p ˝ ˝ ˛ˆ d ˙ ˙˝ ˆ˙: a h˘˙ˇ ˝ ˘˘ ˝ ˘ˆ e ... · • bed master worksheet •...

Patient Surge in Disasters:

A Hospital Toolkit for

Expanding Resources in Emergencies

1st Ed i t ion , Fa l l 2012

Rapid Patient DischargeAssessment Tools

(RPDA)

Health

This publication was supported by Grant Number U3RHS07565 from the Health

Resources and Services Administration. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.

All inquiries about the Patient Surge in Disasters:

A Hospital Toolkit for Expanding Resources in Emergencies may be addressed to: William Lang, MS

c/o NYC Department of Health and Mental Hygiene Office of Emergency Preparedness and Response

42-09 28th Street, 6th Floor CN-22E Queens, NY 11101

Phone: (347) 396-2690 [email protected]

RAPID PATIENT DISCHARGE ASSESSMENT TOOLS

3Fall 2012

Rapid Patient Discharge Assessment Tools

Table of Contents

Project Description........................................................................................................4

General Information Sheet for Bed Management Committee Leader.......................7

General Project Instruction Sheet................................................................................9

Bed Master Worksheet................................................................................................13

Information Sheet for Unit Representatives – Round One......................................14

Patient Care Unit Profile .............................................................................................15

Inpatient Potential Discharge Assessment Profile (IPDAP1 – Med/Surg)..............16

Inpatient Potential Discharge Assessment Profile (IPDAP1 – Critical Care) .........18

Inpatient Potential Discharge Assessment Profile (IPDAP1 – Peds)......................19

Inpatient Potential Discharge Assessment Profile (IPDAP1 – Psych/Detox).........21

Information Sheet for Unit Representatives – Round Two ......................................23

Disaster Scenario ........................................................................................................24

Inpatient Potential Discharge Assessment Profile (IPDAP2 – Med/Surg)..............25

Inpatient Potential Discharge Assessment Profile (IPDAP2 – Critical Care) .........28

Inpatient Potential Discharge Assessment Profile (IPDAP2 – Peds)......................30

Inpatient Potential Discharge Assessment Profile (IPDAP2 – Psych/Detox).........33

Information Sheet for Data .........................................................................................36


4 Fall 2012

Rapid Patient Discharge Assessment (RPDA)

Project Description

Description

With the Rapid Discharge Tool (RDT), the New York City Department of Health and Mental Hygiene (DOHMH) organized and outlined activities that hospitals could engage to effectively discharge patients rapidly and thereby create ready vacant beds for incoming victims of a disaster. In the follow-up Rapid Patient Discharge Assessment (RPDA) pilot project, a rapid discharge exercise was conducted during morning bed management meetings at 6 NYC tertiary hospitals to determine how many inpatient beds could be made available to disaster victims in the immediate phase of an emergency response. On average, hospitals found that 30% of their inpatients could be identified as candidates for potential discharge during normal and rapid discharge reviews. Additionally, the rapidly discharged patients in the post-disaster scenario portion of the exercise showed a greater need for community-based ongoing care than did earlier identified potential discharges. Presumably, if the post-discharge needs of rapidly discharged patients are not met, these individuals could become medically or psychosocially vulnerable, making them likely to return to the hospital in the middle of a response or they would remain in the hospital and continue to be a draw on resources.

Pilot Project Findings Key findings of the pilot project are:

• Many hospitals would be able to generate sufficient capacity to meet the supported, vacant bed needs of most local mass casualty incidents through rapid assessment for transfer or discharge.

• Placement at a community-based care facility was the primary barrier to discharge for patients identified as rapid discharge candidates during RPDA pilot study.

Goals and Objectives Goal

Because census collection activities can be complex, there is a need for gaining a more practical understanding of how hospitals can maximize their rapid patient discharge potential during the immediate and perhaps subsequent phases of a public health emergency. In challenging hospitals to look more closely at how potential discharges are evaluated and how those patients’ post-discharge care needs are met, the goal of the RPDA Project is to provide hospitals and their emergency preparedness planning partners with:


5Fall 2012

o A precise understanding of their rapid discharge potential during a mid-week, morning bed management meeting;

o Detailed awareness of barriers to rapid discharge; o An understanding that some rapidly discharged patients may become medically or

psychosocially vulnerable on discharge; o An understanding of which community-based care providers will help to assure that

above sub-set of rapid discharges does not become vulnerable. Objectives The objectives of the Project are to:

o Capture the number of patient-occupied beds that could be made available to incoming victims of a mass casualty incident;

o Provide a description of each patient identified as a candidate for rapid transfer or discharge (using DOHMH-supplied collection tools).

Exercise Components

RPDA has been designed as a functional exercise that can be folded into an existing bed management (bed board) meeting. The following list of activities was developed from the 2012-13 DOHMH Core Program (ASPR) deliverables guidance document to provide hospital emergency managers with a high level view of the project’s essential components. Actual time needed to complete activity objectives will depend on how these items are adapted to your facility. A. Prior to exercise

1. Submit a daily census report (Wednesday at 9am) to DOHMH approximately two (2) months prior to hospital’s RPD exercise date. Data received will help to inform a component of the exercise and will not be used for any other purpose.

2. Submit name, title and contact information of person leading bed management committee on day of exercise. Shortly after receiving this information, DOHMH will provide hospital emergency preparedness coordinator with the exercise-day toolkit.

B. Day of exercise

1. Convene hospital Bed Management Committee (BMC), or equivalent. [Using a morning bed board meeting would qualify for this activity, assuming that key clinical staff attend]

2. Conduct bed-by-bed census reviews of all patient care units. Floor clinical staff will capture the number of unit-based definite and potential discharges using a DOHMH-provided Inpatient Potential Discharge Assessment Profile (IPDAP).

3. Completed collection tools will be submitted to bed management leader who will capture census detail before handing tools to discharge planners.

4. Discharge planners will review each potential discharge profile to determine feasibility of addressing all identified post-discharge care needs.

C. Post exercise

1. Upon completion of the exercise, hospitals will be expected to develop an After Action Report with Improvement Plan (AAR-IP) encompassing the different components of the exercise, including collection of census data, surge activities, and discharge planning.


6 Fall 2012

2. Within 30 days of the exercise, hospitals will submit to DOHMH completed collection tools and AAR-IP.

Exercise Tools

The original pilot project tools have been updated and streamlined for easier census capture. They have also been significantly improved to provide a more comprehensive picture of rapid discharge candidates (patients) with post-discharge care needs.

The complete set of RPDA forms is as follows: Instruction Sheets

• General Project Instruction Sheet • General Information Sheet for Bed Management Committee Leader • Information Sheet for Unit Representatives – Round One • Information Sheet for Unit Representatives – Round Two

Collection Tools

• Bed Master Worksheet • Patient Care Unit Profile • Inpatient Potential Discharge Assessment Profile (IPDAP1 – Med/Surg) • Inpatient Potential Discharge Assessment Profile (IPDAP1 – Critical Care) • Inpatient Potential Discharge Assessment Profile (IPDAP1 – Peds) • Inpatient Potential Discharge Assessment Profile (IPDAP1 – Psych/Detox) • Inpatient Potential Discharge Assessment Profile (IPDAP2 – Med/Surg) • Inpatient Potential Discharge Assessment Profile (IPDAP2 – Critical Care) • Inpatient Potential Discharge Assessment Profile (IPDAP2 – Peds) • Inpatient Potential Discharge Assessment Profile (IPDAP2 – Psych/Detox)

Miscellaneous

• Project Description • Disaster Scenario • Information Sheet for Data NOTE: RPDA tools and materials are provided for reference only. We strongly recommend that you consult with an expert in bed management/patient-throughput before you begin customizing these forms and designing an RPDA exercise.

Corresponding files of all RPDA exercise tools are available for download at:

http://www.nyc.gov/html/doh//html/em/emergency-surge.shtml


7Fall 2012

Rapid Patient Discharge Assessment

Information Sheet for

Bed Management Committee (BMC) Leader Overview Thank you for participating in the Rapid Patient Discharge Assessment Project! We anticipate this project will enable hospitals to gain a more practical understanding of how they can maximize their rapid patient discharge potential during the immediate and perhaps subsequent phases of a public health emergency. In challenging project participants to look more closely at how potential discharges are evaluated, hospitals will be provided with a unique opportunity to possibly increase their overall rapid patient discharge outcomes and plan appropriately. Potential benefits of working through the RPDA Projects’ deliverables include:

o A more accurate estimate of the number of supported vacant beds that could be yielded by rapidly discharging patients;

o A more accurate description of the population of inpatients that may be considered candidates for rapid patient discharge;

o A clearer understanding of how the rapid patient discharge process will adapt to accommodate surge needs.

o Information on the barriers to discharge your hospital may face, thus allowing more specific emergency planning

This project has been designed to integrate seamlessly into your daily bed management meeting routine. We anticipate, however, that approximately 1-2 additional hours will likely be required to complete the necessary project activities, which include:

• Completion (by each Nurse Manager/Charge Nurse) of a unit-based census form; • Completion (by each Nurse Manager/Charge Nurse) of data capture forms (IPDAP)

for every patient who has been identified as a potential discharge • Completion of Bed Master Worksheet

Timeline

! RPDA activities will be conducted concurrently with daily morning BMC sessions. ! Select one WEDNESDAY to conduct this project. ! Run the drill ! Submit forms for data analysis.


8 Fall 2012

Materials

The following materials/forms will be provided to RPDA Project participants:

! Instructions ! Bed Master Worksheet ! Patient Care Unit Profile Form ! Inpatient Potential Discharge Assessment Profile (IPDAP- 1&2) Forms

Note: Participants will be responsible for printing sufficient copies of all documents (see

instructions sheet). Players involved

• Members of the Bed Management Committee • Unit Representatives • Attending or other physician (for teaching hospitals can be chief resident) with

discharge authority- Needed in Round 2 only • Unit charge nurse- Needed in Round 2 only

See Project Instructions Sheet for next steps


9Fall 2012


Project Instructions Sheet

Preparation Steps:

• Carefully review all documents associated with the RPDA Project.

• Select date for a Wednesday morning Bed Management Committee (BMC)/ Bed Board meeting to conduct this project.

• Provide advance notification to unit management of selected date and inform them that project paperwork will take between 1 to 2 hours to complete, depending upon hospital systems. DO NOT distribute or share any of the RPDA Project forms with unit staff prior to your scheduled RPDA Project BMC meetings.

• Print:

• Prior to printing, type in the hospital name in the header of each document.

• Bed Master Worksheet - one per hospital.

• Patient Care Unit Profile - one form for each patient care unit. • IPDAP-1 Forms:

Print enough forms to cover approximately 20% of current census for each of the following areas:

! Inpatient Potential Discharge Assessment Profile Form 1 Med/Surg (IPDAP-1 Med/Surg)

! Inpatient Potential Discharge Assessment Profile Form 1 Critical Care (IPDAP-1 Critical Care)

! Inpatient Potential Discharge Assessment Profile Form 1 Pediatric (IPDAP-1 Pediatric)

! Inpatient Potential Discharge Assessment Profile Form 1 Psych/ Detox (IPDAP-1 Psych/Detox)

• Information Sheet for Patient Care Unit Representative Round One - one for each patient care unit.

• Information Sheet for Patient Care Unit Representative Round Two - one for each patient care unit.

• IPDAP-2 Forms:

Use appropriate form for unit type, making the same number of copies as you did for the IPDAP-1 forms

! Inpatient Potential Discharge Assessment Profile Form 2 Med/Surg (IPDAP-2 Med/Surg)

! Inpatient Potential Discharge Assessment Profile Form 2 Critical Care (IPDAP-2 Critical Care)


10 Fall 2012

! Inpatient Potential Discharge Assessment Profile Form 2 Pediatric (IPDAP-2 Pediatric)

! Inpatient Potential Discharge Assessment Profile Form 2 Psych/ Detox (IPDAP-2 Psych/Detox)

Activation Steps – Round ONE

The RPDA Project begins once the BMC/Bed Board Meeting is convened:

A. BMC Leader instructs nurse managers/clinical representatives to attend the RPDA Project BMC meeting with their:

o unit census

o identified definite (“confirmed”) discharges

o identified potential discharges

B. BMC/Bed Board meeting begins with clinical representatives from all patient care units:

o Note: PACU, Nursery and Maternity do not need to participate in the exercise, however enter the numbers of capacity and current census on Bed Master Worksheet.

C. BMC Leader explains the project’s goals and requirements to participants (see attached Information Sheet for BMC Leader).

D. BMC Leader distributes and assures completion of a Sign-in Sheet including the following information:

o Staff Name o Department/Unit Name o Title o Signature

E. BMC Leader distributes:

o one (1) Patient Care Unit Profile

o an adequate supply of IPDAP-1 forms (Med/Surge, Critical Care, Pediatric, Psych/Detox) to each patient care unit nurse manager/clinical representative

o one (1) Information Sheet for Patient Care Unit Representative Round One

F. BMC Leader carefully orients unit representatives to the IPDAP-1 forms. Anticipate that extra time may be necessary to gather information. Encourage unit representatives to complete all of the requested information on distributed forms and make them aware that certain questions may require referencing patient charts.

G. Conduct BMC/Bed Board meeting. As the census is reviewed and vacant beds assigned, BMC Leader should capture the numbers on the Bed Master Worksheet.

H. Instruct unit representatives to fill out the Patient Care Unit Profile first, and then the IPDAP-1 forms. It is extremely important that a Patient Care Unit Profile is


11Fall 2012

completed accurately for every unit and an IPDAP-1 form submitted for EVERY identified potential discharge. When completed, all forms are returned to BMC Leader who should review the forms for completion.

Identifying Additional Potential Discharges in a Disaster Scenario – Round TWO

A. After all Round ONE forms have been collected and all unit representatives are present, BMC Leader will read the provided Disaster Scenario aloud to the group.

B. Given the urgent need for vacant beds that the scenario presents, the BMC Leader will challenge unit representatives to emergently identify as many additional patients as possible as potential discharges. Be certain that previously identified patients for potential discharge (i.e. patients for which an IPDAP-1 were filled out and submitted) are NOT included in this round.

C. BMC Leader distributes

o an adequate supply of the IPDAP-2 (Med/Surg, Critical Care, Pediatric, Psych/Detox) forms to unit representatives and instruct them to complete this form for EVERY additional patient they are able to assess as a potential discharge.

o one (1) Information Sheet for Patient Care Unit Representative Round Two

o Anticipate that extra time may be necessary to gather information and encourage unit representatives to complete all of the requested information on distributed forms

D. Completion of IPDAP-2 forms requires the involvement of a physician with discharge authority. Unit representatives are to work with the charge nurse on the unit, the attending physician and any other member involved in discharging patients to identify which patients would be considered for discharge in a disaster scenario. An IPDAP-2 form is to be filled out only for patients who are cleared for discharge by an attending physician given the scenario. NO PATIENTS ARE TO ACTUALLY BE DISCHARGED.

E. BMC Leader instructs unit representatives that if they are unable to identify any additional potential discharges, they should write ‘No Additional Potential Discharges Identified’ on one of the IPDAP-2 forms.

F. BMC Leader collects all IPDAP-2 (Med/Surg, Critical Care, Pediatric, Psych/Detox) forms, while assuring all requested information has been recorded.

G. BMC Leader records on the Bed Master Worksheet the number of potential discharges in a disaster scenario.


12 Fall 2012

H. All forms are reviewed for completeness. Every question should be answered. BMC Leader cross-references the numbers on the Bed Master Worksheet. For each unit, the number in the “confirmed discharges” on the Patient Care Unit Profile should match the number in the column of “Round 1 confirmed discharges” on the Bed Master worksheet. For each unit, the number in the “Round 1 potential discharges” on the Patient Care Unit Profile should match the “Round 1 potential discharges” on the Bed Master Worksheet AND the number of IPDAP-1 forms for that unit. For each unit, the number of “Round 2 potential discharges” should match the number of IPDAP-2 forms for that unit. It the numbers do not match, sort through and reconcile the information.

Check List of items to be submitted for analysis:

" Sign-In sheets " Bed Master Census Worksheet " Printout of the census from the hospital database " Patient Care Unit Profiles - 1 per unit " Completed IPDAP-1 - 1 per each patient initially identified as a potential discharge " Completed IPDAP-2 - 1 per each additional patient identified as a potential discharge

during the disaster scenario


13Fall 2012

RRoouunn

dd 22

Unit

Nam

eCa

pacit

yCu

rrent

Cen

sus

Confi

rmed

D/C

's P

oten

tial D

/C's

Pot

entia

l D/C

's

Tota

l (In

patie

nt)

Num

ber o

f Pat

ient

s in

the

ED w

aitin

g fo

r a b

ed: _

____BBee

dd MM

aassttee

rr WWoorr

kksshhee

eett ffoo

rr RRaapp

iidd DD

iisscchhaa

rrggee RRoo

uunndd

11


14 Fall 2012

Rapid Patient Discharge Assessment (RPDA) Project


Patient Care Unit Representatives

Thank you for participating in the Rapid Patient Discharge assessment. We know your time is valuable. Please know that the information collected here will be directly used to plan for the care of patients in the event of a public health emergency that requires surge beds. Patient Care Unit Profile

• One form to be filled out per unit. IPDAP-1

• One form for every patient on the unit considered a potential discharge • The number of forms should equal the number of “potential discharges” on the patient

care unit profile • All questions are to be answered • Each form will take 3-5 minutes to fill out • If you are on a critical care unit, fill out IPDAP-1 Critical Care • If you are on a pediatric unit, fill out IPDAP-1 Pediatric • If you are on a psych or detox unit, fill out IPDAP-1 Psych/Detox • All other units use the IPDAP-1 Med/Surg IPDAP-1 form


15Fall 2012


Patient Care Unit Profile

Hospital Name: __________________________ Date: ____________________

Unit Name: ______________________________

(Note: on following forms, please be consistent and fill in the unit name as you listed here)

First Name of person filling out this form: ___________________________

Title (e.g., Nurse manager): ___________________________

Unit Type (choose most specific type):

! Medical

! Surgical

! Pediatric

! Cardiology only

! Psychiatric

! Oncology only

! Neurology only

! Chemical Detox

! Physical Rehab

! Hospice or Palliative Care

! Step down (any type)

Critical Care

! Medical CCU

! Surgical CCU

! Cardiac CCU

! NICU

! Other (specify):

____________________

CENSUS

• Total Number of patients currently on the unit: ________

• Number of identified confirmed discharges (except critical care*): _______

*If critical care, number of potential downgrades: _______

• Number of identified potential discharges (except critical care): ________

Return Completed Form to Bed Management Committee Leader


16 Fall 2012

Hospital Name:____________________________

Confidentiality: All data collected will be kept confidential and presented in aggregate form. Please do not include patient name on this form.

Inpatient Potential Discharge Assessment Profile (IPDAP-1) Form 1 Med/Surg

Unit Name: _________________________________

Patient information

Bed number: ______________

MRN: ___________________ (for possible future reference)

Sex: Female Male

Age:_________

Primary diagnosis (Check the one that most specifically describes reason for patient stay.)

Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant

Hospice or Palliative Care

Trauma

Infectious Diseases, incl. TB

Other (specify):

_______________________

Is this patient Homeless? No Yes Unknown

ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : ________________________________

nt l iantePot egrahcsiD

____________________________

__

elifor Ptt Pnemssess Ae

_________

I ( P PDA -1) mro F M 1

gruS/de

_____

oitamroffon itneitaP

rebmu ndBe

MRN: ____ __

x: Se aFem

eAg :_________

_ ____

_______________

no

r: ___ ___________

_____________ ____ osporffor(

e la Male

:_________

ecnereffeererutufelbisos

)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN

(C kche osmtahteoneht

y

ebircsedy llacificepstos

s atstneitaporfoonsaer

ynG/BO

tnalpsnaTr

CveitaillaPoreciposH

amuaTr

y.)

era

yogolcnO

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________

ni,sesaesiDsouitceffeIn

rheOt (s yiffycpe ):

_______________________

TB.lcn

_______________________

tneita psih tsI

sselemo H ? o N

se Y nowknnU

y:tilaitnedifonC adllAemantneitapedulcni

pkeeblliwdetcelolcata.morfforsihtone

tp eserpdnalaitnedifonc

morfforetagergganidetne

otno desaelP.m


17Fall 2012

Hospital Name:____________________________


Is lab work or lab work results required before discharged? Yes No Unknown

Is an imaging study or radiology results required before discharged? (e.g. CT, echocardiogram, X-rays, etc.)

Yes No Unknown

Are meds from pharmacy needed before discharge? Yes No Unknown

Are discharge orders currently written OR is a completed intend to discharge form in the patient’s chart? IF No, Is the patient’s attending physician available to write the discharge order at this moment?

Yes No Unknown

Yes No Unknown

Are prescriptions for after care available now? Yes No Unknown

Is a specialist consult required prior to discharging this patient? Yes No Unknown

Does patient education require greater resources in time beyond the typical discharge instructions? (e.g. diabetes care)

Yes No Unknown

Does this patient have a functional disability (e.g. wheelchair bound, vision or hearing impairment) that requires special arrangements on discharge?

Yes No Unknown

Is patient clothing available now? Yes No Unknown

Is there a language barrier that would require an interpreter? Yes No Unknown

The transportation required for this patient to leave the hospital is:

IF family/ friend picking up, has that person already been notified?

IF ambulance, have arrangements already been made?

pt can leave on their own pt needs assistance of

family/friend pt requires ambulance

Yes No Unknown

Yes No Unknown

Is this patient being transferred to a care facility upon discharge?

If YES, type of facility?

Yes No Unknown

IF YES only: Nursing home/ LTCF Physical Rehab facility Halfway house Substance Abuse Rehab Shelter bed Hospice bed Other, specify _______

Is Home Health Care/ Visiting Nurse Service needed for this patient? Yes No Unknown

ema NlatipsoH

e:____________________________

____________________________

alork orwbalIs

utsgnigaminaIs(e. aochceT,C.g

pomrfsdemerA

oregrahcsiderAgeharrgecchardissc nimorffor

deriuqerstluserk orwb

stlusery ogolidarory duX,marogidr - cte,ysar .)

eorfforebdedeeny camrahp

Onettirwy ltnerrucsred?trahcs’tneitapehtn

?degrahcsideorfforeb

ahcsideorfforebderiuqer

?egrahcside

detelpomcasiRO dneentteniin

Yes o N

?degr Yes o N

Yes o N

o tto d Yes o N

o nowknnU

o nowknnU

o nowknnU

o nowknnU

ge

apehtIso,NIFegrahcsid

sonitpircserperA

onctsilaicepsaIs

udetneitapsoeDhidlit

p

ciyshpgnidnettas’tneita?tneommsihttaredore

elbalivaaeracretfftaorffors

do torirpderiuqertluson

retaergeriuqeronitacuti (?it diabe

htetirwo telbalivaanaic?

?owne

?tneitapsihtgnigrahcsid

yonebemitnisecrousert diabe )

ehYes o N

Yes o N

? Yes o N

ehtdyon Yes o N

o nowknnU

o nowknnU

o nowknnU

o nowknnU

egrahcsidlaciypttneitapsihtsoeD

gniraehoronisvi?geharcdis

nihotlctneitapIs

augnalaerehtIs

onitatorpsnarteTh

tsnie e(?sonitcur .g. diabeasidlaonitcnufaveahtuqertaht)tnemriapmig

?ownelbalivaagn

rdlouwtahtreirrabega

itapsihtorfoderiuqeron

ear cset diabe )e(y tilib . briahcleehw.g

nemegnarralaicepsseri

?reterpretninaeriuqer

atiposhehtveaelo ttne

,dnoubonstn

Yes o N

Yes o N

Yes o N

:sila aelnactp

o nowknnU

o nowknnU

o nowknnU

nowriehtonvea

dneirfy/limafaIF

,ecnalubmaIF

ebtneitapsihtIs

ptahtsah,pugnkicipd

erlastnemegnarraveah

racao tderreffesnartgnie

otnneeby daerlaonsrep

?edamneeby dae

grahcsidonpuy tilicaffaer

i ?deifiot

sdeentpdneirfy/limaffaequire rpt

Yes o N

Yes o N

?eg Yes o N

ofecnatsissad

e ambulancse

o nowknnU

o U nowknn

o nowknnU

ofeypt,ESYIf

y?tilicaffaof

y:lonESYIFgnisruNlaciyshPy awfwlaH

bstanSurelthe SeciposH

FTCLT/eomhytilicaffabaheR

esouhy abehRse buAce

d bedebe

y:tilaitnedifonC Aapedulcniotno d

htlaeHeomHIs

eblliwdetcelolcatadllAmorfforsihtonemantneita

reSesruNgnitisiV/eraC

tpkee pdnalaitnedifonc.m

apsihtorffordedeenecvir

etagergganidetneserp

s,rehtO

?tneit Yes o N

esaelP.morffor

_______________y ffy iceps

o nowknnU

IMPORTANT – Answer ALL Questions


18 Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-1) Form 1 Critical Care

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________

Primary diagnosis (check the one that most specifically describes reason for patient stay):

Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________


This patient can be transferred to: Step-Down Unit

Med/ Surg

Other (specify) ____________________

ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : ________________________________

l iantePot AegrahcsiD

____________________________

__

elifor Ptnemssess A (

_________

IP PDA -1) mro F 1 irC

era Clacit

_____


rebmu ndBe

MRN: ____ __

x: Se aFem

eAg :_________

_ ____

_______________

no

r: ___ ___________

_____________ ____ osporffor(

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN

(c kche osmtahteoneht

y

sebircsedy llacificepstos

s y)atstneitaporfoonsaer

ynG/BO

tnalpsnaTr


amuaTr

y):

era

yogolcnO

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________

tneita psih tsI

a ctneita psihT

sselemo H ? o N

:o tderrefsnar te bna

se Y nowknnU

pet S - tinUnowD

g ur Sd/ Me

heOt (s if )


lliwdetcelolcata pkeeb.morfforsihtone

eserpdnalaitnedifonctp

rheOt (s yiffycpe ) ____________________


____________________

otno desaelP.m


19Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-1) Form 1 Pediatric

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________


Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________

ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : ________________________________

nt l iantePot egrahcsiD

____________________________

__

elifor Ptnemssess Ae

_________

e I ( P PDA -1) mro F 1 Pe

icrtdiaPe

_____


rebmu ndBe

MRN: ____ __

x: Se aFem

eAg :_________

_ ____

_______________

no

r: ___ ___________

_____________ ____ osporffor(

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN


y



ynG/BO

tnalpsnaTr


amuaTr

y):

era

yogolcnO

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________



tp eserpdnalaitnedifonc


otno desaelP.m


20 Fall 2012

Hospital Name:____________________________




Yes No Unknown



Yes No Unknown

Yes No Unknown



Does patient education for family require greater resources in time beyond the typical discharge instructions? (e.g. diabetes care)

Yes No Unknown


Yes No Unknown




pt needs assistance of family/friend

pt requires ambulance

Yes No Unknown

Yes No Unknown



Yes No Unknown



Parents or other caretakers are available to meet the care needs of the child at home

Yes No Unknown

ema NlatipsoH

e:____________________________

____________________________

alork orwbalIs


pomrfsdemerA




dedeeny camrahp eorfforeb




?egrahcside


Yes o N

?degr Yes o N

Yes o N

o tto d Yes o N

o nowknnU

o nowknnU

o nowknnU

o nowknnU

ge


sonitpircserperA

onctsilaicepsaIs

udetneitapsoeDithtdb

p

ciyshpgnidnettas’tneita?tneommsihttaredore


tluson do torirpderiuqer

onitacu ylimaffaorffor riuqerittihidl

etirwo telbalivaanaic he t?

?owne


tnisecrouserretaerger(? dia tbe )

heYes o N

Yes o N

? Yes o N

emit Yes o N

o nowknnU

o nowknnU

o nowknnU

o nowknnU

y ciyptehtdyonebtneitapsihtsoeD


onitatorpsnarteTh

onitcurtsniegrahcsidlacasidlaonitcnufaveahtuqertaht)tnemriapmig


e(?son .g. dia ear csetbe )e(y tilib . briahcleehw.g



,dnoubonstn

Yes o N

:sila sdeentpdneirfy/limaffaequire rpt

o nowknnU

ofecnatsissad

e ambulancse

dneirfy/limaffaIF

,ecnalubmaIF

ebtneitapsihtIs

ofeypt,ESYIf

ptahtsah,pugnkicipd



y?tilicaffaof


?edamneeby dae

er grahcsidonpuy tilicaffa

i ?deifiot Yes o N

Yes o N

?eg Yes o N

y:lonESYIFgnisruNlihP

o nowknnU

o nowknnU

o nowknnU

FTCLT/eomhtilifbhR

htlaeHeomHIs



laciyshPy awfwlaH

bstanSubedter elSh

eciposHs,rehtO

?tneit Yes o N

ytilicaffabaheResouhy

abehRse buAce bed

deb_______________y ffy iceps

o nowknnU


rehotorstneraPeomhtadlihceht

eblliwdetcelolcatadllAmorfforsihtonemantneita

elbalivaaerasrkeaterace

tpkee pdnalaitnedifonc.m

deeneracehtteemo te


ofsd Yes o N

esaelP.morffor

o nowknnU



21Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-1) Form 1 Psych/Detox

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________


Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________


ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : ________________________________

l iantePot AegrahcsiD

____________________________

__

elifor Ptnemssess A I (

_________

IP PDA -1) mro F 1 yPs

oxtch/Dey

_____


rebmu ndBe

MRN: ____ __

x: Se aFem

eAg :_________

_ ____

_______________

no

r: ___ ___________

_____________ ____ osporffor(

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN


y



ynG/BO

tnalpsnaTr


amuaTr

y):

era

yogolcnO

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________

tneita psih tsI

sselemo H ? o N

se Y nowknnU


lliwdetcelolcata pkeeb.morfforsihtone



otno desaelP.m


22 Fall 2012

Hospital Name:____________________________




Yes No Unknown



Yes No Unknown

Yes No Unknown



Does patient education require greater resources in time beyond the typical discharge instructions? (e.g. diabetes care)

Yes No Unknown


Yes No Unknown

Is patient clothing readily available now? Yes No Unknown







Yes No Unknown

Yes No Unknown



Yes No Unknown



ema NlatipsoH

e:____________________________

____________________________

alork orwbalIs


pomrfsdemerA




eorfforebdedeeny camrahp




?egrahcside


Yes o N

?degr Yes o N

Yes o N

o tto d Yes o N

o nowknnU

o nowknnU

o nowknnU

o nowknnU

ge


sonitpircserperA

onctsilaicepsaIs

udetneitapsoeDhidlit

p

ciyshpgnidnettas’tneitaaredore ?tneommsihtt



retaergeriuqeronitacu(?itti dia

htetirwo telbalivaanaic?

?owne


yonebemitnisecrousertbe )

ehYes o N

Yes o N

? Yes o N

ehtdyon Yes o N

o nowknnU

o nowknnU

o nowknnU

o nowknnU

egrahcsidlaciypttneitapsihtsoeD


nihotlctneitapIs

augnalaerehtIs

onitatorpsnarteTh

e(?sonitcurtsnie .g. diaasidlaonitcnufaveahtuqertaht)tnemriapmig

ownelbalivaay lidaergn

rdlouwtahtreirrabega


ear csetbe )e(y tilib . briahcleehw.g


?ow

?reterpretninaeriuqer


,dnoubonstn

Yes o N

Yes o N

Yes o N

:sila aelnactp

o nowknnU

o nowknnU

o nowknnU

nowriehtonvea

dneirfy/limaffaIF

,ecnalubmaIF

ebtneitapsihtIs

ptahtsah,pugnkicipd




?edamneeby dae

grahcsidonpuy tilicaffaer

i ?deifiot

sdeentpdneirfy/limaffaequire rpt

Yes o N

Yes o N

?eg Yes o N

ofecnatsissad

e ambulancse

o nowknnU

o nowknnU

o nowknnU

ofeypt,ESYIf

y?tilicaffaof

y:lonESYIFgnisruNlaciyshPy awfwlaH

bstanSurelthe SeciposH

FTCLT/eomhytilicaffabaheR

esouhy abehRse buAce

d bedebe


htlaeHeomHIs

lliwdetcelolcatadllA ebmorfforsihtonemantneita


pdnalaitnedifonctpkee.m



s,rehtO

?tneit Yes o N

esaelP.morffor

_______________y ffy iceps

o nowknnU



23Fall 2012



Patient Care Unit Representatives

Thank you for participating in the Rapid Patient Discharge assessment. We know your time is valuable. Please know that the information collected here will be directly used to plan for the care of patients in the event of a public health emergency that requires surge beds.

Below to be distributed only AFTER disaster scenario is read IPDAP-2

• One form for every patient on the unit identified as a potential discharge in the event of a disaster.

• If a patient is accounted for in “potential discharges” in Round 1 IPDAP-1, do NOT fill in an IPDAP-2 form for that patient.

• For IPDAP-2, a physician will be required to participate in this project. Please consult with your unit team that would make rapid discharge decisions in the event of a disaster. An attending physician, or physician with discharge authority, will have to initial the IPDAP-2 form under the medical clearance section.

• If you are on a critical care unit, fill out IPDAP-2 Critical Care • If you are on a pediatric unit, fill out IPDAP-2 Pediatric • If you are on a psych or detox unit, fill out IPDAP-2 Psych/Detox • All other units use the IPDAP-2 Med/Surg form • DO NOT DISCHARGE PATIENTS AS PART OF THIS DRILL.

Thank you!


24 Fall 2012

Rapid Patient Discharge Assessment (RPDA)

Disaster Scenario

A residential building collapsed nearby at 9:05am. EMS advises approximately 150 seriously injured survivors, including children, will be heading to your hospital within the next hour. For the purpose of this exercise, this committee is tasked with identifying the maximum number of vacant inpatient beds that can be obtained immediately via rapid patient discharge activities. Note, this exercise is not concerned with obtaining beds through capacity expansion for the longer term.


25Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-2) Form 2 Med/Surg DISASTER SCENARIO

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________


Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________


ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : _________________________________

nt l iantePot egrahcsiDD

: _________________________________

elifor Ptt Pnemssess AeO IRANEC SRETSASID

: _________________________________

PADPI ( -2 M 2mro F)O

gruS/de

________


rebmu ndBe

MRN ______:

x: Se aFem

eAg :_________

__________________

no

r: ______________

osporffor(______________

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN

(c osmtahteonehtk ceh

y

edy llacificepstos sebircs

yatstneitaporfoonsaers

ynG/BO

tnalpsnaTr


amuaTr

y):

era

On yogolc

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________

mo Htneita psih tsI

sselem ? o N e Y

se nowknnU


detcelolcata pkeeblliw.morfforsihtone



otno desaelP.m


26 Fall 2012

Hospital Name:____________________________


Would lab work or lab work results be required before discharged? Yes No Unknown

Would an imaging study or radiology results be required before discharged? (eg. CT, echocardiogram, X-rays, etc.)

Yes No Unknown

Would meds from pharmacy be needed before discharge? Yes No Unknown

Is there a completed intend to discharge form in the patient’s chart? IF No, Is the patient’s attending physician available to write the discharge order at this moment? IF patient’s attending physician is not available now, is there another physician with discharge authority who could write DC orders?

Yes No Unknown

Yes No Unknown

Yes No Unknown


Would a specialist consult required prior to discharging this patient? Yes No Unknown

Would patient education require greater resources in time beyond the typical discharge instructions? (e.g. diabetes care)

Yes No Unknown

Does this patient have a functional disability (e.g. wheelchair bound, vision or hearing impairment) that will require special arrangements on discharge?

Yes No Unknown

If patient’s clothing was destroyed, is clothing available now? Yes No Unknown


If this patient was to be emergently discharged, the required transportation would be:



Would the patient’s ability to independently perform daily tasks on their own be a concern if emergently discharged?

Yes No Unknown

Would this patient be transferred to a care facility upon discharge?


Yes No Unknown

IF YES only: Nursing home/ LTCF Physical Rehab facility Halfway house Shelter bed Hospice bed Other, specify _______

Would Home Health Care/ Visiting Nurse Service be needed for this patient if emergently discharged?

Yes No Unknown

Would a social worker need to be consulted before discharge? Yes No Unknown

ema NlatipsoH :____________________________

____________________________

____________________________

balrokrowbaldluWo

utsgnigaminadluWo,TC.g(e rgoidracohc e

ahpmorfsdemdluWo

dteelpmocareethIs

eriuqerebstluserkrowb

bstluserygoloidarroydu, Xmar - tce,syra .)

eroffoebdedeenebycamra

ottodnettein eharrgeccharsdiis mro f oge

?degrahcsiderofoebde

ahcsideroffoebderiuqereb

?egrahcside

?trah cs’tneita peh tn im

sYe No

?degra sYe No

sYe No

sYe No

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

dteelpmocareethIs

st’netiapethIs,oNIFredr oegrahcsi dgnidntteast’netiapIF dhti wnaicisyh profosnoitpircserpeAr af

noctsilaicepsadluWo

ottodnettein e harrgeccharsdiis mro f oge

avanaicisyhpgnidntteas?tnemo msih tt a

lbaliavat onsinaicisyhp aegrahcsi d cho wytihorut

?wnoeabllavaiearcretafft

sidotroirpderiuqertlusn

?trah cstneita peh tn im

ethteriwtoelbalia

r ethonareethsi,wone?sderorCDe tirwd oulc

?

?tneitapsihtgnigrahcs

sYe No

sYe No

sYe No

sYe No

sYe No

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

p

tacudetneitapdluWotnsige harcsdi snoticru

sihtseDo e haventipatt)entmrpaiming ihear

wgnitholcst’netiapIf

begaugnalareethIs

tosawt netiapsithIf

pq

uoserretaergeriuqernoit(e?s ..g era csetebai d )

(ytilabisdionalituncfa e aralipecse requirlliwhatt

tholcsi,deytrosedsaw gin

reiuqredluowt athr erriab

ergahcsidytlnergemeeb

pgg

ehtdnoyebemitnisecru

e. vbound,rhaicheelwg.harcsdion sentangemrar

?wonlebilaavag

r?tererpteninare

rtaopsntradreiuqreethde

lacipyte sYe No

oron isivge?

sYe No

sYe No

sYe No

notirta eavlan cpt

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

nowrheiton e eav

tosawt netiapsithIf:ebdluwo

as’tneitapehtdluWogenteremfin eroncca be ebtneitapsihtdluWo

ca f aff oepy, tSE Yff I


epyltnednepedniotytilibged?harcsdiylgent

caffaeracaotderrefesnart

?ytilic

rtaopsntradreiuqreeth,de

ehtnosksatyliadmrofore

?egrahcsidnopuytilic

notirta eavlan cptneedspt

neifr/yylimfarequirpt

nworie sYe No

sYe No

ylnoSEYIF

nowrheiton e eavofe anctsisas

deancbulames

No nwonkUn

No nwonkUn

:y

ca f aff f oepy, tSE Yff Y I

ChtlaeHemoHdluWo

?ytilic

vreSesruNgnitisiV/eraC

apsihtroffodedeenebeciv

ylnoSEYIFgnisrNuacisyPhyawffwlHa

ertelShecipsHo

rehOt , s

fitneita sYe No

:yFCTL/emohg

ytilicaffabaehRlaesuohy

edbdebe

______ _yffyicep, s

No nwonkUn


ChtlaeHemoHdluWoged?rhacsdiylgenteremekrowlaicosadluWo


vreSesruNgnitisiV/eraCged?

bdetlusnocebotdeenr


apsihtroffodedeenebeciv

?egrahcsideroffoeb


fitneita sYe No

sYe No

otno desaelP.m

No nwonkUn

No nwonkUn



27Fall 2012

Hospital Name:____________________________


Please check off ALL the concerns/ considerations for discharging this patient in the event of a

disaster:

This patient is medically stable, but remains in the hospital to manage non-life threatening symptoms such

as nausea, weakness, or minor pain. Patient could be discharged in the event of a disaster

If patient could be provided sufficient pain management, patient could be discharged

IV antibiotics could be changed to PO

Postpone procedure, including elective surgery

Outpatient follow up would be sufficient (i.e. monitoring by PCP and lab testing)

If hemodialysis was arranged, patient could be discharged

Once patient voids and/or eats post-op, patient could be discharged

If physical therapy or physical rehab was arranged, patient could be discharged

If mobility issues were addressed, patient could be discharged

Finding follow up care an issue because this patient’s immigration status

Concern this patient may refuse to be discharged

If social issues were attended to, patient could be discharged

please explain _________________________________________________

Other, specify ___________________________________

Medical sign-off by attending physician

In the event of a disaster, the above patient would be considered for rapid discharge. Initialing below

indicates that you, a physician with discharge authority, have assessed this patient as part of the drill and

consider this patient to be medically/clinically stable for discharge either to home or a care facility. THE

DRILL DOES NOT REQUIRE YOU TAKE STEPS TO DISCHARGE THIS PATIENT.

Initials: _______

ema NlatipsoH :____________________________

____________________________

____________________________

ffff okk oceh cesaelP AL

retsasdi :

emsitneitapsiTh

kn

LAL no c/snrecno ceh t

y llacide amertub,elbats

ii tPati

hcsi dro f fosnoitaredisn

amo tlatiposhehtnisni

t idhidbdl

ita psih tgnigrah itne

egana onn - netaerhteffeil

tidoftht

aff a otnev eeh tn

hcussomtpymsgnin

sseknaew,aesuansa

ebdlouctneitapIf

loucsciotibitnaIV

udeocrpeonptosP

owlolfotneitaptuO

hIf siyslaiodme aw

,s or niapornim . tenPati

aptneiciffffusdedovirpe i

degnahcebd OPo t

usveitcelegnidulcni,eru

tneiciffffusebdlouwpu (i

ouctneitap,degnarrasa

t c nidegrahcsidebdlou

tneitap,tnemeganamni

yregru

(i.e. PCPy bgniortionm

degrahcsidebdlou

retsasidaoftnveeehtn

degrahcsidebdlouct

gnitsetbaldna )

r

y

sdvoitneitapecnO

pIf yparehtlaciysh

mIf seussiy tiliob w

puowlolfognidniF

eitapsihtnreconC

sIf seussilaioc ew

tospstaeor/dnas - p,op

y sawbaherlaciyshpor

neitap,desserddaerew

tesuacebeussinaerac

sidebo tesufery amtne

tneitapo,tdednettaere

rahcsidebdlouctneitap

dlouctneitap,degnarra

degrahcsidebdlouct

onitargimmis’tneitapsiht

degrahcs

degrahcsidebdlouc

degr

degrahcsidebd

sutatson

____

sIf seussilaioc ew

xplain _______________________ eeasple

___y ffy iceps,rehtO

ngi slacideM - y bff bfffo

asidaoftnveeehtIn

hatindic

__________________________


xplain _______________________

____________________

y naicisyh pgnidnetta

tneitapovebaeht,retsa

hdhh

_

__________________

degrahcsidebdlouc

__________________________ ______

______________

n

fderedisoncebdlouwt

hh

__________________________

tiIn.egrahcsiddiparorfo

hd

owlebgnilait

dlldhof

________

hat tseatindic a,you

tneitapsihtredisonc

EQRT ONESODLILRD

_______:slaitiIn

grahcsidhtiwnaiciyshp

/llacidemebo t calini/cly

TEPSE KTAUOYE IRUEQ

sessaveahy,tiorhtuaeg

yl eegrahcsidorfforelbats

EGRAHCISDTOSTEP ISTH

trapsatneitapsihtdess

eracaoreomho trehtie

T.TIENAATIENPIS

dnallirdehtoft

y.tilicaffae E TH





otno desaelP.m


28 Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-2) Form 2 Critical Care DISASTER SCENARIO

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________


Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________


This patient can be transferred to: Step-Down Unit

Med/ Surg

Other (specify): _____________________

ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : _________________________________

l iantePot AegrahcsiDD

: _________________________________

elifor Ptnemssess A (O IRANEC SRETSASID

: _________________________________

PADPI -2 2mro F) irCO

era Clacit

________


rebmu ndBe

MRN ______:

x: Se aFem

eAg :_________

__________________

no

r: ______________

osporffor(______________

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN


y

edy llacificepstos sebircs

yatstneitaporfoonsaers

ynG/BO

tnalpsnaTr


amuaTr

y):

era

yogolcnO

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________

mo Htneita psih tsI

e bna ctneita psihT

sselem ? o N e Y

:o tderrefsnar te

se nowknnU

pet S - tinUnowD

g ur Sd/ Me




g d/

(srheOt yiffycpe ): _____________________


_____________________

otno desaelP.m


29Fall 2012

Hospital Name:____________________________



In the event of a disaster, the above patient would be considered for rapid discharge, or for CCU to be

transferred to a less acute care unit. Initialing below indicates that you, a physician with discharge authority,

have assessed this patient as part of the drill and consider this patient to be medically/clinically stable for

discharge either to home or a care facility. THE DRILL DOES NOT REQUIRE YOU TAKE STEPS TO

DISCHARGE THIS PATIENT.

Initials: _______


30 Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-2) Form 2 Pediatric DISASTER SCENARIO

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________

Primary diagnosis (Check the one that most specifically describes reason for patient stay.)

Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________

ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : _________________________________

nt l iantePot egrahcsiDD

: _________________________________

elifor Ptnemssess AeO IRANEC SRETSASID

: _________________________________

e PADPI ( -2 2mro F) PeO

icrtdiaPe

________


rebmu ndBe

MRN ______:

x: Se aFem

eAg :_________

__________________

no

r: ______________

osporffor(______________

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN

osmtahteonehtk cehC(

y

ebircsedy llacificepstos

atstneitaporfoonsaers

ynG/BO

tnalpsnaTr


amuaTr

)y.

era

On yogolc

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________





otno desaelP.m


31Fall 2012

Hospital Name:____________________________



Would an imaging study or radiology results be required before discharged? (e.g. CT, echocardiogram, X-rays, etc.)

Yes No Unknown



Yes No Unknown

Yes No Unknown

Yes No Unknown



Would patient education for family require greater resources in time beyond the typical discharge instructions? (e.g. diabetes care)

Yes No Unknown


Yes No Unknown







Yes No Unknown



Yes No Unknown

IF YES only: Skilled Nursing facility Physical Rehab facility Other, specify _______


Yes No Unknown


Parents or other caretakers are available to meet the care needs of the child at home

Yes No Unknown

Social Services (e.g. ACS) involvement is required Yes No Unknown

lapitHos ema N :____________________________

____________________________

____________________________

balrokrowbaldluWo

utsgnigaminadluWo(e. ogrdiarhocec,TCg.

ahpmorfsdemdluWo

dteelpmocareethIs

eriuqerebstluserkrowb

bstluserygoloidarroyduX,amogr - tce,syra .)

eroffoebdedeenebycamra

egrrgahcchisddisottodnettein mro f oe

?degrahcsiderofoebde

ahcsideroffoebderiuqereb

?egrahcside

?trah cs’tneita peh tn im

sYe No

?degra sYe No

sYe No

sYe No

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

dteelpmocareethIs

st’netiapethIs,oNIFredr oegrahcsi dgnidntteast’netiapIF dhti wnaicisyh parofosnoitpircserpeAr

noctsilaicepsadluWo

e grrgahcchisddisottodnettein mro f oe

avanaicisyhpgnidntteas?tnemo msih tt a

lbaliavat onsinaicisyhp coh wytirohtu aegrahcsi d?wonelbaliavaeracretffta

sidotroirpderiuqertlusn

?trah cstneita peh tn im

ethteriwtoelbalia

r ethonareethsi,wone?sredr oC Detir wdluo c

?

?tneitapsihtgnigrahcs

sYe No

sYe No

sYe No

sYe No

sYe No

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

p

tacudetneitapdluWoergahcsidlaciptyeth

evahtneitapsihtseDot)entmrpaiming iheararegnitholct netiapIs

begaugnalareethIs

tosawt netiapsithIf

pq

noit ylimfarfo regreiuqretsni (e?snoticru .g. ebai dfae (ytilabisdionalitunc

aralipecse requirlliwhatt?wonelbaliavaylida

reiuqredluowt athr erriab


pgg

bemtinisercuosrer teareera csete )

e. vbound,rhaicheelwg.harcsdion sentangemrar

r?tererpteninare

rtaopsntradreiuqreethde

dnoyeb sYe No

oron isivge?

sYe No

sYe No

sYe No

notirta eavlan cpt

No nwonkUn

No nwonkUn

No nwonkUn

No nwonkUn

nowrheiton e eav

tosawt netiapsithIf:ebdluwo

as’tneitapehtdluWogenteremfin eroncca be ebtneitapsihtdluWo

ca f aff oepy, tSE Yff I


epyltnednepedniotytilibged?harcsdiylgent

caffaeracaotderrefesnart

?ytilic

rtaopsntradreiuqreeth,de

ehtnosksatyliadmrofore

?egrahcsidnopuytilic

notirta eavlan cptneedspt

neifr/yylimfapt riuqe r

nworie sYe No

sYe No

ylnoSEYIF

nowrheiton e eavofe anctsisas

decnalubm ase

No nwonkUn

No nwonkUn

:y

ca f aff f oepy, tSE Yff Y I

ChtlaeHemoHdluWoged?rhacsdiylgenteremekrowlaicosadluWo

etracerhotorstenrPa

?ytilic

vreSesruNgnitisiV/eraCged?

bdetlusnocebotdeenr

mo te lbaliavae raserkaet

psihtroffodedeenebeciv at

?egrahcsideroffoeb

htofseedne race hteetm

ylnoSEYIFedlliSk

acisyPhs,rehOt

finteiat sYe No

sYe No

dlihce sYe No

:yytilicafagnisruNytilicaffabaehRla_______yffyiceps

No nwonkUn

No nwonkUn

No nwonkUn


etracerhotorstenrPaemhoat

ACS).ge.(escivSerlaiSoc


mo te lbaliavae raserkaet

ueqrsitenemvolvniACS)


htofseedne race hteetm

edriu


dlihce sYe No

sYe No

otno desaelP.m

No nwonkUn

No nwonkUn



32 Fall 2012

Hospital Name:____________________________



disaster:




IV antibiotics could be changed to PO

Postpone procedure, including elective surgery

Outpatient follow up would be sufficient, (i.e. monitoring by PCP and lab testing)

If hemodialysis was arranged, patient could be discharged

Once patient voids and/or eats post-op, patient could be discharged

If physical therapy or physical rehab was arranged, patient could be discharged

If mobility issues were addressed, patient could be discharged


Concern parent/guardian may refuse discharge

Concern that parent or caretaker cannot meet the needs of the child


please explain _________________________________________________

Other, specify ___________________________________






Initials: _______

lapitHos ema N :____________________________

____________________________

____________________________

Aff Afff okk oceh cesaelP

retsasdi :

emsitneitapsiTh

kn

no c/snrecno ceh tLL A


ii Pati

ro f fosnoitaredisn hcsid


t idhidbdl



tidoftht

aff a otnev eeh tn

hcussomtpymsgnin

sseknaew,aesuansa

ebdlouctneitapIf

loucsciotibitnaIV

udeocrpeonptosP

owlolffoltneitaptuO

hIf siyslaiodme aw

,s or niapornim . enPati

ptneiciffffusdedovirpe ia

degnahcebd OPo t

usveitcelegnidulcni,eru

tneiciffffusebdlouwpu , (i

ouctneitap,degnarrasa

ct en idegrahcsidebdlou


yregru

, (i.e. PCPy bgniortionm

degrahcsidebdlou

etsasidaoftnveeehtn

degrahcsidebdlouct

itsetbaldnaP ng)

re

y

sdvoitneitapecnO

pIf yparehtlaciysh

mIf seussiy tiliob w

puowlolfognidniF

nreconC ug/ttnerap

eraptahtnreconC

tospstaeor/dnas - p,op

y sawbaherlaciyshpor

neitap,desserddaerew

tesuacebeussinaerac

csidesufery amnaidrau

otnnacrkeateracortne

rahcsidebdlouctneitap

dlouctneitap,degnarra

degrahcsidebdlouct


egrahc

cehtofsdeenehtteem

degr

egrahcsidebd d

sutatson

dlihc

____

eraptahtnreconC

sIf seussilaioc e w

xplain _________________________________________________ eeasple


ilid bfffff

__________________________

otnnacrkeateracortne

ere tneitapo,tdednetta

xplain _________________________________________________

____________________

iihid

__________________

cehtofsdeenehtteem

degrahcsidebdlouc

xplain _________________________________________________

______________

dlihc

xplain _________________________________________________

ngi slacideM - y bff bfffo

asidaoftnveeehtIn

a,youtahtsetacidni

tneitapsihtredisonc

EQRT ONESODLILRD





TEPSE KTAUOYE IRUEQ

n

fderedisoncebdlouwt

y,tiorhtuaeg sessaveah


ISTHE GRAHCISDTOSTEP




T.TIENAATIENPIS

owlebgnilait

dnallirdehtoft

y.tilicaffae E TH

________


_______:slaitiIn




otno desaelP.m


33Fall 2012

Hospital Name:____________________________


Inpatient Potential Discharge Assessment Profile (IPDAP-2) Form 2 Psych/Detox DISASTER SCENARIO

Unit Name: _________________________________

Patient information

Bed number: ______________


Sex: Female Male

Age:_________


Surgical

Cardiology

Respiratory

Neurology

Oncology

Orthopedics

Psychiatric

Spine

Chemical Dependency

OB/ Gyn

Transplant


Trauma


Other (specify):

_______________________


ema NlatipsoH :____________________________

____________________________

____________________________

nteitInpa

ema NtinU : _________________________________

l iantePot AegrahcsiDD

: _________________________________

elifor Ptnemssess A I (O IRANEC SRETSASID

: _________________________________

PADPI -2 2mro F) yPsO

oxtch/Dey

________


rebmu ndBe

MRN ______:

x: Se aFem

eAg :_________

__________________

no

r: ______________

osporffor(______________

e la Male

:_________


)e

yraimPr signosadi

calrgiSu

yogolidraC

y ortaripseR

y ogolrueN


y


y)atstneitaporfoonsaers

ynG/BO

tnalpsnaTr


amuaTr

y):

era

On yogolc

cideophtrO

cirtaihycsP

e nSpi

DlacimehC

s

y cnednepeD

_______________________



_______________________

TB.lcn

_______________________

mo Htneita psih tsI

sselem ? o N e Y

se nowknnU





otno desaelP.m


34 Fall 2012

Hospital Name:____________________________



Would an imaging study or radiology results be required before discharged? (e.g. CT, echocardiogram, X-rays, etc.)

Yes No Unknown



Yes No Unknown

Yes No Unknown

Yes No Unknown



Would patient education require greater resources in time beyond the typical discharge instructions? (e.g. diabetes care)

Yes No Unknown


Yes No Unknown







Yes No Unknown



Yes No Unknown


lapitHos ema N :____________________________

____________________________

____________________________

alork orwbaldlouW

tsgnigaminadlouWd? (egeharcdis . T,C.g

hpomrfsdemdlouW

dtlhtIs

iuqerebstluserk orwba

stlusery ogolidarory dutX,marogidraochceT, - ysar

offorebdedeeneby camrah

d hidditdti f

?degrahcsideorfforebder

eorfforebderiuqerebscte,ys .)

?egrahcsideor

th’tithti

Yes N

Yes N

Yes N

?t Yes N

o N nowknnU

o N nowknnU

o N nowknnU

N knU

detelpomcaerehtIs

’tneitapehtIso,NIFedoregrahcsidgnidnettas’tneitapIF

htiwnaiciyshporfforsonitpircserperA

tilidlW

d eggerrgahcchsiisddio tto dnetteniin orffor

anaiciyshpgnidnettas’?tneommsihttar

alivaaotnsinaiciyshpgo hwy ty iorhtuaegrahcsid

ownelbalivaaeracretffta

dtiditl

trahcs’tneitapehtnimor

ehtetirwo telbaliva

hotnaerehtsi,ownelbasredorCDetirwdlouco

?ow

titihtihid

?t

re?

Yes N

Yes N

Yes N

Yes N

? Yes N

o N nowknnU

o N nowknnU

o N nowknnU

o N nowknnU

N knU

onctsilaicepsadlouW

acudetneitapdlouWtsniegrahcsidlaciypt

neitapsihtsoeD veahtpmigniraehoronisvi

?geharcdisergnihotlctneitapIs


serretaergeriuqeronite(?sonitcurt .g et. diabe

y tilibasidlaonitcnufaveiuqerlliwtaht)tnemriap

?ownelbalivaay lidae

tneitapsihtgnigrahcsid

tdyonebemitnisecrousear cse )

e(y . dnoubriahcleehw.gtnemegnarralaicepseri

? Yes N

eht Yes N

,donst

Yes N

Yes N

o N nowknnU

o N nowknnU

o N nowknnU

o N nowknnU

begaugnalaerehtIs

o tsawtneitapsihtIfdlouwonitatorpsnart

as’tneitapehtdlouWfinreconcaebnow

iuqerdlouwtahtreirrab

rahcsidy ltnegremeebo :ebd

y ltnednepednio ty tiliba?degrahcsidy ltnegreme

?reterpretninaeri

deriuqereht,deg

onkssaty liadmorfforrep?

Yes N

elnactpsdeentpneirfy/limaffa

quire rptrieht Yes N

o N nowknnU

nowriehtonveaeofecnatsissas

dne ambulancsequir

o N nowknnU

econcaebowebtneitapsihtdlouW

afaofeypt,ESYIf

degacsdy tegeeferacao tderrefesnarte

y?tilica

?egrahcsidonpuy tilicafa

Yes N

y:lonESYIFgnisruNaciyshPawffwlaH

bstanSuter elSh

o N nowknnU

y:FTCLLTC/eomhg

ytilicafabaheRlaesouhy se buAce bstan habRe

bedter





ter elSheciposH

,rehtO

________

otno desaelP.m

bedter debe

_______y ffy iceps



35Fall 2012

Hospital Name:____________________________



disaster:



If detox taper was adjusted, earlier discharge could occur


Outpatient follow up would be sufficient, (i.e. monitoring by PCP and lab testing)


Concern this patient may refuse to be discharged


please explain _________________________________________________

Other, specify ___________________________________






Initials: _______


Yes No Unknown


Is there a court order in place requiring this patient to be in treatment? Yes No Unknown

Is there a problem/delay in identifying an appropriate outpatient referral? Yes No Unknown

lapitHos ema N :____________________________

____________________________

____________________________

htlaeHeomHdlouWy ltnegremefitneitap

keorwlaiocsadlouW

edortroucaerehtIs

/melobrpaerehtIs d

eSesruNgnitisiV/eraC?degrahcsidy

detlusoncebo tdeenrke

sihtgniriuqerecalpnire

niy aled yiffyntide ing an pa

sihtorfodedeenebecvire

?egrahcsideorfforeb

mtaertniebo ttneitaps

etairoprpp ertneitaptou

s Yes N

Yes N

?tnem Yes N

?larrefee Yes N

o N nowknnU

o N nowknnU

o N nowknnU

o N nowknnU

Aff Afff okk oceh cesaelP

retsasdi :

emsitneitapsiTh

kn

no c/snrecno ceh tLL A


ii Pati

hcsi dro f fosnoitaredisn


t idhidbdl



tidoftht

aff a otnev eeh tn

hcussomtpymsgnin

sseknaew,aesuansa

sawrepatoxtedIf

ebdlouctneitapIf

owlolfotneitaptuO

puowlolfognidniF

eitapsihtnreconC

,s or niapornim . enPati

csidreilrae,detsujdas h

iaptneiciffffusdedovirpe

tneiciffffusebdlouwpu , (i

erac tesuacebeussina

sidebo tesufery amtne

ct en idegrahcsidebdlou

rucocdloucegra


, (i.e. PCPy bgniortionm


degrahcs

etsasidaoftnveeehtn

degrahcsidebdlouct

)gnitsetbaldnaP

sutatson

re

____

sIf seussilaioc ew

xplain _________________________________________________ eeasple


ngi slacideM - y bfffffo

__________________________


xplain _________________________________________________

____________________


__________________

degrahcsidebdlouc

xplain _________________________________________________

______________

n

xplain _________________________________________________

ngi slacideM y bff bfffo

asidaoftnveeehtIn

a,youtahtsetacidni

tneitapsihtredisonc

EQRT ONESODLILRD

l





TEPSE KTAUOYE IRUEQ

n

fderedisoncebdlouwt

y,tiorhtuaeg sessaveah


ISTHE GRAHCISDTOSTEP




T.TIENAATIENPIS

owlebgnilait

dnallirdehtoft

y.tilicaffae E TH

________


_______:slaitiIn




otno desaelP.m


36 Fall 2012

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE (NYCDOHMH) OFFICE OF EMERGENCY PREPAREDNESS AND RESPONSE (OEPR)



Data Management and Analysis All forms (Bed Master Worksheet, Patient Care Unit Profile, IPDAP-1, IPDAP-2) were designed with data entry, management and analysis in mind. A Microsoft Access database or Excel Spreadsheet can be created to enter data into. All questions, with one exception, have mutually exclusive responses. The one question with possible multiple responses is on IPDAP-2, “Please check off ALL the concerns/ considerations for discharging this patient in the event of a disaster.” Data analysis can be completed using any statistical software. Data can be analyzed to meet the specific inquiries of your hospital. Highlighted analyses include:

• Total number of potential vacant beds gain through discharging patients in the event of a disaster. Add “round 1 confirmed discharges” + “round 1 potential discharges” + “round 2 potential discharges” – “number of patients in ED waiting for a bed” [found on the Bed Master Worksheet].

• The logistical, social and clinical considerations and/or obstacles that your hospital may face during a rapid discharge event by evaluating the information in the chart on IPDAP-2.

Health

p ˝ ˝ ˛ˆ d ˙ ˙˝ ˆ˙: a h˘˙ˇ ˝ ˘˘ ˝ ˘ˆ e ... · • bed master worksheet •...

Documents