April Guthrie in the hallway
With the ED overcapacity, April Guthrie, Nurse Manager Patient Flow, coordinated the response to relieve the pressure and get patients flowing again. (Photo: UHN)

There were 37 admitted inpatients without assigned beds, including 15 patients on stretchers in the hallways, when Dr. Anil Chopra, Medical Director, Emergency Medicine, arrived at the Toronto General Hospital Emergency Department (ED) one morning late last month.

With an influx of patients, the ability of the ED to treat new patients was compromised – it was way overcapacity. It was a real-life scenario that highlighted the importance of work underway across UHN.

Just days before that Jan. 24 situation at the Toronto General ED,  more than 80 UHN leaders and team members from across the organization – including nurses, physicians, professional practice, supports services and more – gathered for a rigorous two-day workshop to specify the triggers that indicate when action must be taken to address elevated risk due to high patient volumes.

Since then, teams across all sites, with the support of the Lean Process Improvement team, have been working on developing UHN's Overcapacity Protocol (OCP), establishing four escalation levels in the event of a surge in patient volumes, determining the actions and resources needed by healthcare teams to meet the demands, and how to de-escalate appropriately to get back to regular operating levels.

OCP in real-time

That morning, Dr. Chopra alerted Mike Nader, UHN's Chief Operating Officer, and Dr. Charlie Chan, Vice-President Medical Affairs and Quality. Together, all three took action, attending the morning patient flow meeting to support the Clinical Directors, inpatient managers and the flow team in dealing with the crisis.

While the Over Capacity Protocol (OCP) is in the development stages, teams at UHN are already changing how they work to more effectively respond when patient volumes surge, exceeding capacity.  

"We were in crisis mode," says Dr. Chopra. "This was at the beginning of the day when we were expecting to admit an additional 20 to 30 patients over the next 24 hours."

Thanks to the herculean efforts of multiple Toronto General teams, including Transportation, the ED and flow, 13 patients were moved out of the ED and up to inpatient units in less than three hours.

By finding a way to safely care for the additional patients, the inpatient unit teams significantly improved the ability of the ED team to see new patients.

Level Four escalation

"In the new OCP language this was a Level Four escalation, which is the highest level," says April Guthrie, Nurse Manager Patient Flow, MOT/Nephrology and Apheresis at Toronto General. "We had the opportunity to try some of the new actions we are considering as part of the OCP to see if they are effective in helping us return to a lower escalation level."

All managers attended the patient flow meeting, and according to April, that carries a strong message back to the units that the hospital is in a crisis situation, requiring the movement of patients in a timely fashion. At the meeting, each unit was assigned one additional patient and told the patient would be arriving within the hour.

"The inpatient managers and their teams did an outstanding job," says April. "Thanks to their efforts we were able to take some of the pressure off the ED."

'Win-win' for patients

This example demonstrates how the new OCP will help ensure the safe and timely delivery of care to patients, especially in times of overcapacity.

"The impact on patients is always the most important consideration," says Dr. Chopra. "The objective of the OCP is to get patients to the right place at the right time. That means once admitted, patients should be on floors where inpatient teams can look after them.

"We know that patients are more satisfied in an inpatient hallway than in an ED hallway, and studies show that patient outcomes are better when ED stays are shorter for inpatients," he says.

"From a safety and patient satisfaction perspective, a shorter length of stay in the ED for admitted patients is a win-win."​

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