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

nemeth@bcm.edu