Plan de manejo de saturación hospitalaria

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L:/ClinicalOverflowWhitePaper 12’02.doc HASC WHITE PAPER Clinical Overflow Management Plan for Hospitals’ Overflow December 2002 IntroductionHospitals in Los Angeles County periodically experience severe clinical services overcrowding due to a number of reasons including flu outbreaks. These high demand episodes have stressed the limited staffing, equipment and facilities resources and resulted in community wide shortages of critical medical services. HASC’s Los Angeles Healthcare Steering Committee appointed its Emergency Health Services Committee to form a task force, convene other local public and private health sector health agencies and develop contingency guidelines for use by hospitals in the event of clinical services saturation in Los Angeles County. Included on the task force were representatives of the Los Angeles County Department of Health Services Public Health Division, the Emergency Medical Services Agency, LAC Health Facilities Division (Licensing and Certification), physician group practices, urgent care centers, emergency physicians and hospitals and health systems. The Task Force produced three products in the development of its HASC White Paper – Clinical Services Contingency Management Plan: A. Checklist of Recommended Management Actions B. Regulatory Flexibility Guide: Title 22, Section 70129 C. Countywide Coordination of Activities: EMS Agency H A S C 515 South Figueroa St., Suite 1300 Los Angeles, CA 90071-3300 (213) 538-0700 Fax: (213) 629-4272 www.hasc.org
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Clinical Overflow White Paper December 2002 Page 2 L:/ClinicalOverflowWhitePaper 12’02.doc Section A Checklist of Recommended Management Actions 1. Sponsor local immunization programs for staff members, physicians and their families, including children, as well as other at-risk members of the community. See attached LAC Department of Health Services recommendations for the inoculation of children. (Appendix 1, Seniors & Persons with Chronic Diseases) 2. Staffing considerations: • Ensure that the hospital’s time-off policies and procedures adequately consider staffing needs in periods of clinical crisis. Vacation requests granted as planned time off may be complicated by unplanned staff illness or illness of members of a staff’s family. • Encourage practices that flex the hospital’s registered nurse staff resources through use of registered nurses currently serving in administrative positions within reasonable limits of clinical competency. • Urge management sensitivity to balance the impact of planned time off between direct patient services categories of staff and those relied on for essential operational support. • Plan to implement staff to patient ratio flexibility consistent with patient safety; contact the Health Facilities Division (Licensing and Certification). (See Section B of this White Paper.) Note: the EMSA has instructed the MAC to alert the Licensing Division of diversions resulting from staffing shortages. Note: The State Licensing and Certification agency’s Worksheet for its field officials addresses hospital-staffing action prior to consideration of program flexibility (see Worksheet, attachment to Section B of this White Paper). • Petition the court system to excuse critically needed health care workers from jury duty.
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Clinical Overflow White Paper December 2002 Page 3 L:/ClinicalOverflowWhitePaper 12’02.doc 3. * Critical and acute medical services capacity: • Ensure that the hospital and medical staff policies, rules and operating procedures address expediting the patient discharge processes during periods of clinical services overflow/unmanageable patient demand, including: Triage and discharge processes for intensive and acute units with formally designated and empowered triage physicians in place Procedures for discharge and transfer to SNF’s and similar facilities • Review guidelines and policies allowing triage physicians to discharge patients from the hospital and allow for a quicker transfer of patients from critical care units when indicated. • Consider creating a patient discharge holding area or discharge lounge. • Pre-plan space needs for flexible use of alternative space. Consult with the Licensing Division. (See Section B of this White Paper.) • Urgent care or fast track areas in or adjacent to the emergency department may need to be converted to treat patients with the flu who entered through the ER. 4. * Elective surgery and diagnostic patients: review policies for postponing the admission or scheduling of elective procedures in a capacity crisis or disaster situation. 5. Consider or expand hospital-sponsored day care and sick care services for dependent family members of hospital staff. 6. Review planning for transportation of discharged patients in overflow situations. 7. Review policies and procedures addressing adequate physician staffing in the emergency department and critical ancillary areas. 8. Consider appointment of a registered nurse triage officer to manage patient flow in the ER. * Note: Sections are addressed in L&C Worksheet requirements (see attached, Section B).
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Clinical Overflow White Paper December 2002 Page 4 L:/ClinicalOverflowWhitePaper 12’02.doc 9. Review hospital’s high census procedures, assure that they have been updated and are in force. 10. Alert local physicians, physician groups, urgent care centers and community clinics for their availability during peak periods; develop joint contingency plans. 11. Participate in the LAC/EMS Agency and MAC programs coordinating scarce critical resources in Los Angeles County. Ensure that your ReddiNet equipment is updated and monitored regularly. For assistance with ReddiNet, contact the LAC/EMS Agency. 12. Anticipate equipment and supply needs, including availability of respirators, gurneys and supply carts.
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Clinical Overflow White Paper December 2002 Page 5 L:/ClinicalOverflowWhitePaper 12’02.doc Section B Regulatory Flexibility, Title 22, Section 70129 The Department of Health Services is expecting recurrent overflow situations such as flu seasons. When this occurs, your facility may be stressed in providing some medical services and need temporary relief from Title 22 facility or staffing requirements. Section 70129 provides for flexibility in specific situations, consistent with patient safety and adequate care of patients. Title 22 requires a written request from the hospital and a written approval of the Department. (See Code language below) In this regard, the Health Facilities Division (Licensing and Certification) has been available to advise and assist hospitals in the past and will continue to do so in the future. The facility CEO or his/her designate must initiate all such requests. You should call: • Eric Stone, Supervisor – (323) 869-8205 • Beverly Williams, Program Manager – (323) 869-8504 • Sanford Weinstein, MD, (323) 869-8517 • Facsimile – (323)-890-8751 If the event occurs after normal hours, the hospital should handle the situation in the most appropriate fashion and notify Health Facilities Division ASAP in the morning. You may be able to expedite the Health Facilities Division action on your request by being prepared to address the following issues: 1. Registry has been called and is not available. 2. Transfer opportunity has been sought and is not available. 3. CEO has been notified and all alternative resources have been exhausted. 4. Transfer of lower acuity patients from ICUs and acute areas to appropriate treatment areas.5. Curtailment of elective surgical and diagnostic procedures.
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Clinical Overflow White Paper December 2002 Page 6 L:/ClinicalOverflowWhitePaper 12’02.doc Title 22, S. 70129 (a) All hospitals shall maintain continuous compliance with the licensing requirements. These requirements do not prohibit the use of alternate concepts, methods, procedures, techniques, equipment, personnel qualifications or the conducting of pilot projects provided such exceptions are carried out with the provisions for safe and adequate care and with the prior written approval of the Department. Such approval shall provide for the terms and conditions under which the exception is granted. The applicant or licensee to the Department shall submit a written request including supporting evidence. (b) Hospitals which by reason of remoteness that are unable to comply with provisions of the regulations for basic services and perinatal or pediatric services shall submit a written request to the Department for exception. In reviewing such requests, special attention may be required regarding qualifications of medical staff and personnel. (c) Special exceptions may be granted under this section for hospitals required to provide services and accommodations for persons who may have dangerous propensities necessitating special precautions, personnel with special qualifications, locked accommodations, special protection for windows, type and location of lighting and plumbing fixtures, signal systems, control switches, beds and other furnishings. This applies to psychiatric units and detention facilities where added protection is necessary for patients, staff members and members of the public. (d) Any approval of the Department granted under this section or a true copy thereof shall be posted immediately adjacent to the facility’s license that is required to be posted by Section 70123. History Editorial correction of subsection (b) (Register 95. No. 44).
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Clinical Overflow White Paper December 2002 Page 7 L:/ClinicalOverflowWhitePaper 12’02.doc HOSPITAL PROGRAM FLEXIBILITY and INCREASED PATIENT ACCOMMODATION REQUEST WORKSHEET District Office: Date: Reviewing Staff: Facility Name: Address: Brief description of problem: Staffing program flexibility and/or space/facilities/increased patient capacity requested: Criteria for program flexibility request under Title 22, Section 70307: Increase staffing by canceling leaves, use of administrative professional staff and registry personnel.Reschedule non-emergent surgeries and diagnostic procedures.Transfer critical care patients to step-down or other beds as appropriate.Set up clinics for non-emergency cases (if possible).Request ambulance diversion from LEMSA.LEMSA area of operation is impacted i.e. multiple hospitals on diversion due to hospital overcrowding. Program Flex approved: Yes No From: To: Signature and TitleDate
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Clinical Overflow White Paper December 2002 Page 8 L:/ClinicalOverflowWhitePaper 12’02.doc Section C Community Wide Coordination and Control Los Angeles County Emergency Medical Services Agency As part of an overall preparedness plan for dealing with periods of severe excess emergency services demand, the Department of Health Services, in cooperation with HASC-LA, will implement the following if needed: 1. Initiate a tracking system for trending the impact of the flu season on hospitals. Tracking, utilizing data generated through the ReddiNet system, may be accomplished by: • Determining the number of hours hospitals in Los Angeles County are on Emergency Department Diversion each day during the study period. • Determining the number of hospitals on Emergency Department diversion at a given time each day (i.e. 0800, 1600, 2400 hours). • Determining the number of hospitals or the actual number of hours hospitals in a given area (usually by Disaster Response Group) are on Emergency Department Diversion. 2. If trending demonstrates that the majority of hospitals in an area or region are equally impacted and there is no value in diverting ambulances away from emergency departments, the Director of Emergency Medical Services will require all hospitals to maintain an “open” emergency department and no emergency department diversions will be honored. Re-evaluation of this policy would take place every 24 hours until the crisis is over. 3. Issue a DHS Public health Advisory regarding flu crisis and use of ED vs. clinics/urgent care centers via media when trending indicates crisis situation is imminent.
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Clinical Overflow White Paper December 2002 Page 9 L:/ClinicalOverflowWhitePaper 12’02.doc 4. Assist hospitals with unusually heavy patient volumes by giving transfer priority into the county hospital system provided all of the following criteria are met: • Hospital is in danger of exceeding bed capacity. • Hospital has performed “in-patient triage” to free up as many ICU and ward beds as possible. • Hospital is currently on Emergency Department Diversion. • Hospital has implemented procedures to obtain additional staff. • Hospital is unable to provide/obtain needed equipment or special services needed due to overwhelming conditions. 5. Assist in expediting the patient transfer process to County-operated hospitals. 6. Coordinate requests for equipment and supplies through the Medical Alert Center. If a hospital has exhausted its own supply mechanisms for obtaining urgently needed equipment (e.g. ventilators), the Medical Alert Center would issue a request for equipment to all hospitals over the ReddiNet. Once a resource is located, the Medical Alert Center would provide the information to the requesting party. 7. Coordinate the transport of supplies/equipment from once hospital to another through the Medical Alert Center in the event that no other means of facilitating this was available. 8. Permit BLS ambulances to honor Emergency Department diversion and transport patients to the next closest facility provided that it is within 15 minutes of an open facility.
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L:/ClinicalOverflowWhitePaper 12’02.doc APPENDIX 1 Seniors and Persons with Chronic Diseases: Get Your Flu Shots Now Public health officials say the flu shot is the best protection availableLOS ANGELES – It is not possible to predict how severe the flu season is going to be, but the one fact on which all Los Angeles County’s health officials agree is that getting a flu shot is the best protection against getting the flu. The county health department is urging those most at risk — 65 years and older, individuals with chronic diseases or impaired immune systems, women who are more than three months pregnant and children between the age of 6 – 23 months — to get their flu shot now. “We don’t want these individuals to put off getting their shot,” said Jonathan Fielding, M.D., M.P.H., Director of Public Health and County Health Officer. “The flu virus weakens the body and makes older victims more susceptible to serious complications such as pneumonia. A case of the flu can become serious quickly.” Flu shots become available to these high-risk groups in October. The county’s flu shot outreach clinics begin next week, however many private health care providers have their vaccine now. It generally takes 10 – 14 days before the vaccine becomes effective. The following influenza strains are in the vaccine this year: A/Panama, A/New Caledonia and a B/Hong Kong-like strain. For Immediate Release For more information contact: October 9, 2002 Maria Iacobo or Cathy Pascual (213)240-8144241 N. Figueroa Street, Room 348 • Los Angeles, CA 90012 Tel: (213) 240-8144 • Fax: (213) 481-1406 www.ladhs.org
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Clinical Overflow White Paper December 2002 Page 11 L:/ClinicalOverflowWhitePaper 12’02.doc Patients should contact their health care provider. If they do not health insurance, they should contact the county health department’s Health Info Line (1-800-427-8700) for information on low-cost clinics throughout the county. This year marks the first time that health officials are recommending flu shots for very young children – ages 6 months to 23 months. These children are more susceptible to the influenza virus and their immune systems are not as well developed. They are more likely to end up in the hospital with the serious side-effects from the flu. Parents should speak with their child’s pediatrician. Take steps to keep the flu virus away There are also precautions patients with the flu can take to avoid transmitting the virus to others. “Influenza is extremely contagious,” said Alvin Nelson, M.D., M.P.H., and medical director for the Immunization Program. “People with flu-like symptoms such as a combination of high fever, cough, headache and muscle ache should stay home during the first three to five days of their illness to avoid exposing others to the disease. It is important to drink plenty of fluids, eat lightly and use acetaminophen or ibuprofen needed for pain and fever.” Additional advice includes the common-sense measures most of us heard from our parents: cover your mouth when you sneeze and wash your hands with soap and water frequently. Public Health is committed to protecting and improving the health of the nearly 10 million residents of Los Angeles County. Through a variety of programs, community partnerships and services, Public Health oversees environmental health, disease control and community and family health. Public Health comprises more than 3,800 employees and has an annual budget exceeding $465 million. ###

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