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Table 2 Full capacity protocol adaptation framework

From: What is full capacity protocol, and how is it implemented successfully?

Green
Things that can be changed:
•Name of the protocol (e.g., escalation policy)
•Time of morning safety huddle
•Incentives for participation
•Format and wording of the protocol
Yellow
Things that can be changed/modify with caution:
•Number of levels (generally 3 or 4 levels)
•Activation triggers for each level
•Actions in each level
•Order of actions in each level
•Add other ED crowding interventions (e.g., use of discharge lounges, surgical smoothing)
•Generally aim to place no more than 1 to 2 patients on any one-inpatient hallway. Hospitals cautiously can change this to whatever is needed, depending on crowding situation, the physical environment on each inpatient unit, and available staff and resources in inpatient units.
Red
Things that cannot be changed/ignored:
•Do not change the order of the levels (sequence)
•Do not delete an entire level of the protocol
•Place patients in areas with access to a bathroom
•Place patients in areas that least obstruct flow
•Do not transfer patients who are not eligible to transport to inpatient hallways including:
1. Patients need intensive care unit (ICU) or cardiac care unit (CCU) bed
2. Patients requiring negative pressure room
3. Patients requiring 4 L or greater of oxygen
4. Patients that require suctioning
5. Patients with unstable vital sings
6. Patients with Glasgow Coma Score < 15
7. Mechanically ventilated patients
8. Psychotic patients
9. Patients that have diarrhea or are incontinent of stool
10. Patients at immediate risk of seizures
11. Patients with open wounds
12. Patients at high risk of bleeding
13. Children and patients who are 75 years and older
14. Patients with recent high-risk coronary artery disease
15. Patients with history of heart failure, stroke
16. Patients with history of peripheral arterial disease
17. Patients with chronic obstructive pulmonary disease