The Use of a Hospital-Wide Surge Plan to Decrease Emergency Department Overcrowding

Aim: : This hospital is challenged by the highest ED patient visits to inpatient bed ratio in San Diego County, and possibly the whole state. This has led to an inability to absorb new admitted patients into the hospital and results in significant boarding of admitted patients in the ED. At times this has led to 15 hours or higher of ED boarding per admitted patient, with little inpatient awareness or communication of the ED’s conditions. The aim of this project was to create a hospital-wide response to ED overcrowding.

Framework:: Lean Six Sigma

Setting:: This hospital is a Level II Trauma Center located in the north county region of San Diego. When the Palomar Medical Center Escondido (PMCE) opened in 2012, there were approximately 58,000 ED visits per year with 286 inpatient beds. In 2022, ED visits increased to over 100,000, and the inpatient bed number decreased to 228 (36 Critical Care, 36 IMC, 96 Telemetry, 60 Medical/Surgical). The remaining beds were reclassified for Women’s and Children’s services. The emergency department has 72 licensed beds and 2-trauma bays.

Stakeholder Team::
Melvin Russell, Chief Nursing Executive
Jami Piearson, Regulatory Director
Tricia Kassab, Vice President of Quality and Patient Safety
Ryan Fearn-Gomez, Director of Clinical Operations
Bruce Friedberg, Emergency Department Medical Director
Thomas Siminski, Director of the Emergency Department
Tracy Page, Nurse Manger of the Emergency Department

Methods: : A surge plan was created, with the purpose of establishing a hospital-wide approach to handle an increase in demand for patient care services when faced with limited resources and bed capacity, and to mitigate and manage issues affecting patient flow, staffing, and productivity throughout patient care areas. Palomar Health uses the National Emergency Department Overcrowding Score (NEDOCS), a nationally validated measurement of emergency department and hospital overcrowding, as the objective measure of emergency department and hospital overcrowding. Levels of overcrowding are determined by a “score” which is calculated using statistically significant variables. NEDOCS has been shown as an accurate measure in discriminating between busy and crowded ED conditions.

Outcomes:: We implemented 6 Code Delta Pages between 11/18/2022 - 12/2/2022. Inpatient leaders responded after each page to a meeting 30 minutes later with discharges that they could produce within 30 and 60 minutes from the meeting. In 5 of the 6 cases, we were able to reduce the NEDOCS score, decrease ED waiting room and ambulance offload times, and obtain early discharges to decrease emergency department overcrowding

Implications:: Emergency Department overcrowding is really a symptom of hospital-wide overcrowding. To provide the best possible care to our community, this problem must be solved by the hospital as a whole. By planning ahead for these situations using pre-defined triggers, clear communication across the whole facility and set responses to levels of overcrowding, we are better able to care for our patients in times of surge.
br/>