capability in a step-by-step process. It is important to note that SURGE does not change organizational priorities—its purpose is to allow the overall system to continue to manage patients entering the system from all portals of entry—ED, OR, Cath lab and directs and transfers, and to ease the overburdened ED.

A Surge team membership is well established in advance. A typical Surge team would include ED Director, Hospitalist director, Bed-management director, Cath lab director, OR/ PACU director, Administrative representative, med/surg floor director, Radiology director, and Echo/Stress test director.

A typical Surge process, organized into steps, is as follows:

Step-1. A text message is sent to SURGE team members to notify of SURGE activation.

Step-2. Environmental services set up hall-way beds in various med/surg units to flex capacity—this is typically 1-2 beds per unit.

Step-3. A 7 am team meeting for 5 min determines the anticipated bed needs for the day based on the current state of the ED, OR and Cath lab schedules, expected incoming transfers, and expected discharge volume. This short meeting will also determine what flex space beyond the anticipated hallway beds will be utilized.

Step-4. Determine Flex space to be used, such as Cath Lab holding, Boarding in PACU, and other identified hospital space suitable for patients. These may vary by institution and availability, but the Surge team must all be clear on a specific plan, which should be 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- Extended Service Capability—Testing hours are extended. These usually involve Cardiac studies, nuclear stress tests, Echos, MRIs, CTs, USN, and other stress testing and Radiographic studies. The facilities and staff that normally would operate with limited hours will now 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. Consideration should be made to prioritize inpatient testing over scheduled outpatients. If it is felt to be a need to initiate availability of certain study types early in the am, that decision should be directed to the appropriate study area at step 2.

Step-6. Focus on discharges. Hospitalists should focus efforts on early discharges while environmental services focus on immediate room cleans and communication back to bed assignment. 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 around noon and 4 pm, 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.

Only when the system has decompressed below the initiating SURGE criteria should SURGE activation be canceled. 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.