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California hospital deploys surge tent to handle sudden influx of flu patients


April 1, 2018

Review supplies needed to treat potential influenza patients and ensure your patient-flow tracking can extend to use of a surge tent in the event flu-ridden patients threaten to overwhelm your ED.

The CDC reports the incidence of flu-like cases in week three of 2018 is running about three times the national baseline in some areas and all 10 regions of the nation are reporting activity. The number of cases can spike week to week, or even day to day.

A sudden spike prompted one California hospital to break out its surge tent December 27 as patients filled its ER.

As with many ERs, the number of patients arriving at Sharp Grossmont Hospital in La Mesa, Calif., northeast of San Diego, generally slows in the early morning hours and the waiting room usually clears of patients before the new shift begins the day, says Marguerite Paradis, the hospital’s director of the Emergency Services and Critical Care.

But the Tuesday morning after Christmas brought an unexpected “gift” of more than 40 patients still in the waiting room, most complaining of flu-like symptoms. Wednesday morning there were 60 patients waiting.

December holiday brings flu surge
The last three months of the year — the first months of the unofficial flu season — brought only 75 patients to the hospital who tested positive for influenza, says Paradis.

That day after Christmas would be the start of a surge of patients that would top 700 positive cases in just the first three weeks of 2018 at Sharp Grossmont.

Looking at a full waiting room for the second day in a row, Paradis began to discuss a plan with hospital administrators and Senior Safety Management Specialist Joe Burdenski. As part of its emergency preparedness, the hospital staff practices setting up a surge tent every six months or so, says Burdenski.

With concerns about controlling potential infection and freeing up space for patients with other medical emergencies, Paradis, Burdenski, and administrators decided about 9:30 a.m. to set up the surge tent outside the entrance to the ED.

As part of the hospital's disaster surge plan, a multi-disciplinary team including the security, environmental services, clinical and nursing departments, as well as ancillary services and supply chain representatives, immediately deployed, and the team set up the 15-by-30-foot tent alongside the ED. Blue screens were used to create a triage entrance area. Police tape secured the area along the ED driveway in front of the tent.

Inside the tent, chairs, tables and treatment areas were established, and the temporary locations were created within the hospital’s electronic patient-tracking system. Internet access was established and computers set up to run the electronic health records (EHR), printers and other equipment, and medical supply carts were also brought in.

No extra personnel needed
By 11 a.m., when the next shift of doctors and nurses was expected to take over, the tent was ready for patients. No extra personnel were called in, says Paradis, although nurse managers and other clinicians who might not normally see patients stepped in to help as needed. Hospital administrators volunteered to run specimens to the lab and do other errands as needed.

The number of patients grew throughout the day, with several cases serious enough to admit them as inpatients. However, the surge-tent capacity allowed the hospital to keep up, says Paradis.

In the months before, as flu patients began trickling in, the hospital had instituted a process for tracking the low-acuity patients who, while they needed less attention from clinical staff, still needed to be processed through the ED as quickly as possible, says Paradis.

About half the patients waiting in the ED that day were higher-acuity flu cases, meaning their care would take more time and personnel, so the hospital instituted an accelerated patient-tracking process using that low-acuity model, Paradis noted.

That, combined with the ability of the hospital’s EHR to expand to include the temporary locations of patients inside the surge tent, kept patients flowing smoothly through the process, she says. As lab results came back, the information was relayed to the patient’s exact location for clinicians to respond.

Sundown on the tent
From about noon to 5 p.m., about 40 patients were processed through the tent. The number of patients were dwindling and the setting sun meant either shutting down operations for the night or providing more heat to the tent.

The decision was made to shut the surge tent down for the evening. While it could have been used again the next day, the relief provided by the surge treatment had allowed facility engineers, environmental services personnel and medical staff to prepare an unused area within the ED for future use as the flu triage area. The room is a treatment area that normally is not needed and used primarily for storage, says Paradis.

That capacity allowed the hospital the next day to take the tent down. However, that didn’t mean the flu surge was over.

Portable infection control stations with masks and hand sanitizer was set up at all the hospital entrances and at key areas throughout the facility, and personnel were assigned to ensure that everyone who came in to the hospital was asked to wear a mask and wash their hands.

Cover your cough
The CDC offers hospitals and other providers information to educate the public on how to keep from spreading flu germs. The posters and other “Cover Your Cough” information is available online (see link in Resources).

All hospital personnel are required to have a flu vaccination each year, unless they have an allergy or other reason to decline the shot, notes Paradis. Anyone who does not have a vaccine is required to wear a mask, she says.

For coughing patients or anyone suspected of having influenza, the CDC recommends that they wear a mask at all times “until they are isolated in a private room,” according to the agency’s “Interim Guidance for the Use of Masks to Control Seasonal Influenza Virus Transmission.”

“Masks should be worn by these patients until it is determined that the cause of symptoms is not an infection that requires isolation precautions or the patient has been appropriately isolated, either by placement in a private room or in some circumstances by placement in a room with other patients with the same infection (cohorting). The patient does not need to wear a mask while isolated, except when being transported outside the isolation room,” according to the guidance.

Remember public affairs
Paradis said that in 2016, the hospital had almost 1,200 cases of flu. But from October through the middle of January, the hospital registered more than 1,033 positive cases, with about a third of those in the last two weeks of December and beginning of January.

Overall, the process of deciding to use the tent, deploying it and breaking it back down went well, say Paradis, Burdenski and Kevin Grubbe, also a senior safety management specialist.

A lot of that was because of the regular drills the hospitals does with all levels of personnel, notes Grubbe.

There was one key lesson learned, though. While all the hospital major emergency incident plans include notifying the hospital’s public affairs department, no one thought to let them know.

The first notice public affairs had was when local media called to ask about the tent, says Bruce Hartman, Sharp Grossmont’s director of marketing and communications. One local television station even sent a helicopter news crew to get aerial footage.

While the lack of communication was not a major problem, it was a missed opportunity to get someone from the hospital in front of a camera to talk about the positive efforts by Sharp Grossmont to help patients and to provide community education about influenza, says Hartman.

That will be part of the critique that will be written up, notes Grubbe. The Joint Commission does require at least two tests of a hospital's emergency operations plan a year, and that hospital's assess performance and update and improve plans accordingly. 

CDC guidance for health professionals: https://www.cdc.gov/flu/professionals/index.htm
Mask guidance: https://www.cdc.gov/flu/professionals/infectioncontrol/maskguidance.htm
CDC-HICPAC on hand hygiene: http://www.shea-online.org/images/guidelines/SHEA_hand.pdf
Cover your Cough materials: https://www.cdc.gov/flu/protect/covercough.htm

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