Checklist for Emergency Department (ED) Surge/Overcapacity

Service: Risk Management
Type: Risk Notes

Organizations utilize various terms to describe situations where client volumes exceed expectations such as surge, mass casualty events, overcapacity, gridlock, escalation, Code Orange, and others. The specific meanings and triggers of these terms may differ between organizations and regions. However, in the context of this document, all these terms are understood to indicate a sudden increase in demand for services or resources that could potentially overwhelm an organization’s capability to respond effectively. 

This resource was co-designed with HIROC Subscribers. Please note that this checklist does not provide a comprehensive guide for all organizations, regions, or sectors, and it is not intended to replace your organization’s processes and protocols. The purpose of this checklist is to complement your organization’s existing protocols, or other tools related to capacity constraints. Before making any changes to your current procedures, please engage internal and external subject matter experts. Command, control, and communication is critical for saving lives during emergencies. Focusing on people, places, resources, and systems enhances emergency preparedness and response, and recovery.


Planning

  • Ensure your organization has a plan and reviews your surge response on a regular basis
    • Define what is considered a surge and establish indicators of surge activation
  • Engage multidisciplinary team in surge planning. As an example and not an exhaustive list: Physicians, Nurses, Intensive Care Units (ICUs), Infection Prevention and Control (IPAC), Pharmacy, Social Work, Cultural Care / Spiritual Care, Physiotherapy, Emergency Medical Services (EMS), Ambulatory/patient transport, Primary Care and Homecare, Community Agencies, and alternate care facilities (to support and facilitate temporary care)
  • Include Communications, EMS, Ambulatory/patient transport, Human Resources, and Support Services
    (such as maintenance and environmental services) in planning activities
    • Consider development of templated communications
  • Ensure Materials Management and Pharmacy has a plan for surge capacity related to supplies,
    equipment and medications that may be required during a surge
  • Anticipate surges; monitoring of large community events/concerts/festivals/respiratory outbreaks,
    wildland fire and smoke, etc., that may trigger surge response
  • Ensure policies and procedures are in place for client flow management and hospital capacity
    management:
    • Timely client discharges where safely possible
    • Multidisciplinary client discharge rounds
    • Plans for client follow-up post-discharge/priority home care process
    • Plans and processes for family reunification
    • Determine space available, i.e., Medical/Surgical, Post-Anesthesia Care Unit (PACU), hallways,
      and alternative sites
    • Process for rapid triage
  • Transportation plan to move clients to other sites/care facilities
  • Consultation and early planning with equity deserving communities, external/community partners and community leaders
  • Consider contracts with external/third parties to establish terms, roles and responsibilities, and
    insurance, as required

Preparedness

  • Tabletop exercises, training exercises (seminar, tabletop and/or functional)
    • Provide training in person, virtually and/or self-directed online
    • Conduct regular training and drills to familiarize roles and understanding of response activities
    • Ensure command, control and communication by understanding Incident Command Systems
  • Reinforce the plan on a regular basis
  • Review previous exercise outcomes through debriefs and learning sessions and adjust plans accordingly in consultation with subject matter experts and organizational input
  • Document organizational decisions and engage in proactive ethical considerations to ensure clarity
    and awareness of the surge response process

Activating Surge Response

  • Consider the activation of an Incident Management/Command System to aid in coordinating an effective response that establishes early command, control and communication including:
    • Decision by Leadership to activate surge response:
      • Confirm compliance with organizational criteria for defining a surge event
      • Clearly identify contributing factors of defining a surge event
      • Record start date and time of onset of deemed surge event
      • Prospectively determine the expected duration of the surge event
      • Consider activation of established regional and system partner responses where applicable
    • Assess the need to divert EMS to alternative sites according to your local processes for bypass activities
    • Engage human resources to assess and assist with staffing needs
    • Access and review relevant emergency plans (i.e., Code Orange, Code Grey)
    • Communication with partner agencies for assistance (e.g., government system partners,
      emergency response authorities, etc.)

Physical Space

  • Evaluate areas for potential client overflow
  • Assess the functionality of these overflow areas as it relates to client and work areas, storage, equipment, supplies, waste management and utilities, temporary morgue facilities
  • If pre-determined overflow areas exist, assess functionality to accommodate equipment and personnel
    to meet client needs
  • Confirm adequate visibility for staff of clients and access to call bells, code buttons, or other
    emergency alerts
  • Ensure adequate lighting, and seating for medical record charting
  • Provide access to hand hygiene stations, hand sanitizer, handwashing sink
  • Consider medication preparation carts/areas, ensure medications are secured
  • Establish access to clean and dirty utility room/laundry/decontamination, if needed
  • Designated areas for Incident Command System activities as well as, where applicable, Family Reunification
  • Identify visitor/non patient waiting area
    • Mechanical access control should be considered to prevent unauthorized access to care area(s)
  • Follow organization’s Business Continuity Plan 

Communications

Internal Communications:

  • Appoint a Lead to be accountable during the surge event
  • Implement communication plan to alert organization of the surge
  • Communication plan:
    • Notification of Senior Management and Executive Leadership of surge status
    • Establish a communication channel or command center for real-time updates and coordination
      among different departments
    • Ensure frontline staff have access to information and are updated frequently regarding surge:
      • Inform the organization’s security (protective services) team, or designate to manage any
        potential crowd control or safety issues
      • Contact the ancillary departments (Laboratory, Radiology, Pharmacy, etc.) to notify them of the
        surge activation
      • Engage Human Resources to support need for additional staff/staff call in/agency support
      • Notify the client units and request their collaboration in managing Emergency Department admissions, transfers and discharges
    • Establish a feedback loop to gather input and suggestions from staff and external/community
      partners to improve the response and address any concerns
    • Consider triggers to reach out to the hospital’s supply chain department to ensure an adequate supply of essential items such as medications, personal protective equipment (PPE), and medical equipment
    • Summarize surge situation for future reference and debriefing 

External Communications:

  • Develop and have access to plans for public communication and media relations:
    • Designate an official spokesperson to provide all communication and media updates
    • Establish process for media inquiries and interview requests
    • Coordinate messaging with the organization's Communications or Public Relations department
    • Consider utilizing corporate social media accounts to release official updates to public
    • Consider utilizing organization’s internal and external websites to provide surge-related information and updates for staff and the public
    • Provide clear signage on access routes and around facility to inform public awareness
    • Consider local languages and translate developed materials
  • Develop a clear and concise message for the public regarding the surge event; consider including:
    • Brief overview of the surge situation
    • Impact on client care and wait times
    • Actions being taken to manage the surge
    • Any special instructions or precautions for the public
  • Initiate communication with key system partners (e.g., equity deserving communities, government entities, news outlets, etc.) related to:
    • Admissions and discharges
    • Re-direction to other organizations/facilities
  • Communication to the key external/community partners:
    • Local Emergency Medical Services (EMS) providers
    • Nearby hospitals and healthcare facilities
    • Public health agencies
    • Regulatory authorities
  • Establish effective communication process for clients and families

Client Tracking and Re-Direction (Client Flow)

  • Assess capacity and existing client populations in the Emergency Department
  • Identify clients who are ready for transfer/discharge or alternative levels of care
  • Begin rapid placement of clients (same day) during surge
  • Assign a delegate to contact family members of clients that are being transferred
  • Adhere to admission and discharge criteria
  • Plan for cancellation of scheduled/non-emergent service admissions

Human Resource/Staffing

  • Redeploy staff to areas where experiencing surge
  • Estimate and document the minimum number and categories of personnel needed to care for the current client population
  • Obtain staffing inventory
  • Assess the staffing needs:
    • Consider available staff
    • Consider skill set requirements
    • Consider alternative shift lengths
    • Consider staffing over a prolonged period of time
  • Call in all available staff
  • Identify other sources of available staff (e.g. former ED staff, agency, other hospital ED staff, etc.)
  • Consider alternative forms of transportation to enable staff to safely arrive
  • Maintain up-to-date staff contact information
  • Develop process for time tracking and check in/check out for responding employees
  • Consult with unions and Regulatory bodies

Other Considerations

  • Designated environmental services team to ensure rapid bed turnover
  • Security assessment with plans to address vulnerabilities
  • Food and water for clients, staff, families, and volunteers
    • Consider unique dietary requirements
  • Consider critical incident stress management, employee assistance programs and other mental health
    supports for staff
  • Notify system partners including HIROC as needed

Post-Surge/Debriefing

  • Process for debriefing and learnings:
    • Contributing factors identified (e.g., influenza/gastrointestinal outbreak, contaminated drug supply, inadequate Homecare/Long-Term Care resources)
    • Feedback loop to gather input and improvement suggestions from staff and stakeholders to improve future response and address any concerns
    • Monitor internal patient relations data related to surge
  • Determine if Critical Incident Stress Management sessions are to be coordinated for staff involved with
    overcapacity event
  • Revise existing response plans based on debrief findings
  • Ensure all organizational documentation related to the surge/overcapacity is maintained and retained

Resources

Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.