San Gorgonio Memorial Hospital supports and follows the California Crisis Care Continuum Guidelines

Assumptions

• San Gorgonio Memorial Hospital health care professionals will continue to provide the best possible care to all patients under the circumstances.
• Health care professionals will continue to respect patients’, families and patient representative’s wishes within the constraints of the circumstances and insofar as institutional policy, sound medical judgment and ethical considerations allow.
• These guidelines provide a framework for decision-making, but should be viewed as flexible and adapted to local circumstances of COVID-19.

Leadership Structure:

• Maintains current C-suite structure with enhanced clarity of assignments and tasks.
• Daily huddles, timelines and assigned tasks. Key elements: Space, Staff, Supplies and Communication
• Engages key leaders in decision making but not every meeting.
• Dyad model pairing nursing/physician leader.

SPACE:

ICU/DOU

• We are currently licensed for 16 ICU & DOU/Stepdown beds. We have doubled up patients to place confirmed COVID positive patients together in the same room and confirmed negative COVID patients in the same room. This increases our ICU/DOU capacity from 16 to 24 beds
• All of our ICU/DOU rooms have been converted to a negative pressure environment.
• We have also opened up our PACU (post-anesthesia care unit) as an ICU/DOU for our non-COVID patients. This allows for total of 8 beds.
• During crisis mode, will open up “old ICU” (currently used a storage space) to staff up to 6 COVID positive ICU/DOU patients and also open up ICU lobby as patient care area to staff 6 patients

Med/Surg

• The South hall of our Medical & Surgical Center Postoperative space can double up confirmed non-COVID patients to create 8 more beds 
• We have maximized bed utilization and now are using postpartum beds for adult female patients that are confirmed COVID negative.

OB

• We will increase our 15 licensed OB bed capacity to double up our rooms to create a total of 9 new beds
• We can add 6 hallway beds in our OB department
• We will continue to have designated bed available for our L&D patients for delivery
• We are using our Classroom B and main hospital lobby for our teams’ Covid vaccinations.

Emergency Department

• We have physically divided our ED lobby into 2 areas, one for COVID PUI and ED patients with non-COVID complaints.
• We have transitioned into creating our ED lobby as part of our treatment area for our patients as well, opening up space for up to 20 patients to be assessed
• We have acquired a temporary building from EMD to house up to 8 confirmed COVID positive patient
• Use the emergency department family grief room as patient care area for the emergency department
• We are utilizing our dedicated psychiatry room in the ED to evaluate COVID PUI in chairs, allowing up to 6 patients to be assessed in chairs.
• We are utilizing our two resuscitation bays to house our admitted-holds COVID positive patients, this way we can place up to 5 patients in these rooms, increasing our bed capacity by 3.
• During crisis, we will utilize our lobby and our rapid care area as treatment area for admitted/hold patients
• Crisis potential is to increase ICU capacity to 54 and Medical/Surgical Capacity to 71

STAFFING

Nursing and Non-clinical Staff:

• Recently hired new grads to be a part of the team nursing model.
• Will continue to actively recruit more clinical staff, including travelers
• Staffing, outside tent/building, and inpatient MRI waivers submitted and accepted
• Applied for state resources
• Clinic staff helping in all areas; combination of voluntary recruitment and re-assignment.
• Nursing ratios for each level of care to be adjusted so there is more flexibility in assignments
• Adjusted case management hours to assess needs of patients awaiting home oxygen
• OR and GI suite staff redeployed to acute care areas
• During crisis:  Nursing administration will be deployed as house supervisors/department charge nurses to allow charge nurses to take patientsWill deploy non-clinical staff to each department (Office Assistants 24/7 as runners, enhanced communication), helping with morgue management, helping with lab runners.Deploy nursing students and RT students to provide bedside careNew hires start department orientation prior to general hospital orientation
  • Will execute nursing team model to assign a team of ICU nurse (as lead) with 2 med/surg or 2 OR nurses to staff 10 ICU patients.

Physician Coverage Plan:

• ED team created a protocol to safely discharge COVID patients on home oxygen directly from the emergency department, this has actively reduced 4-6 admissions per day.
• Expanded coverage in the emergency department by adding dual physician coverage in the emergency department as well as added advanced practice provider (APP) coverage expanded to staff the ED and rapid care area safely.
• Protocol written to administer monoclonal antibodies (Regeneron & Bamlanivimab) to administer to high risk COVID patients in the emergency department in an effort to avoid further deterioration in their clinical course
• Allowing temp privileges for new members of medical staff to staff acute care areas of the hospital
• Activated procedure team of anesthesiologists to respond to emergent intubations in the hospital 24/7
• ED physicians respond to code blue throughout the hospital 24/7, supporting nursing, facilitating ED admissions, performing procedures and provide back up support for medical staff
• Implement a team model for staffing patients where the intensivisit provides expert services for ICU/DOU patients as the hospitalists are primary admitting attendings in ICU/DOU patients.
• Outpatient Clinic physicians deployed to inpatient service as hospitalists to round on admitted patients and admit new patients to the hospital
• Elective surgeries cancelled and deploy general surgeons to provide procedure services for admitted patients
• During crisisExtend pharmacist to 24/7 availability to help staff with medications/dripsIntensivists to extend their in-house availability given the acuity of patients in the hospitalDeploy outpatient specialty clinic physicians (surgical specialties) to provide in hospital care
  • Surgeons will be primary admitted attending physicians for surgical patients

CLINICAL DECISIONS:

• Starting Palliative care discussions and identifying next of kin as soon as possible in the Emergency Department.
• Involving case management staff and palliative care to clarify end of life decisions. Increasing POLST completion at admission and hospital discharge.
• Team working to define and minimize futile care/CPR limitations and develop treatment guidelines.
• Minimize CT utilization in COVID patients.
• Execute our home follow-up program with case management staff to engage communication within 24 hours of ED discharge for patients requiring home oxygen
• Host COVID grand rounds with clinical and medical staff to ensure in hospital care matches with most up to date research and clinical guidelines to provide quality care to our patients.
• Temporarily suspend ED Bridge Program to redirect patients to outpatient clinics and minimize their exposure to COVID in the hospital setting. Also reduces strain on our system during this surge.

SUPPLIES

• Invested in house RT-PCR COVID-19 testing machine developed by BDMAX, expected to arrive this month to all PCR testing of all admissions to the hospital
• Obtained several hundred POC COVID Antigen testing kits (BioNex) to have a rapid test (turnaround time 15 min) to test all admissions and Emergency Department patients
• Submitted resource request through the MHOAC for additional beds, cots, external building, freezer for decreased patients
• Purchased 6 new ventilators for the hospital
• Recently obtain 10 ventilators from Riverside EMD
• Utilizing telehealth One-Touch Monitors in different departments to minimize exposure to clinical staff and wastage of PPE
• Added cots to emergency trailer for additional surge
•  Increased volumes of Pumps, linen, PPE, Normal supplies, pharmacy
• Interchangeably use ventilators as BiPAPs or as ventilators to allow for flexibility for staff
• Attempt to utilize HFNC up to 15 L prior to transitioning to Vapotherm
• Utilize PO medications as much as possible, discharge patients with prescriptions for medications from ED instead of administering them from hospital’s pharmacy supply
• Conserve telemetry boxes for ideal patients, constant communication with medical staff to identify appropriate candidates for telemetry
• Use Dial-a-Flows for stable patients (No titrated drips) when no IV  pumps available
• During crisis:Utilize BVM as a CPAP when used in conjunction with HFNC; Utilize donated home CPAP machines for admitted patients requiring NPPVActivate Medical Staff Ethics Team to review cases daily in accordance with scarcity of resourcesUtilize cardiac chairs and disaster medicine cots for additional patients Pharmacy to create sedation drips in larger bags to last >72 hours to minimize time and supplies wasted
  • Split 1 ventilator among 2-4 patients in an effort to conserve resources

HiFlow/Vapotherm/BiPAP — NEED NUMBERS

LEVEL OF CARE

• Relatively stable DOU patients can be staffed in Med-Surg depending on acuity and capacity of ICU
• PACU to staff mixture of ICU/DOU/Med-Surg level of care patients
• Telemetry patients can be admitted with bedside monitor in place and camera in room if telemetry monitors are unavailable
• ED patients can wait for >1 hour for Triage and MSE exam, length of stay in ED can be significantly prolonged
• Admitted patients will be “admission holds” in the emergency department until bed available in the hospital, potential delay in inpatient care dependent on acuity and volume of ED patients at the time

Patients awaiting home 02 will be occupying bed space in hospital until vendor able to deliver oxygen

During crisis:

• Only intubated patients in ICU upstairs; All DOU patient to be staffed in Med/Surg
• PACU to staff only ICU/DOU patients
• Telemetry boxes made available for ICU/DOU level patients when no cardiac monitors are available
• ED patients can wait for >3 hour for Triage and MSE exam
• Patients awaiting home 02 will be waiting outside the ED tent on oxygen until vendor able to deliver oxygen
• Paper documentation for all clinical staff to allow maximum time at bedside and minimize interruptions

CHALLENGES:

• Small community hospital with limited physical space making it difficult to expand capacity.
• Small pool of clinical staff makes it challenging to create flexible assignments. A few staff members not reporting for duty can have a big impact on our hospital given its already existing small pool of clinical staff members.
• Absence of tertiary care services, including surgical specialties, cath lab, has impacted patient care as patients cannot be transferred for high level of care for definitive management, thus impacting regional patient care.
• Maintaining adequate oxygen supply at the hospital – due to recent holidays and patient surge, we were at critically levels of oxygen storage 
• Rise in ambulance volumes due to ambulance re-direction from neighboring hospitals. Continue to have excellent off-load times in spite of significant volume increases.

Morale’ and Communication:

• Provided a call-in number for EAP for individual counseling and support.
• Developing a daily dashboard to review current surge status which will included departmental bed capacity by physical space, staffing and resources.
• COVID Task Force – Virtual meetings with entire medical staff where physician and nursing leaders update them on surge volumes, plans and resources.
• Regular medical staff and nursing leadership team meetings to review and adopt protocols, discuss best practices and address issues.

Skilled Nursing Outreach and Support:

• Communication with medical and nursing leadership of local skilled nursing facilities
• Connected with local medical directors to update each patient’s code status and POLST form on admission