During the 2017-2018 influenza season, Yale New Haven Hospital was experiencing close to record levels of ED presentations and inpatient admissions, and the hospital's Capacity Coordination Center needed to find a solution.
The hospital had created the center in October 2017 in response to existing capacity issues, and the ensuing flu season “just put us over the top,” said hospitalist Robert L. Fogerty, MD, MPH, ACP Member, medical director for the center. “All the levers that we normally pull had already been pulled—doubles into triples, extra staffing, and flexing some of our ICU rooms to general floor rooms—and we were still totally backed up in the emergency department,” he said.
While the idea of creating a new unit had been suggested in the past, logistical hurdles were too daunting, said Dr. Fogerty, who is also director of bed resources for the hospital. But now, with the hospital more capable of handling census surges, “We had the opportunity to get creative in what to do about it,” he said.
How it works
The center's creative solution: Convert a conference room into a medical unit.
The makeshift unit would need to have a bathroom, a tube station, and power supply, as well as be located near an existing tower for code response. Dr. Fogerty walked around the hospital with the senior bed manager, and they found a viable conference room, complete with two points of egress for fire safety. They prepared the room using resources from the hospital incident command system, a disaster team which included staff from facilities to pharmacy to information technology. “It took us about 72 hours to make it more or less functional. . . . We did everything that we could to make it a true unit,” Dr. Fogerty said.
That Friday, it was time to open the unit to patients, with strict exclusion criteria (e.g., continuous oxygen dependence, nonambulatory status, diarrhea, vomiting, telemetry, and altered mental status). Dr. Fogerty, who was not scheduled to be on clinical service that weekend, served as the medical director and attending physician for the unit, assisted by a physician assistant from the adult hospital medicine service, with overnight coverage provided by one hospitalist. Two to three nurses were on the unit at all times, and a nurse manager from another unit agreed to serve as nurse manager for the converted conference room.
A total of two patients, one with influenza and the other with presumed gastrointestinal hemorrhage, were admitted to the conference room unit, and they experienced care with no complications. “The weirdest thing about it, I would say, was when I went home at night, making sure that those patients had a cross-cover provider in the building and having to have that conversation with them. . . . ‘Hey, I know this sounds a little weird, but you have two patients tonight in the NP4 conference room,’” said Dr. Fogerty.
After about 36 hours, the team made the decision to close the unit as the hospital census had dropped below disaster levels. The two patients were transferred to other units in the hospital. “Over that weekend, we were able to get a lot of discharges out, and we got our head above water, so we didn't put any more patients in there,” said Dr. Fogerty, lead author of a paper about the unit that was published in the July 2019 Joint Commission Journal on Quality and Patient Safety.
In addition to immediate patient care, the unit provided a morale boost to the institution, he said. “We did something that, as far as we know, no one had ever done as quickly as we did, and we got it up and running, and it worked,” Dr. Fogerty said. “We really will go to the ends of the earth for our patients and do everything that we can.”
The biggest structural barrier was getting all the right people involved quickly, and having the Capacity Coordination Center helped with that, he said. “I think the next biggest one was figuring out a way to efficiently use the resources that we were putting into it—the human capital, the nurses and the doctors—and that's eventually why we [phased it out] pretty quickly,” Dr. Fogerty said.
While the conference room is back to being a conference room, “We could do it again, if we needed to,” he said. The hospital's capacity management plan now includes the potential unit as part of a disaster component in a multitiered surge response. “Now everybody knows how much goes into it, so for us to do this, we have to be in an institutional disaster mode,” Dr. Fogerty said.
He added that a more forward-looking idea is for hospitals to be proactive. “Wouldn't it be nice if, going forward, every hospital that gets built has . . . nonclinical areas [that] are built in such a way that they, in a true crisis, could be turned into clinical areas, rather than putting up tents in parking lots?” A basic example would be making sure that large conference rooms have two doors that are big enough for beds, he said.