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Preparedness: Disasters Do Not Stop at the Emergency Department

Preparedness: Disasters Do Not Stop at the Emergency Department. Ira Nemeth, MD, FACEP Co-director of EMS and Disaster Medicine Section Baylor College of Medicine October 17, 2013. Background. Healthcare Systems are working at capacity daily Waiting room times are increasing

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Preparedness: Disasters Do Not Stop at the Emergency Department

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  1. Preparedness: Disasters Do Not Stop at the Emergency Department Ira Nemeth, MD, FACEP Co-director of EMS and Disaster Medicine Section Baylor College of Medicine October 17, 2013

  2. Background • Healthcare Systems are working at capacity daily • Waiting room times are increasing • Admitted patients are boarding in EDs

  3. CMS • Financial penalties for readmission • Discharge planning takes significant time • Have you heard of the RED Project

  4. CMS • Financial penalties for readmission • Discharge planning takes significant time • Have you heard of the RED Project • All these pressures lead to longer lengths of stay

  5. No Notice Events • Many incidents have the potential to overwhelm the current system • No warning events continue to occur at high frequency • Recent mass shootings and bombings

  6. Madrid Bombing • More than 2000 injured • 177 killed instantly • One hospital saw 272 patients within 2 hours and 20 min of explosion How do you free up resources in that timeframe?

  7. Boston Bombing • 264 people injured • 90 patients were moved to hospitals in 30 min • Multiple hospitals received over 30 patients • Many needed immediate surgery Do We Have Enough ORs Immediately Available?

  8. Regular Operations Arrivals Discharges Average Weekday Census – 600 patients Average Weekday Turnover – 70 patients Average Weekday ED Volume – 280 pts/day

  9. Current Hospital Disaster Planning • ED based • Increasing resources to the front end • Increased vendor pipelines • Securing and protecting the facility

  10. Sudden Surge Arrivals Discharges Surge of 250 patients in 2.5 hours

  11. Clear ED • Rapidly decide which patients can go home and which need to be admitted • Move the admitted patients to floor ???

  12. Decrease Arrivals • Tell waiting room • Cancel elective procedures • Regional patient sharing

  13. Increase Hospital Capacity Arrivals Discharges HPP Goal: Increase Capacity by 20% (120 staffed beds)

  14. Increased Hospital Capacity • Increased ORs • Increased ICUs • Physical space limitation • Very difficult to increase

  15. Increased Infrastructure • Increased Radiology • Increased Pharmacy • Increased Administration • Requires Additional Supplies • Requires Additional Qualified, Credentialed Staff

  16. Strategies to Increase Hospital • Open up non-conventional spaces • Bring in extra staff and supplies • Decrease standards of care

  17. Increase Discharges Discharges Arrivals

  18. Real Life Example • Royal Darwin Hospital • Northern Territory Australia • 353 Bed Trauma Center • April 16th 2009 at 10:00 local time • Bomb explosion on a boat • 520 miles from facility • Hospital was full with backlog of admits in ED • RDH was asked to take 30 blast victims

  19. RDH Hospital Flow

  20. Discharges vs Time of Day

  21. Rapid Discharge 18% increase in discharged Hospitalized patients 5% of total hospital capacity

  22. Rapid Discharge Planning • How do you identify who can go home? • This requires a significant change in daily practice • Transport resources

  23. Reverse Triage

  24. Triage by Resource Allocation for IN-patient (TRAIN)

  25. Rapid Patient Discharge Tool (RPDT) • Developed by NYC – Department of Health • Pilot exercise of six facilities in 2011 • Exercised by all 46 NYC hospitals in 2013

  26. RPDT- Planning

  27. RPDT - Response

  28. NYC Data • Pilot exercise • 7.9% of hospital patients were slotted for d/c • Additional 11.5% were identified as potential d/c • Once informed of the scenario an additional 12.8% of patients were identified • Total of 32.2% of patients were able to be d/c • Prelim data from April showed 14.1% potential d/c

  29. Identified Barriers • Transport away from facility • Adjusting ingrained practice patterns

  30. Discussion • Is 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?

  31. Ira Nemeth, MD, FACEP Co-director of EMS and Disaster Medicine Section EMS Fellowship Director Baylor College of Medicine nemeth@bcm.edu

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