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Standard Work: Diversion Standard Process: NICU Document Owner(s): Julie De Salaberry, Sandesh ShivanandaDepartment: Neonatal Program
Created: April 17, 2018 Last Revised: July 19, 2018 December 5, 2018 July 20, 2019 Aug 14, 2019 September 23, 2019
Date Approved: 16-Nov-2020
Decision Making: Neonatal Program Director and Medical Director (Days Mon to Fri)BCW Manager On Call (Nights, Weekends)CNL, Neonatologist On Call
Other Roles Involved: NICU Medical Lead, Program Manager,Neo on call / on service, PC, CNL
Process Summary: Diversion is initiated when demand exceeds capacityDemand = # of NICU patients plus known pending admissionsCapacity = available staffed bed (with nurse) plus anticipated discharges Diversion is considered when pending # of bed needs exceeds # of staffed beds available. This can be due to increased # of patients, and/or increased acuity and / or the # of nurses available does not meet patient demand and the status will not change within the next 12 hours
TWO NICU beds available for non-refusal patientsObjective: To outline a standard process for leaders to manage
(1) putting NICU on diversion, (2) monitoring while on diversion, and (3) taking off of diversion
Diversion Standard Process Algorithm (see Appendix A for Quick Reference) Patients that cannot be diverted (non-refusal patients):
1. All infants who require Level 3b/quaternary care will continue to be admitted to the BC Women’s NICU.
2. Infants will not be diverted in the following scenarios: Deteriorating infant in postnatal care/Mother Baby Care. Unplanned emergent delivery of infants from mothers already admitted to BCW antenatal
unit (Evergreen)/Labour and Delivery/Birthing Suites. Sick infants who present to BCCH emergency or BCW Urgent Care Centre.
PUTTING THE NICU ON DIVERSIONMajor Step Days Nights, Weekends, Holidays
Decision to put NICU on Diversion
Program Manager and Medical Lead (or designate) will contact the Neonatal Program Director and Medical Director (or designate) via phone, email, or in person, review NICU status and make the decision to put the NICU on diversion if demand exceeds capacity.
**CNL/Charge Nurse and Neonatologist On Call review NICU status after 0755 huddle and make the decision to put NICU on diversion if demand exceeds capacity, then page Manager On Call (see Appendix B for SBAR tool to guide notification of NICU status). Manager On Call will based upon recommendations put the NICU on diversion.
Send Diversion notification
The Program Director sends out standard BCW NICU on Diversion email to
Manager On Call sends out standard BCW NICU on Diversion email to [email protected] to
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[email protected] to inform CW site and BCW leaders, other Level 3 NICU leaders, Level 2 NICU leaders in Lower Mainland, and Infant Transport Team leader about Diversion Status.
Subject Line: BC Women’s NICU On Diversion
Diversion was initiated at (time and date) due to No NICU Capacity. Exception to infants needing Level 3b/quaternary care.
Updates will be provided later today.
This email goes to the following members: Program Director Mat/Gyne Medical Director Mat/Gyne Medical Leads, Birthing/PP/Antepartum Neonatal Program Director Neonatal Program Medical Director Neonatal Program Managers Mother Baby Care, Medical Lead NICU, Medical Lead All Neonatologists BCW Chief Operating Officer All CW Exec On-Call All BCW Manager On-Call ITT Supervisor All L3 NICU Managers and Directors L2 NICU Managers and Directors in
the Lower Mainland Medical Director for Pediatric and
Neonatology at FHA Chief Operating Officer at FHA FHA MICY Access Coordinators Neonatology Section Head at Island
Health BCCH PICU and Med Surg Program
Managers BCCH Bed Booking
inform CW site and BCW leaders, other Level 3 NICU leaders, Level 2 NICU leaders in Lower Mainland, and Infant Transport Team leader about Diversion Status .
Subject Line: BC Women’s NICU On Diversion
Diversion was initiated at (time and date) due to No NICU Capacity. Exception to infants needing Level 3b/quaternary care.
Updates will be provided later today.
Put Visual Control on Patient eWhiteboard
CNL/Charge Nurse updates the eWhiteboard and posts the RED “Diversion” sign beside the eWhiteboard in Communication
Same as Days process
C-06-16-60873 Published Date: 30-Nov-2020Page 2 of 8 Review Date: 30-Nov-2023
This is a controlled document for BCCH& BCW internal use. Refer to online version. Print copy may not be current. See Disclaimer at the end of the document.
Center.
Notify CNL in LDR, UCC and SRMC will also put up the RED “Diversion” sign in their areas.
Notify Neonatologists in other Level 3 NICU’s of BCW Diversion
Transport/Consult Neonatologist calls other Neonatologists at other Level 3 NICU’s (RCH, SMH, Victoria General Hospital) using SBAR tool (See Appendix C)
Neonatologist On Call calls other Neonatologists at other Level 3 NICU’s (RCH, SMH, Victoria General Hospital) using SBAR tool (See Appendix C)
Key Meetings that are run during diversion and leader attendance
0630 Check In o CNL/Charge Nurse Calls PTN
o Calls to confirm that outstanding transports are still on track.
o Escalate to the Transport Neo to problem solve
0730/1930 Inter-professional Handover Huddle (MFM/OB/FP/MW/Peds On Call)
o CNL/Charge Nurse attendso CNL/Charge Nurse informs
multidisciplinary team that NICU is in Diversion
0755 Huddleo Attended by Normal attendees o +PMo Page NICU ML / MBC ML (or
Peds on Call) if attendance required
o CNL/Charge Nurse identifies NICU on Diversion status
1130 Provincial Bed Utilization Teleconference
o CNL/Charge Nurse informs other NICUs that BCW is on Diversion
1145 Bed Utilization Meetingo Follow BUM Standard Work
0630 Check In o Same as Days process
0730/1930 Inter-professional Handover Huddle (MFM/OB/FP/MW/Peds On Call)
o Same as days process
0755 Huddleo Attended by Normal attendees o CNL/Charge Nurse identifies
NICU on Diversion statuso Notify Manager On Call after
0755 huddle to put NICU on diversion (see Appendix B for SBAR tool to guide notification of NICU status)
1130 Provincial Bed Utilization Teleconference
o Same as Days process
1145 Bed Utilization Meeting
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o Attended by Normal attendeeso + PMo + NICU ML/MBC ML (or Peds
on Call)o PM to notify MD & PD to attend
1600 End of Day Huddleo Review status of planned
transferso Identify reasons for transfer
delayso Develop contingency plan o Attended by on-coming Neo /
transport Neo / Sea & Sky Neos / PM / CNL
2000 Check Ino Neo on service and CNL/Charge
Nurse discuss current bed status and plans for shift (in house or by phone)
o Follow BUM Standard Worko CNL / Neo on-Service
2000 Check Ino Same as Days process
PROCESS WHILE ON DIVERSION
Major Step Days Nights, Weekends, HolidaysUpdate Utilization Status
Program Director and Program Medical Director reviews status with PM/ML to keep NICU on diversion if demand exceeds capacity.
Program Director sends email update to [email protected] as needed.
Manager On Call reviews status with Neonatologist On Call and CNL/Charge Nurse review status to keep NICU on diversion if demand exceeds capacity. CNL/Charge Nurse pages the Manager On Call to notify NICU continues on diversion. Manager On Call sends email update to [email protected] as needed.
TAKING THE NICU OFF DIVERSION
Major Step Days Nights, Weekends, HolidaysUpdate Utilization Status
CNL/Charge Nurse updates Program Manager / Medical Lead who then notify Program Director / Medical Director regarding NICU utilization data.
Program Director makes decision to take NICU off of Diversion.
CNL/Neonatologists on Call page the Manager On Call to recommend NICU come off Diversion.
Notification re: NICU Off Diversion
Program Director sends email to [email protected]
Manager On Call sends email to [email protected]
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Subject Line: BC Women’s NICU Off Diversion
NICU is now off diversion yet remains on surge.
Subject Line: BC Women’s NICU Off Diversion
NICU is now off diversion yet remains on surge.
Remove Visual Control on Patient eWhiteboard
CNL/Charge Nurse updates the eWhiteboard and removes the RED “Diversion” sign.
Notify CNL in LDR, UCC and SRMC to remove the RED “Diversion” sign.
Same as Days process
Notify Neonatologists in other Level 3 NICU’s of BCW OFF Diversion
Transport/Consult Neonatologist to phone Neonatologist at other Level 3 NICU’s (RCH, SMH, Victoria General Hospital) to notify “off diversion”
Neonatologist On Call to phone Neonatologist at other Level 3 NICU’s (RCH, SMH, Victoria General Hospital) to notify “off diversion”
APPENDICES
Appendix A – Diversion standard processAppendix B – Hospital utilization on call communication toolAppendix C – Level 3 Utilization communication tool
Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN16-Nov-2020 C-06-16-60873 Standard Work: Diversion Standard Process: NICU Approved at: Neonatal
Leadership Committee
DISCLAIMERThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.
APPENDIX A: DIVERSION STANDARD PROCESS
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APPENDIX B: NICU Diversion Communication Tool from CNL to Manager On-Call
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S Situation: What is the situation you are calling about?
CNL name: __________________________
“The NICU has been experiencing a surge since (time) and mitigating strategies have not resolved the situation.”
B Background: Pertinent information could include the following
“Current patient demand is _____ (number)”
□ # of L3 beds occupied: _______ □ # of L2 beds occupied: _______
o reasons for deferring transfer/discharge of L2 babies□ # of Rabbit/MBC patients: _______□ # of anticipated admissions: _______ □ # of confirmed discharges: _______ □ # of potential discharges: _______□ # of NICU staff on shift: _______
“Currently NICU is overcapacity with ____ beds available
A Assessment: What is your assessment of the mitigating actions taken thus far?
“I have tried to create bed capacity by:”
□ Discharged/Transferred all potential patients □ Expedite appropriate discharges □ Escalated delays with transferring out to other hospitals□ Escalated delays with discharging to PICU, BCCH wards□ Review possible patients who could transfer to Ladybug□ Review possible NICU patients to transfer to MBC
“I have tried to create staff capacity by:”
□ Review and adjust patient assignments □ Review and adjust RN:patient ratio □ Re-assign available RNs from other pods □ Ensure that calls for additional staff have been made □ Assign Clinical Support Nurses(CSN) to take admissions if needed □ Request leadership to support CNLs, do break relief or take
bedside assignment as needed. Includes CRN, PCE, and Discharge Planning Coordinators.
□ Cancel non CTF preceptorships
R Recommendation: What do I recommend/ request to be done?
“I recommend that we go on Diversion due to:” Overcapacity in L3 NICU No Capacity in MBC Reduced Staffing Levels
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APPENDIX C: LEVEL 3 UTILIZATION COMMUNICATION TOOL
(To be used by the Transport Neo or On-Call Neo to review the status of the hospital with other Level 3 NICU Leaders)
S Situation: What is the situation you are calling about?
Neonatologist name:_________________
“The NICU has been experiencing a surge since (time) and mitigating strategies have not resolved the situation.”
B Background: Pertinent information could include the following
“Current patient demand is _____ (number)”
□ # of L3 beds occupied: _______ □ # of L2 beds occupied: _______
o reasons for deferring transfer/discharge of L2 babies□ # of Rabbit/MBC patients: _______□ # of anticipated admissions: _______ □ # of confirmed discharges: _______ □ # of potential discharges: _______□ # of NICU staff on shift: _______
“Currently NICU is overcapacity with ____ beds available
A Assessment: What is your assessment of the mitigating actions taken thus far? “I have tried to create staff capacity by:”
□ maximizing staff capacity within all aspects of our surge protocol
“I have tried to create bed capacity by:”
□ repatriations, discharges, overflow into the BCW L2 beds □ we are placing BCW NICU on diversion, closing all but 2 non-
refusal beds
R Recommendation: Inquire re the following strategies?
“Are you able to Repatriate/transfer patients to increase L3 capacity Assist us by receiving out of health authority outborn
infants/mothers Bring in additional nurses, including overtime Increase capacity by 3 beds for 3 days
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