Harbor:Surge plan

Closing to EMS (ALS) Ambulances "ED Sat"(uration)

  • Joint decision by the MICN, AED charge nurse and AED attending(s), informing Overall Charge Nurse (OCN) and House Supervisor (house sup)/Patient Flow Facility (PFF)
    • Consider carefully as it results in longer transport times for potentially critically ill patients
    • Indicators to consider:
      • NEDOCS>140 (must be done hourly while on diversion status) and Hospital Surge level
      • EMS closure criteria
      • Surrounding hospital status
      • All ED rooms are full (Peds=18, AED=55 [Tr 5 beds, AED 22 beds, RME 6-9, 13-20, Gold 16 beds]) and 30% or greater of the ED patients are ESI1, ESI2, or admit boarders
    • If group decision is to close, proceed with the 1 hour ED closure; must reevaluate the department before going on ED ALS diversion again[1]
      • Closure to ED saturation should always be accompanied by closure to interfacility, ED to ED, and other transfers through the Medical Alert Center (MAC). All MAC closures are discussed with the House Supervisor/Patient Flow Facilitator (PFF) or Administrative Officer of the Day (AOD).
  • Other potential reasons for ambulance diversion:
    • CT: based on the availability of alternate scanners; AED Attending will notify the ED Overall Charge for Reddinet entry
    • Trauma: joint decision by Trauma and ED Attendings; based on equipment issues, OR unavailability, primary and backup trauma team encumbrance
    • Peds: PED Attending contacts ED Overall Charge RN to close via Reddinet; PICU beds have no influence on PED diversion status
    • STEMI: Joint decision amongst Interventional Cardiologist, AED Attending, House Supervisor, and ED Overall Charge Nurse; due to cath lab team encumbrance, mechanical failures, or internal disaster; automatically re-open after 3 hours unless further diversion is deemed necessary
    • Internal Disaster (see https://www.wikem.org/wiki/Harbor:Disaster_plan)
    • Helipad: due to unsafe landing conditions, damage to the helipad, current helicopter on the pad, deployment of the decon trailers for a large Hazmat incident; MAC must immediately be notified of closure

Schlesinger/Chappell/Wu 5/5/22

Surge Plan

  • There are three levels of surge. The surge level is determined by meeting the "Resource Utilization Indicators" (see below). When a surge level is met, the patient flow facilitator (PFF), in consultation with the ED attending and OCN will enact the surge plan. Alerts go out to all hospital leadership. If you think criteria have been met to activate the Surge Plan - contact the PFF at 68647, pager x0939.
  • Refer to [1] for things we can do internally to maximize use of ED space and when to escalate to DEM admin on duty and Clinical Nursing Director.
  • Things to consider in ED for pre-surge with OCN:
    • Maximize use of all available rooms
    • Xchairs outside RME hallway if staffing allows, assign to Fast Track, Green/Purple, and PED if adult trained attending
    • Chairs outside rooms or in waiting room (WR) for discharge for quicker room cleaning for next patient
    • Second clerk or router RN to help check in patients into WR
    • NA to help take vitals before triage
    • Provider to help triage get caught up
    • Consider closure to ALS to decompress rooms for next sick patient
    • In prolonged surge, consider Urgent Care Clinic (UCC) expanding scope to include Out of Plan (OOP) patients.
    • Consider adding additional ED physicians to address surge in patients
  • Things to consider inpatient for pre-surge:
    • Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending
    • Maximize use of discharge lounge

Resource Utilization Indicators (Need any 3)

  • Policy updated on 4/2022 File:337 - Surge Capacity Plan.pdf
  • ED census for surge criteria includes internal waiting rooms and tasking rooms R1-R5 and ambulance triage (ATri)
  • Level 1 Criteria: near max capacity for ED and inpatient with demand expected to increase
    • 50 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
    • 16 or more boarders in ED (hospital icon for admission orders up)
    • 5 or more ESI2s and Amb Tri waiting to be seen
    • PACU at capacity (PFF will know)
    • ED staffing in yellow (no breakers)
    • 2 or more inpatient units' staffing in yellow
  • Level 2: max capacity for ED and patient and additional resourced needed to meet demand
    • 60 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
    • 8 or more ESI2s and Amb Tri waiting to be seen
    • 20 or more boarders in ED (hospital icon for admission orders up)
    • PACU at capacity (PFF will know)
    • ED staffing in red (charge RNs in ratio)
    • 2 or more inpatient units' staffing in red
  • Level 3
    • 75 or more patients in Triage/Waiting Room (WR+Triage+R1-5+ambulance triage)
    • 10 or more ESI2s and Amb Tri waiting to be seen
    • 30 or more boarders in ED (hospital icon for admission orders up)
    • PACU at capacity (PFF will know)
    • ED staffing in red (charge RNs in ratio)
    • 3 or more inpatient units' staffing in red

What Happens at Different Surge Levels

  • Level 1
    • Actions from pre-surge (see above)
    • Consider ambulance diversion (ALS only)
    • Discharge patients to the WR to wait for transportation when appropriate
    • UCC to see all ESI4/5s (no exclusions) --> RME Director and UCC Director to coordinate
    • OR/PACU: Hold patients in OR and procedural areas if PACU full
    • ED hospitalist rounds with ED Charge RN on boarders and contacts inpatient teams for downgrades/discharges
    • ICU identifies stable patients to transfer to Rancho Los Amigos or LAC+USC
    • Transfer female patients to open 7W rooms
    • Inpatient charge RN identify potential downgrades/discharges w/in 2 hours of Surge 1 being declared
    • Get additional nursing to work in ED and inpatient areas
  • Level 2
    • Above and:
    • Close to ALS for 1-2 hours to decompress
    • Evaluate patients to see if they can be moved out of ED monitored rooms into hallways or chairs to free up monitored rooms
    • Utilization Management (UM) request transfer to capitated hospitals, and transfer for decompression or lower level of care
    • Reschedule end of day Tier 2 procedures/surgeries (care needed w/in 2-4 weeks) and above inpatients
      • Surgery/Procedure Acuity Tiers
        • Tier 0 - needs immediate care
        • Tier 1 - care needed w/in 2 weeks
        • Tier 2 - may need care w/in 2-4 weeks
        • Tier 3 - may need care w/in one to two months
        • Tier 4 - " " w/in two to three months
        • Tier 5 - can be posted greater than three months
  • Level 3
    • Above and:
    • Consider closure to BLS (needs MAC approval)
    • Consider closure to STEMI (needs approval by Interventional Cardiologist on duty)
    • Consider closure to Trauma (needs approval by Trauma Division Chief and CEO/designee)
    • Notify DEM AOD to consult hospital leaders if need to open command center.
    • ED attending/OCN identify staff to safely monitor patients in WR
    • ED attending/OCN to adjust staffing assignments as needed
    • CNO to evaluate need to implement alternate staffing plan
    • Inpatient attendings to see patients and decide dispositions

(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)

See Also


  1. Harbor ED Policy 20.4, LA County EMS policies 503, 506, & 513