Preparedness: Disasters Do Not Stop at the Emergency Department
Ira Nemeth, MD, FACEPCo-director of EMS and Disaster Medicine Section
Baylor College of MedicineOctober 17, 2013
BackgroundHealthcare Systems are working at capacity dailyWaiting room times are increasingAdmitted patients are boarding in EDs
CMSFinancial penalties for readmissionDischarge planning takes significant timeHave you heard of the RED Project
DischargeAdvocate
Physician
Nurse
Pharmacist
Sample "Ideal State" Project RED Flow Map
AdmissionOrder
EstablishClinical
Pathway
Receives REDPatient
AdmissionAssessment
Verifies MedOrders
Med Rec andMAR
DischargePlanningRounds
Initiates andTeaches DCCare Plan
Care Plan
EducatesPatient about
diagnosis,tests andstudies
EducatesPatient aboutPlan of Care
andMedicationTeaching
Assists withMedicationTeaching
DischargeOrder
ReinforcesDischarge Plan
Schedules F/UTests, and
Appointments
Schedules F/UPhone Call
MedicationReconciliation
SchedulesDC Rounds
Participates inF.U Phone
Call
CompletesPatient's DC
Care Plan
DC Plan andSummary
sent to PCP
PatientDischarge
DC MedRec
CMSFinancial penalties for readmissionDischarge planning takes significant timeHave you heard of the RED ProjectAll these pressures lead to longer lengths of stay
No Notice EventsMany incidents have the potential to overwhelm
the current systemNo warning events continue to occur at high
frequencyRecent mass shootings and bombings
Madrid BombingMore than 2000 injured177 killed instantlyOne hospital saw 272 patients within 2 hours and
20 min of explosion
How do you free up resources in that timeframe?
Boston Bombing264 people injured90 patients were moved to hospitals in 30 minMultiple hospitals received over 30 patientsMany needed immediate surgery
Do We Have Enough ORs Immediately Available?
Regular Operations
Arrivals Discharges
Average Weekday Census – 600 patientsAverage Weekday Turnover – 70 patientsAverage Weekday ED Volume – 280 pts/day
Current Hospital Disaster Planning
ED basedIncreasing resources to the front endIncreased vendor pipelinesSecuring and protecting the facility
Sudden Surge
Arrivals Discharges
Surge of 250 patients in 2.5 hours
Clear EDRapidly decide which patients can go home and
which need to be admittedMove the admitted patients to floor ???
Decrease ArrivalsTell waiting roomCancel elective proceduresRegional patient sharing
Increase Hospital Capacity
Arrivals Discharges
HPP Goal: Increase Capacity by 20%(120 staffed beds)
Increased Hospital Capacity
Increased ORsIncreased ICUsPhysical space limitationVery difficult to increase
Increased InfrastructureIncreased RadiologyIncreased PharmacyIncreased AdministrationRequires Additional SuppliesRequires Additional Qualified, Credentialed Staff
Strategies to Increase Hospital
Open up non-conventional spacesBring in extra staff and supplies
Decrease standards of care
Increase Discharges
Arrivals Discharges
Real Life ExampleRoyal Darwin Hospital
Northern Territory Australia353 Bed Trauma Center
April 16th 2009 at 10:00 local timeBomb explosion on a boat520 miles from facilityHospital was full with backlog of admits in EDRDH was asked to take 30 blast victims
RDH Hospital Flow
Discharges vs Time of Day
Rapid Discharge
18% increase in discharged Hospitalized patients5% of total hospital capacity
Rapid Discharge PlanningHow do you identify who can go home?This requires a significant change in daily
practiceTransport resources
Reverse Triage
Triage by Resource Allocation for IN-patient (TRAIN)
Rapid Patient Discharge Tool (RPDT)
Developed by NYC – Department of HealthPilot exercise of six facilities in 2011Exercised by all 46 NYC hospitals in 2013
RPDT - Planning
RPDT - Response
NYC DataPilot exercise
7.9% of hospital patients were slotted for d/cAdditional 11.5% were identified as potential d/cOnce informed of the scenario an additional 12.8% of
patients were identifiedTotal of 32.2% of patients were able to be d/cPrelim data from April showed 14.1% potential d/c
Identified BarriersTransport away from facilityAdjusting ingrained practice patterns
DiscussionIs there a group of patients that can be
discharged with instructions to return to an outpatient planning clinic on the following day to continue their discharge planning?
Ira Nemeth, MD, FACEPCo-director of EMS and Disaster Medicine Section
EMS Fellowship DirectorBaylor College of Medicine
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