We are also working on this issue.  We use a patient tracking and documentation program called IBEX which calculates the EDWIN-R score in real time.  Because we have this available, and it is validated is some population, it is what we are going to use to trigger our surge plan.  We have decided that we will use a score of 1.3 (score ranges 0-2) to indicate that there is a problem.  Currently, our staffing goes from 3 attendings (2 in the main ED, 1 in our fast track) to 1 attending at midnight.  We have decided that the score of 1.3 indicates that an attending who is supposed to leave (one of the main ED attendings) will stay extra until the score drops.

We still have lots of kinks to work out in the system.  Here are some of them:
1) The number of attendings who are seeing patients greatly influences the EDWIN-R score.  Potentially, the EDWIN-R score could be 1.25 at 11p, but when the attendings sign out and the staffing goes from 3 to 1, the EDWIN-R score will jump considerably.  So we need to figure out if we need to use the score pre- or post- change in staffing to indicate what our needs are.
2) What do we do if the EDWIN-R score is great than 1.3 when we have our full complement of attendings?  We do not currently have anyone "on call" to increase staffing.  There is much debate amongst the group about the desirability of having to carry a pager 3-4 times a month.
3) Attendings are not the only limiting factor when looking at over staffing.  How do we utilize other staffing to deal with over crowding (RNs, ED techs, PAs/APRNs, residents)?  We have just started using the primary care clinic space in the last 2 weeks when physical beds seems to be the limiting factor.  This space is distant from the ED and there are logistic issues in it's use.  How do we best staff that area without depleting the main ED if there is no change in the total staff available?
4) If 1.3 indicates that we should not leave the ED with only a single attending, what number will we use to indicate that we can.  Part of the reason that we want to use strict cutoffs and validated criteria is that the attendings will be reimbursed by the hour for extra hours that we stay.  The hospital administration has asked us to come up with criteria and track the usage to insure that if attendings are to be paid extra, it is for the right reasons.

I look forward to hearing other ideas and suggestions as well as any advice or comments people may have based on our plan.


Adam Silverman, MD
CCMC Emergency Department Residency and Medical Student Site Coordinator
Morbidity and Mortality Coordinator
Assistant Professor of Pediatric Emergency Medicine and Pediatric Critical Care
Connecticut Children's Medical Center
282 Washington Street
Hartford, CT   06106

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>>> Alison Tothy <[log in to unmask]> 03/03/09 5:45 PM >>>
I was wondering if anyone has created a surge plan protocol for their Pediatric 
Emergency Department and would be willing to talk to me about their policies 
in place?  Most of the literature out there relates to Adult ERs.  Also, 
wondering if there is a NEDOCS or EDWIN overcrowding score equivalent for 

Alison Tothy

Alison Tothy, MD
Medical Director; Pediatric Emergency Medicine
The University of Chicago Medical Center
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