GUIDELINE FOR SURGE CAPACITY/DIVERSION PLANNING
PURPOSE: The purpose of this guideline is to provide a formal structure for the
processes to be followed during times of high census on the Labor & Delivery and
Postpartum units. The goals are to clearly identify leadership, improve lines of
communication, and distribute resources in a manner that will allow safe and quality care
for our patients at all times. In addition, the information gained by tracking and analyzing
each diversion event, will be used to improve strategic planning for Maternity Services at
Mount Auburn Hospital.
DEFINITIONS:
1. SURGE CAPACITY - a state of high census on Labor & Delivery and/or the
Postpartum unit OR any time the team of providers and nurses, on either unit, feels there
is a unique situation requiring in-depth evaluation of capacity and resources. During
"Surge Capacity", the charge nurse and coordinating physician, together with input from
the on call OB Department Administrator, will make decisions regarding the ability to
accept patients for triage/evaluation/care on an individual basis.
2. DIVERSION - a state where it has been determined that the units can not accept
another patient AND that one or more patients are sent to other area facilities to receive
care. The decision to go on diversion will only be made by the on call OB Department
Administrator, after consultation with the charge nurse and coordinating physician.
LEADERSHIP:
During times of "Surge Capacity", the designated charge nurse and coordinating
physician together will make decisions regarding utilization of resources, staffing needs
and capacity planning. Individual providers, on call as well as in the offices, are to direct
questions regarding patient triage or admission for evaluation to this unit leadership team.
There will be a call schedule for an on call OB Department Administrator (Chair of
OB/GYN, Director of Department of Obstetrics, Director of Department of Midwifery,
Beth Hardiman MD) available on Labor & Delivery at all times.
The OB Department Administrator on call will be notified whenever the unit is in "Surge
Capacity" status and when a decision regarding the need for diversion arises. The OB
Department Administrator on call will be available to assist in planning, and will
ultimately be responsible for making a decision about the need for Diversion.
The Nurse Manager, or Nursing Supervisor during off shifts, will be readily available to
help with resource utilization, and coordination of patient care, including helping to make
calls to other hospitals to evaluate their capacity for accepting transferred or diverted
patients.
PROCEDURE:
1. During times of "Surge Capacity" a team meeting should be held and a clear plan for
managing patient care/resources developed. These team meetings should involve not only
the nurses/providers on L+D, but also the on call anesthesiologist, pediatrician, and
charge nurse for the Postpartum unit. These meetings should include (but are not limited
to):
- assessment of the clinical status of the patients currently being cared for on the units
- assessment of current space available for patient care and anticipated needs
- identification of planned numbers of discharges for each unit
- staffing needs for nursing, MD's and CNM's
- consideration of need to move the patients scheduled for the Antenatal Testing Unit to
other available spaces
- urgency of planned inductions (utilizing the departmental rating system located on the
front of the Induction Scheduling book and available on the MAH CareGroup portal)
- consideration of deferring or rescheduling all elective procedures
- need to mobilize resources from ancillary departments of the hospital (i.e. Dietary
services, Housekeeping, Transport, etc)
2. While in "Surge Capacity" status, a team meeting should be held at least every two
(2) hours to reassess the needs and function of the units.
3. When the team decision to move into "Surge Capacity" status is made, a burst page
will go out to a leadership group including members of the OB Department leadership,
Nursing and Hospital Administration Leadership.
4. When in "Surge Capacity" status:
- all providers should direct questions regarding patients needing evaluation/triage to the
L+D charge nurse and coordinating physician team. No patient should be advised to
come into the hospital until the team has reviewed/discussed the situation and made a
clear plan for the unit.
- the L+D charge nurse will send a "OB Surge Capacity" burst page and notify the OB
Department Office administrative staff
- the "Surge Capacity" status will be communicated to the outpatient offices by the OB
Department Office administrative staff (utilizing the existing phone tree)
- the Nurse Manager (or designee) will call area hospitals to determine the availability for
transfer/diversion of patients if needed
- the OB Department Administrator on call will call in and be available for decision
making assistance
- the OB Department Administrator on call will notify by email the other Department and
Hospital Administrators of the change in unit status
- team meetings should be held at least every two (2) hours to reassess the need to
continue or cancel "Surge Capacity" status
5. When it is determined the unit can not safely accept another patient AND a patient
must be sent to another facility, the status will be changed to "Diversion". This decision
will only be made by the OB Administrator on call, after
consultation with the leadership team on the unit.
6. When in "Diversion" status:
- all of the above outlined steps for "Surge Capacity" planning should be revisited
- the L+D charge nurse will send a "OB Diversion" burst page and notify the OB
Department Office administrative staff
- the "Diversion" status will be communicated to the outpatient offices by the OB
Department Office administrative staff (utilizing the existing phone tree); if "Diversion"
status occurs after office hours, the CNM groups/Blue call/Gold call providers should
send an email via the group email utilized for sign outs and include the unit status and
names/clinical situations of any patient sent to another facility
- the OB Department Administrator on call will notify by email the other Department and
Hospital Administrators of the change in unit status
- frequent reassessment of the needs of the unit should be performed by the charge nurse
and coordinating physician
- the diversion/transfer of each patient must be from one provider to another; it is the
responsibility of the provider to make sure the prenatal record is sent to the accepting
provider
- providers should discuss each diverted patient with the charge nurse and coordinating
physician, and pertinent information regarding the patient and clinical situation recorded
in the Diversion Log
7. When it is determined that the unit can safely come off of "Surge Capacity" or
"Diversion" status:
- the status change will be communicated to the outpatient offices by the OB Department
administrative staff (utilizing the existing phone tree)
- the OB Department Administrator on call will notify by email the other Department and
Hospital Administrators of the change in unit status
- the Nurse Manager will make sure the Diversion Log information is correct and entered
into the diversion tracking tool, contact providers whose patients were diverted to obtain
follow up information regarding the patient care/outcomes, and will send a letter/gift card
to those patients who were diverted.
8. Regardless of the status of the unit, any unannounced patient arriving on the hospital
campus seeking emergency care (including labor) is covered by EMTALA, and must be
evaluated and stabilized prior to transfer, if transfer of care is appropriate.
SURGE CAPACITY/DIVERSION EQUIPMENT RESOURCES
Cribs:
Cambridge Health Alliance - 617-665-1000, ask for the Nursery; can lend cribs
OR - has one large crib
UHS (Rental Company) - Monday thru Friday, regular work hours:
contact Kevin Minnick ext 5056 to order more cribs
Off hours contact UHS directly 1-800-585-5464
account number: 581520
SURGE CAPACITY/DIVERSION CONTACT INFORMATION
ADMINISTRATIVE PERSONNEL
Burst Page: OB Surge Capacity - send text page through CareGroup Web
portal
This will contact the following: Dr. Huang, Dr. MacDonald, Dr. Hardiman, Margi
Coggins CNM, Phyllis Gorman CNM, Pat Lavin RN, Deb Baker RN, Maria
Smyth, Assistant Nurse Manager L&D, Deb Farrell RN, Assistant Nurse Manager
South 5 & Stanton 5
Burst Page: OB Diversion - send text page through CareGroup Web portal.
This will contact the same group as in Surge Capacity 1 plus the following: Deb
Baker, Pat Lavin, and Nick DiIeso.
OB Department Office - extension 5161 or extension 4600
Dr. Huang:
pager # 7056 or 617-339-0529
cell # 617-775-1706
home# 781-777-1122
Dr. MacDonald
pager # 6961 or 617-339-2711
cell # 508-981-3055
home # 617-559-9929
Dr. Hardiman
pager #7069
cell # 617-816-7967
home # 617-484-9774
Margi Coggins, CNM
pager # 6586 or 617-802-0345
cell # 781-521-9754
home # 781-641-0201
Phyllis Gorman, CNM
pager # 6408 or 617-339-1082
cell # 617-620-5855
home # 617-965-8178
Maria Smyth
pager #6252
cell # 978-239-4675
home # 978-373-8054
HOSPITALS
For MD or CNM patients:
1. BIDMC: Labor & Delivery 617-667-2295
2. St. Elizabeth’s: Labor & Delivery 617-562-7050
3. Cambridge Hospital: Labor & Delivery 617-665-1309
4. B+W: 617-732-5435, ask to speak with the Nurse in charge (NIC)
4. MGH: 617-724-9410, ask for the attending on call specifying that you would
like to transfer a patient
5. Tufts: 617-636-4250, ask for the Chief Resident for a transfer call
For CNM patients transferring to another CNM group:
1. Cambridge Health Alliance Midwifery Group - 617-665-2229, ask for CNM on
call Contact person: Leslie Ludke, CNM
2. MGH Midwifery Group - 617-724-9410, ask for the L&D Attending and
request a
CNM to CNM transfer
Contact person: Marie Henderson, CNM 617-724-2229
3. St. Elizabeth’s Midwife - Kathy Jones McWilliams 617-562-7007 (last resort)
Policy Category:
Approved by:
Effective Date:
Department of Obstetrics & Gynecology
Chairman, Obstetrics/Gynecology
Reviewed:
Revised:
Current Owner:
7/6/12
7/6/12, 3/1/13
Cross Reference:
Regulatory Reference:
Keywords:
February 2012
Chairman, Obstetrics/Gynecology