Patient Flow Enewsletter
Volume 1, Issue 4
Tuesday, March 2, 2004
Resources in this article:
"This is your captain speaking. Air traffic control has said we are 23rd in line for take-off. Sit back, relax and we will get you to your destination eventually."
As frequent fliers, we have become accustomed to this type of delay. However, what may be acceptable for the airline industry is egregious in the emergency department (ED). If admit/holds - or "boarders" - are lining your ED hallways and occupying a significant part of your time and talent, then this is the single biggest problem you have to solve.
Not Just an ED Problem
The Joint Commission on Accreditation of Health Care Organizations (JCAHO) has accepted as a central tenet that ED overcrowding is a hospital-wide patient flow problem, not limited to the ED itself. To address this, JCAHO recently issued new standards to take effect on January 1, 2005, that are poised to become the central tenet of hospital patient flow.
Multiple factors are responsible for overcrowding - higher patient acuity, prolonged ED evaluation, nursing shortage and inadequate inpatient bed capacity. A patient sick enough to be admitted, should not lie on a stretcher in the hallway of a busy, noisy, brightly lit, crowed ED with limited privacy, sleep and bathroom facilities.
The goal is a bed for every admission. If there is a shortage of available inpatient beds, why hold patients in the ED hallways? Why not in the hallways of the inpatient units? Dr. Peter Viccellio at Stony Brook University Hospital and Medical Center has pioneered and promoted the concept of In-House Hall Bed Placement with the Emergency Department Full Capacity Protocol.
This concept of moving patients upstairs, called "Adopt a Boarder," is also being implemented by Dr. Thom Mayer and colleagues at Inova Fairfax Hospital as part of their Urgent Matters Demonstration Project.
Let us assume that you have a 20-bed ED. Every bed occupied with a boarded inpatient admission reduces your productive capacity by five percent. Holding 10 boarded patients means productive capacity is cut in half. Effective capacity may be reduced further, because these patients often require a fair amount of nursing time and attention.
Our primary business, and what we are actually best at, is taking care of the acute needs of the urgent patient population. Quality, service and patient safety suffer when inordinate numbers of patients are boarded in the ED. Data from JCAHO suggests that nursing errors increase dramatically when staffing is stretched thin. This has overwhelming implications for the ED, because the conclusions likely apply equally to physician and support staff.
Dr. Viccellio has reported that patients who are boarded in the ED average one day longer LOS than patients who are admitted to inpatient beds. This conclusion has been substantiated by our colleagues in Australia and can translate into significant financial costs.
Exposing In-Patient Staff to ED Overcrowding
Dr. Viccellio has also reported that when they first introduced this policy, they couldn't place patients in a hallway bed. The idea of a patient lying in an inpatient hallway was such a powerful stimulus to the inpatient staff that steps were taken to expedite patient transitions so that a bed or space could be immediately cleared.
A number of benefits resulted. Diversion hours went down, and revenue went up. Patients in upstairs hallways were a visible index of the state of overcrowding and a stimulus for change.
However, sharing the pain leads to sharing the solutions, so expect cultural resistance. This is an idea that has to come from the top. For inpatient culture and expectations to change, the mandate has to come from within, preferably from one of the "High C's" - the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO) or the Chief Executive Officer (CEO).
We would all agree that admitted patients deserve to be placed in a room that is appropriate to their needs. However, if the hospital is overcrowded with admissions, placing patients in upstairs hallways is an acceptable temporary solution. It is a stopgap and a potential life-affirming solution for ED patient flow.
We all dream of a world without "boarders." Until that day comes, we look forward to the work of hospitals like Stony Brook University Hospital and Inova Health System to point the way to solutions.
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Kirk Jensen, M.D., F.A.C.E.P.
Faculty, Urgent Matters
Medical Director
Emergency Care Center of Nash Healthcare Systems
Rocky Mountain, NC
