Red to Bed Process

STURGEON COMMUNITY HOSPITAL

APPROVAL AUTHORITY INITIAL EFFECTIVE
Sturgeon Community Hospital Senior Leadership September 5, 2024
SPONSOR SCHEDULED REVIEW DATE
Sturgeon Community Hospital August 2025
OBJECTIVE
To outline the red to bed process at the Sturgeon Community Hospital.

RED TO BED DEFINITION

Red to bed refers to the process of transferring patients to a hallways space within 30 minutes due to capacity
demands in the Emergency Department (ED).

TRIGGERS
• The red to bed process will be enacted when the ED overcapacity triggers have not been resolved
despite two cycles of internal actions. See below for ED overcapacity triggers.
• The Site Overcapacity Plan will be enacted 30 minutes after the ED Overcapacity Plan has completed its
2 internal cycles with no capacity created.

ED overcapacity triggers occur when any ONE of the following are happening in the ED:
1. Any CTAS 2 patients waiting longer than 30 minutes for a room.
2. CTAS 2 x 3 patients waiting for a room.
3. ICT space full, and there is no space to offload an EMS crew.
4. The ED Team Lead's judgment indicates that the ED Overcapacity Protocol is needed.

Definition: CTAS 2 is a patient requiring emergent care and rapid medical intervention.

ENACTING THE PROCESS

• In the event senior leadership cannot be reached, the PSS has the authority to initiate the call to
switchboard to enact the Site’s Overcapacity Plan.
• Approval for overhead paging is required after business hours by the Manager on Call.
• A site-wide overhead page announcing that the Site's Overcapacity Plan is in effect will be completed by
switchboard.
o EXCEPTION: No site overhead overcapacity paging shall be conducted from 2400-0700.
• The PSS will escalate site capacity to the IOC.
• If there is no improvement in site capacity after business hours, the Manager on Call will be required to
escalate site capacity to the IOC.
• Units with an alternative care model enacted may be unable to admit a hallway patient. A discussion
between the PSS/UM/Charge Nurse is required.

PROACTIVE PLANNING
1. On the Units: Every day the Unit Manager (UM) or charge nurse will identify all potential inpatients for
the red to bed space.
i. Rationale: If no Emergency Inpatient (EIP) meets the criteria, the pre-selected inpatient will
be moved to the red to bed space in order to admit the EIP to the room.
b. During PSS hours, UMs or charge nurses are to notify PSS before initiating patient transfers to red
to bed spaces.
2. In the Emergency Department: The nurse responsible for the patient's care will initiate a proactive
conversation with the patient to prepare the with EIP for the potential of being transferred to an alternative
care space until a bed is available.

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Red to Bed Process DURING PSS Hours

Proactive Planning
 UM/Charge Nurse will identify all potential inpatients appropriate for the
red to bed space.

Red to bed triggers met.

ED Team Lead notifies PSS.

 PSS/Senior Leadership will notify switchboard to overhead page “Level ___ Site
Overcapacity Plan is now in effect. Follow the required actions in your
department”.
 PSS identifies an available space and collaborates with unit UM/CN on
EIP selection.

If no appropriate EIP ED to transfer patient to unit

within 30 minutes.

Ward to transfer
preselected inpatient to
red to bed space.

When the room has been cleaned for

more than 15 minutes, the PSS to notify
the ED to transport the patient.

• The PSS will assist with coordinating communication between the units to ensure a
timely transfer of the patient.
• PSS to notify the Manager on Call if this process is enacted after business hours.
• For additional support or concerns contact the UM during office hours or the Manager
on Call after hours.
•

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Red to Bed Process AFTER PSS Hours

Unit Proactive Planning
 Unit Charge Nurse will identify all potential inpatients appropriate for
the red to bed space.

PSS Proactive Planning

Before the end of the PSS shift:
 PSS identifies the next accepting unit.
 Collaborates with the next-to-accept unit Charge Nurse on EIP selection.
 If there is no appropriate EIP, ensure the unit is aware that their preselected inpatient will be transferred if the red to bed
process is enacted.
 Notify the Manager on Call of the plan.
 Communicate the plan via a secure chat on connect care to the current and oncoming ED Team Lead and the current
and oncoming unit Charge Nurses on Unit 15 &19.

Red to Bed Triggers Met

ED Team Lead notifies the next to accept unit Charge Nurse.

If no appropriate EIP ED to transfer EIP to unit within 30

minutes.

 Unit to transfer preselected inpatient to red

to bed space.
 Unit Charge Nurse will contact
Environmental Service’s Team Lead at 780-
718-1854 to request a stat bed clean.

 When the room has been cleaned for more than 15

minutes, the unit Charge Nurse to notify the ED to
transport the patient.

▪ The red to bed process does NOT require approval from the Manager on Call and
patient movement can be facilitated by the ED Team Lead and unit Charge Nurses.
▪ For additional support or concerns contact the Manager on Call.
▪ If required, the MOC can assist with coordinating communication between the units
to ensure a timely transfer.

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LOCATIONS AND UNIT SPECIFIC PATIENT CRITERIA

UNIT 15
Location: Near room 1524
Assigned Bathroom: 1528
Equipment Considerations:
• IV Pumps: If no plug-ins are available, IV pumps can be switched when the battery is low. If no extra IV
pumps are available, check with the ED or other units for spares.
Patient Criteria
Inclusion Criteria Exclusion Criteria
 Stretchers only.  Oxygen therapy.
 Ability to mobilize to the washroom (standby/1  Cardiac telemetry.
person assist).  Imminent death (e.g.,12-14 hours).
 Airborne, contact, and droplet precaution
 Special care- e.g. seizure risk, noninfectious
diarrhea/drainage, peritoneal dialysis.
.  Behavioral-e.g. wandering/elopement risk,
disruptive/aggressive, unpredictable/suicidal,
risk of delirium, on a behavioral safety plan.
 Chest tube/drains.
 Airway and suction needs.
• Patient should remain in hallway spaces for a maximum of 24 hours.
• Exceptions can be made at the discretion of the Site Capacity Lead (Mon-Fri 0800-1600 excluding
statuary holidays) or after-hours the Manager on Call.

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UNIT 19
Location: Outside of room 1909
Assigned Bathroom: 1907
Equipment Considerations:
• IV Pumps: If no plug-ins are available, IV pumps can be switched when the battery is low. If no extra IV
pumps are available, check with the ED or other units for spares.
Patient Criteria
Inclusion Criteria Exclusion Criteria
 Stretchers only.  Oxygen therapy.
 Ability to mobilize to the washroom (standby/1  Cardiac telemetry.
person assist).  Imminent death (e.g.,12-14 hours).
 Airborne, contact, and droplet precaution
 Special care- e.g. seizure risk, noninfectious
diarrhea/drainage, peritoneal dialysis.
 Behavioral-e.g. wandering/elopement risk,
disruptive/aggressive, unpredictable/suicidal,
risk of delirium, on a behavioral safety plan.
 Chest tube/drains.
 Airway and suction needs.
• Patient should remain in hallway spaces for a maximum of 24 hours.
• Exceptions can be made at the discretion of the Site Capacity Lead (Mon-Fri 0800-1600 excluding
statuary holidays) or after-hours the Manager on Call.

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UNIT 26
Location: Unit 26
Patient Criteria
Inclusion Criteria Exclusion Criteria
 Stretchers only.  Oxygen therapy of greater than 4 L of 02.
 Surgical patient ONLY.  Cardiac telemetry.
 Imminent death (e.g.,12-14 hours).
 Airborne, contact, and droplet precaution
 Special care- e.g. seizure risk, noninfectious
diarrhea/drainage, peritoneal dialysis.
 Behavioral-e.g. wandering/elopement risk,
disruptive/aggressive, unpredictable/suicidal,
risk of delirium, on a behavioral safety plan.
 Chest tube/drains.
 Airway and suction needs.
• Patient should remain in hallway spaces for a maximum of 24 hours.
• Exceptions can be made at the discretion of the Site Capacity Lead (Mon-Fri 0800-1600 excluding
statuary holidays) or after-hours the Manager on Call.

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