Every year emergency departments across the land have several expected and predictable surges in census, according to data from the Emergency Department Benchmarking Alliance. Summer months bring patients wounded at play, late December brings the generically ill (because over the holidays the ED is the only show in town), and typically sometime in midwinter there is the flu season.
The flu causes an increase in census, and the extreme ages of patients with the flu frequently cause a rise in the admission rate. This year's numbers will likely look quite different, and even if a department has a surge capacity management plan in place, accommodating the early and less typical flu season of 2009–2010 is proving to be a challenge.
Intermountain Medical Center in Salt Lake City, UT, is a Level I tertiary care trauma center with a 56-bed emergency department. It could be categorized as one of the ultra-large EDs. It sees nearly 300 patients a day in high-census months, and is continually trying to improve its efficiency and operations. Utah was lucky: The flu season began to hit several weeks after it struck the eastern seaboard. Hearing about the difficulties emergency departments back east were having with 30 percent to 50 percent increases in census in some locations, Intermountain's medical director, David Barnes, MD, and his nurse manager, Ruth Caldwell, decided to get upstream in preparation for the surge. “We wanted to create a space in our emergency department where the influx of flu patients would receive rapid efficient care, and not create dangerous wait times for our general ED population,” he explained.
One of the first steps Dr. Barnes and his team took was to identify a place in the department where patients could be cordoned off and not even enter the main flow of the department. At Intermountain where bed spaces aren't as tight as at other facilities, they identified an area of five beds that can be expanded to 11 if needed. These beds occupy one end of the department, and can be entered and exited separately, allowing infectious patients to be kept away from the rest of the department. Patients with flu-like symptoms are sent directly to the Rapid Flu Treatment Center, processed rapidly, and discharged through a different door where registration occurs at the back end. Curtains cordon off the entire area. If a patient is deemed by the provider to be too ill for rapid treatment or is high risk, he is masked and transferred to a bed in the main emergency department for more extensive evaluation and treatment.
Another version of the Rapid Flu Treatment Center involved placing chairs in a hallway. Sharon (PA) Regional Medical Center found its capacity outstripped when its usual census of 93 patients a day suddenly became almost 140 patients a day. This 22-bed department, with an annual census of 33,000 visits and operating benchmarks indicative of a well-run department, was being crushed by the influx of patients with flu-like symptoms. When a patient with a heart rate of 160 bpm in triage had no hope of a bed in the department, they knew they had to take decisive and rapid action to accommodate the sudden surge. Twenty-four hours, 10 chairs, and one sign later, they had a Rapid Flu Treatment Center ready to roll.
Several important issues come up when trying to set up such a center. First and deserving of your attention is the simple question of what to call it. At Intermountain Medical Center, the physicians and staff were concerned about calling it a Flu Clinic because the patients would be billed an emergency department charge. Other departments like Sharon Regional using chairs for quick evaluations wanted to dampen the expectation that the patient would be going to an ED bed at all. One recommendation is that the sign indicate that the patient is being cared for in the emergency department, while conveying the nature of the services provided. A few ideas for the sign included Rapid Flu Treatment Center, Express Flu Treatment Center, Flu Care Services, and Express Flu Clinic.
The next big issue to be addressed was the paperwork associated with these patients, who largely will be mildly ill or worried well. This paperwork should allow providers to keep up with the volume and expeditiously process patients. Dr. Barnes and his team developed a one-page paper chart that was adapted from one already being used successfully at the local pediatric hospital ED, Primary Children's Medical Center, also in Salt Lake City. The paper chart is a marvel in its simplicity and its ability to help the clinician make a case for a flu diagnosis. (One of the most difficult aspects of this surge is the lack of real-time confirmation of the diagnosis. Patients and clinicians have to get used to the diagnostic uncertainty.) This paper chart justifies a limited encounter, and offers triggers for moving the patient from the Rapid Flu Treatment Center to the main ED. T-System has a flu chart template that was a consideration before Dr. Barnes' team came up with its homegrown version.
The Intermountain team also developed preprinted discharge documents with simplified instructions explaining when to return and what to do to alleviate symptoms. Preprinted Tamiflu prescriptions and an information packet also were created. The Centers for Disease Control and Prevention has a comprehensive array of information and resources called “Flu and You” that can be downloaded from its web site. (www.cdc.gov/h1n1flu/freeresources.htm) There is also information for practitioners and parents as well as special disease categories. They are available in English and Spanish. At Sharon Regional, the hospital volunteers have put together flu bags that include information, a mask, and a small package of tissues for distribution to patients in the Rapid Flu Treatment Area. Pre-prepared discharge materials expedite throughput for a subset of patients who should spend as little time as possible in public settings due to the public health risks. Both departments are using Fast Track staff as providers to see these patients, with other providers floating in to help if the Rapid Flu Treatment Area is overwhelmed. If patients are moved as the processes have been designed to move them, however, this should seldom happen.
Other adjuncts in information dispensation include posters explaining the facts and guidelines for managing influenza-like illnesses. These can be posted in lobbies, waiting rooms, elevators, the gift shop, the pharmacy, and the hospital cafeteria. Consider putting posters anywhere visitors might be exposed to them. Videotaped materials in the lobbies and waiting rooms of all outpatient hospital-based services also could work.
The point is this: The surge in patients coming to the ED will require changes in processes, but it is manageable. The flu season is always a challenge, but with this year's media-driven hysteria, even greater numbers will be coming through the ED doors. At Intermountain, the team set up their processes before the surge. At Sharon Regional, the surge took them by surprise, but they responded creatively and decisively to meet the demand. Cordon off rooms or put chairs in the hallways. Do anything except throw up your hands. With some operational thinking and small process changes, every ED can manage this flu season.