Patient Flow E-Newsletter
Volume 4, Issue 4
October/November 2007
Special Focus Issue-Integrating Pre-hospital and Hospital Care

Innovations
Avoiding ED Gridlock and Staying Open: A Culture Change at Presbyterian Intercommunity Hospital

In July 2005, the Centers for Medicare & Medicaid Services (CMS) published a memo warning hospitals that failure to release ambulances back into the field in a timely manner poses safety concerns and could result in an Emergency Medical Treatment and Labor Act (EMTALA) violation.

Recognizing a problem in their area, Los Angeles County set a new rule for hospital ED closures in mid-2006. After going on ambulance diversion for one hour, area hospitals now have to reopen their EDs for at least 15 minutes. Hospitals must report the reasons for closing to the local authorities, and document the need to do so by tracking the number of patients waiting in the lobby, the number of occupied, monitored beds, and the hospital's ability to move patients from these beds.

By the time the CMS memo came out and L.A.'s new rule put into place, Presbyterian Intercommunity Hospital, in Los Angeles County, had already begun to focus on the problem of ambulance diversion, says Joan Rolland, R.N., B.S., M.B.A., Administrative Director of Emergency and Workcare Services. "We feel strongly that our ED is the door to our community," she says, "and because our lobby was full, some of the sickest patients arriving by ambulance were turned away."

A Systemic Problem
Presbyterian Intercommunity Hospital is southeast of the city, in an area where refineries and other industries, a psychiatric facility, and a sheriff's training facility supply the ED with a steady stream of sick and injured patients--some 65,000 a year.

Two years ago, the hospital regularly turned away ambulances in an attempt to catch up and clear the backlog of emergency patients; the ED was on ambulance diversion nearly 20% of the time. Rolland and other administrators realized that "going on diversion" was not an antidote to ED overcrowding, but a symptom of a larger workflow problems.

"If staff put the hospital on diversion, they thought they'd gain some relief in terms of slowing the volume of patients," explains Rolland. "But it became a crutch."

Ian Kramer, M.D., the ED's Medical Director, compares ambulance diversion to putting a plug in a drain: it might stop the flow of new patients for a while, but when you eventually open up the drain, you're likely to be inundated. One reason for this is that as soon as one ED closes, other area hospitals are likely to become overwhelmed and follow suit--exacerbating the problem.

To find ways to improve patient flow, Rolland and Kramer reached out to frontline staff and managers from departments across the hospital, including critical care, radiology, case management, social services, registration, and environmental services. This multidisciplinary group, known as the Emergency Department Focus Team, began meeting for weekly focus group sessions in early 2005. According to Rolland, the goal of the discussions was to promote a "culture change," to shift from saying, 'Let's go on diversion because we are overwhelmed' to asking 'What did we gain from going on diversion?'

Small Changes, Big Impact
During the first few focus group sessions, participants tended to deflect responsibility ("We're doing this in 10 minutes, we're not the reason for the bottleneck") or point fingers at the ED staff ("They're bringing up patients during changes of shifts," "they're sending us too many labs").

"I knew it was a hospital-wide problem," says Rolland, "but we started by saying: 'What can the ED do to improve, and help you in your work?'" Based on issues raised during the discussions, they began making small changes, typically giving staff a week's notice and testing a new system before implementing it throughout the hospital.

For example, the ED began point-of-care testing to avoid delays from waiting for lab results. To expedite the admission process, they initiated bedside registration. Eventually, departments beyond the ED began to suggest areas for improvement. To ensure beds were open for arriving patients, inpatient departments began discharging patients earlier in the day. Even environmental services got involved, developing a checklist system to ensure that the bathrooms in the ED lobby were cleaned every hour.

To smooth care transitions, the hospital adopted the "pull" system advocated by the Institute for Healthcare Improvement, in which any transition from one stage to the next becomes the primary responsibility of the downstream (i.e., subsequent) department. Now, pediatric nurses come to Presbyterian's ED to receive bedside reports about pediatric patients being admitted--pulling these patients rather than having them "pushed" into their care. The hospital plans to roll out a similar approach for critical care patients.

The focus group sessions now occur biweekly, with discussions focusing on ways of continuously improving workflow throughout the hospital.

Extra Hands in the ED
In addition to streamlining work processes, the hospital added staff resources. Like Las Vegas' Valley Hospital (see Best Practice), Presbyterian Intercommunity Hospital hired paramedics to help offload ambulance patients. Today, two EMTs work in the ED at all times, with a third assisting during the 12pm-12am shift, the busiest time. Ambulance patients needing advanced life support are taken straight back for treatment, while patients requiring basic life support are immediately triaged. The hospital also developed standardized protocols, so that ED nurses are able to begin treating basic life support patients by starting EKGs, blood tests, or other initial steps.

In addition, after much discussion, the hospital brought case managers into the ED.

"We thought case managers would slow us down, or function as gatekeepers and prevent us from admitting patients," says Rolland. "But they are able to facilitate movement of patients and make recommendations for home care, skilled nursing, or other needs."

Having the help of case mangers in the ED has made "an incredible difference," agrees Kramer, noting that they are better equipped than clinicians to coordinate care, particularly for elderly patients who may have multiple conditions and providers.

The hospital now has one nurse for every three patients, exceeding California's mandatory nurse-to-patient ratios. In addition, since October 2006, there have been two staff hospitalists on site at all times, making it possible to admit patients to the ICU within an hour after deciding to admit them. Since late 2005, there also has been a critical care intensivist on duty at all times, helping improve coordination of care from the ED to critical care unit.

Measurable Improvement
These workflow changes and additional staff resources have resulted in a true change of culture at Presbyterian Intercommunity Hospital. Today, says Rolland, "it's a badge of honor among staff to fight to stay open." In January 2005, the ED went on diversion a quarter of the time, turning away 69 patients in that month. Since then, the overall trend in diversion rates has declined (see graph). This past July, the ED went on diversion just 15.75 hours, or about 2% of the time.

click here to view a larger image

By staying open more of the time, the ED has been able to accept more ambulance arrivals--some because other area hospitals are on diversion, and some because of patient requests. Over the past five quarters, Presbyterian's ED has treated an additional 668 patients, compared with the baseline of the second quarter of 2006, leading to a significant increase in operational revenue.

The hospital is now involved in a statewide effort to disseminate best practices for improving patient flow and avoiding ED saturation. They are also collaborating with social services agencies, local politicians, and case managers to help connect patients with sources of primary care and other community services.

"Overuse of the ED and of the EMS system for non-urgent care is a real problem," says Kramer. "We're working on helping people get appointments, providing them with transportation and access to community services. For example, we had the idea of putting health clinics in high schools. If we can knock out the 30% to 50% of non-urgent stuff in the ED, it would have a phenomenal impact on patient flow."

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