What is your surge plan?

Mike Radzienda writes…

Hospitalists’ certitude number one-hundred-one: “It is never a good thing to be speaking with the chairman of Emergency Medicine at 1:00 AM on a Monday.”

And there I was trying to explain why the admitting medical officer hadn’t returned a page to the emergency department (ED) for thirty minutes; and why, when he did, he seemed “so overwhelmed.”

This was not flu pandemic season; it was just one of those busy “full moon” nights. Our hospitalists are adept at managing the service when volumes suddenly go up. However, on this particular Sunday evening, it was the perfect storm. Fifty patients in the ED, resident teams capped, four rapid responses, three Unit transfers, an agitated patient punched a nurse, four consults from Orthopedics, the dog ate my homework, I got a flat tire…fill in the rest.

Our program is staffed similar to many academic programs. We rely on the house staff to a significant degree; we have two faculty in-house twenty-four/seven, a jeopardy call, night floats, and my pager is always on. Still, I found myself apologetic, rattled, and second guessing myself when the Chairman, as he managed a full ED and ten pending admissions, asked that fateful question, “We are busy down here! What is your surge plan?”

I had worked the numbers, tracked the data, plotted the admitting cycles, projected the number of admission per hour, estimated standard deviations, and reached consensus over our staffing model. We were comfortable with our ability to absorb the peaks.

And when we reach capacity, I would come in to help or I would call someone to help us out. There really is no “surge plan,” just some good Samaritans we can count on when situations get hairy. So how could I answer the question except to say, “This is our surge plan?”

Flash forward a few months: I am convening a meeting to draft the patient flow and triage plan for an influenza pandemic. The task: how will we handle that perfect storm every night for weeks on end? Indeed, we would be testing the limits of our system at every decision tree node, process map event, and Ishikawa diagram “bone.”  We could utilize LEAN/Six Sigma methodology in crafting our model. One of the committee members had a queuing theory program we might tap into. The stakeholders assembled, we were invested, aligned, and had heard the voices of the customers.

The problem was defined; we had data and the support of the administration. In stage one of the surge, it would be business as usual. In stage two, incident command would be activated and there would be mobilization of the workforce. Stage three allowed for alteration in some standards of care and stage four would be the ultimate in disaster management protocols.

Stakeholders from every department submitted their workforce plan. Respiratory Services was at the table with access to one-hundred extra ventilators. Nursing had an overtime workforce pool. Environmental services would step up their hours.

It was my turn.

How would we cover the house assuming twenty percent of the doctors fell ill? I pondered my conversation with the Chairman. “What is my surge plan? If the surge hit, would we rely on those good Samaritans stepping in to help us? What would happen to the patients if those good Samaritans fell ill too? We can’t staff a hospital with systems engineering theory,” I thought to myself.

A Yogi Berra quote seemed fitting, “If people don’t want to come out to the ballpark, how are you going to stop them?” But I restrained myself.

As I sat next to the MICU director (a brother in arms), we looked at each other and smiled (much like Butch Cassidy and the Sundance Kid before they charged Los Federales on their last stand). “I’ll cover you,” he said.

On the last full moon he was pimped about his surge plan too…