Surge Plan: Code Alpha, Bravo, Charlie

With the increase volumes and demands of the emergency departments comes the increase need for throughput efficiency. By embracing principles, of lean, to “pull” patients from the emergency department, utilization of the National Emergency Department Overcrowding Score (NEDOCS) and implementation of a surge plan policy, we ensure the right patient is admitted or discharged to the right place in the right time. Driven by Emergency Department (ED) volumes, acuities, admits, boarding time and wait times the NEDOCS calculates whether the ED is in Code Alpha, Bravo, Charlie or Internal Disaster.

     Based on code status, huddles are facilitated by the House Supervisor and are attended by all departments at set times of 0900 and 1500 in Code Alpha, in Code Bravo, huddles are held every four hours and if in Code Charlie every two hours. “The most successful lean-based projects incorporate an interdisciplinary approach who identify and are involving the key individuals directly impacted by the problem resulting in the sharing of unique perspectives that play an important role in the design of a viable initiative” (Vickers, 2014, p.44).

     The multidisciplinary tiered approach has directly impacted, and decreased, discharge length of stay (DLOS), the time at which a patient arrives to the ED and is discharged from the ED, and admit length of stay (ALOS), the time at which a patient arrives to the ED and arrives to an admit unit, despite an increase in ED volumes. In 2013 68,000 patients were seen in the 28 bed ED with an average ALOS of 363 minutes and average DLOS of 209 minutes. In 2015, total ED volume was 74,228 with an average ALOS of 282 minutes and average DLOS of 139 minutes. This is an increase of 9% in patient volume with a decrease of 22% in ALOS and decrease of 33% in DLOS.

      The organization learned that true throughput is a 24 hour a day, seven days a week process with a continuous goal for process improvement. To ensure nurses remain at the bedside, caring for the patients, the surge plan clearly defines roles, for all departments to follow, which assist in providing tools necessary for nurses to nurse, thus increasing productivity and decreasing ALOS and DLOS.

     The surge plan is a proactive process that embraces thoughts and concepts that increase ownership and decreases silos through teamwork. Inpatient departments don’t wait for the ED to call report; instead they “pull” the patient by initiating the call for report. Department directors and managers have ownership of their patients and assist in transporting patients to decongest the ED because it’s the right thing to do.

     As patient safety and continuity of quality of care is dependent on effective communication, the handoff process is integral to the exchange of pertinent patient information between the nurses during transition of care (Johnson & Throndson, 2015). When inpatient units are full, discharged patients await their rides in a discharge suite located on each unit. If rooms are dirty and in Code Bravo, one admitted ED patient is placed in inpatient hallway. If in Code Charlie, two are placed in inpatient hallways while awaiting their rooms to be cleaned. This not only ensures quality in that they are in the appropriate department receiving the appropriate level of care, but directly decongests the ED to allow for other patients to be evaluated and treated. The surge plan is applicable to all facilities, both big and small, because every facility has a goal of going from good to great.