Transcript Emergency Department Overcrowding: Right diagnosis, wrong

How can we fix this mess?
Hospital
Overcrowding
1
Answer
Simple
 Costs nothing
 Makes money
 Increases
safety
 Improves
nurse/patient
staffing ratios
 No ambulance
diversion

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The “undramatic” problems
 Unreported
bed
 Uncleaned room
 MD failure to discharge
 Silos with full and empty beds
 Weekend vs. weekday
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Institutional perspective
Have one!
 We must do the best thing for
ALL of the patients, not the ED
 ED is necessary
 Inpatients don’t belong in the
ED

 ED
provides LOUSY care of
inpatients

The problem and the solution
should be in the hands of the
“right” people
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Itsy-bitsy ED
HUGE inpatient areas
Everything is filled to the brim
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Current model
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Current solution to
HOSPITAL
overcrowding
Crowd the ED
Space
Staff
Structure
Expertise
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Current model
Core measure: Timely
administration of antibiotics
 Core measure: Door to balloon
time
 Timely treatment of strokes
 Patient satisfaction

Inadequate staff
Inadequate space
Lots of
meetings
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x x x x xx
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Is this your ED model?
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What are your SYSTEM incentives?
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Our ED
 Pre
(25,000)
 Incentives?
 One
Day Change
 Bedside
registration
 NO patients wait in waiting
room
 Incentives?
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90 ………… 12
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x x x x xx
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+/- Radically new model – 1970’s
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Xxxxxxxxx
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nasty
x
nice
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WHY can’t we make it happen?
 “Against
the rules”
–“DOH won’t allow”
–
OB OB OB
 “That’s
the way things are done”
Keep
the chaos IN the ED
ED vs. rest of hospital
The problem is not admissions
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Defining the real problem
Too
Many
Admitted
Patients
In the wrong space, in the wrong place, with the wrong staff
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A fateful day
… in isolation
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DOH April 2002
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“continuing issue of hospital overcrowding”
“Emergency Departments must remain open”
“Maintaining admitted patients within the ED is not
acceptable”
“the use of beds in solariums and hallways near
nursing stations should be considered”
“Regardless of location within the facility, staffing,
services, privacy, infection control and
confidentiality protections must be consistently in
place”
www.viccellio.com/overcrowding.htm
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What about ambulance diversion?
Simply Diverts to
other overcrowded
ED’s
 Not good business
 Can’t divert walkins
 Works?

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Our CQI Efforts
•
•
•
•
•
Meetings
Measures
Graphs
Memos
Repeat the above
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Behavior is driven by incentives
What are the incentives?
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Predict incentives ….
NO move to
inpatient unit
 ED does
admission
paperwork
 ED gives
treatment
 Day can be better
organized
 Less total work
Move to inpatient
unit
 Decrease the
number of
patients to
decrease the
amount of work
 Discharges
 Clean beds
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The Administrative Decision
Focus on what is best
for the patient
How is being in the hallway better for the patient?
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Four questions
Space, load, expertise, and
necessity
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Question 1 - Space
 Good
space
 Bad
space
Action plan??
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Question 2 - Load

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Unit A
No space
15 additional
patients beyond
“good” space
capacity
Interferes with
prime function



Units B, C, D, E, F,
G, H, I, J
No space
No additional
patients beyond
“good” space
Action plan??
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Question 3 - Expertise

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Unit A
6 nurses
Needs 11
Wrong expertise
Wrong
environment

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Units B, C, D, E, F,
G, H, I, J
6 nurses
Needs 6
Right expertise
Right
environment
Action plan??
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Question 4 - Necessity
Is your emergency
department necessary?
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Answer to questions 1-4
Move
the
patient
upstairs.
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Where leadership meets the road….

Implementation of full
capacity protocol

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A hallway -> a hallway?
Leadership Concerns


Nobody does this
Not safe
 Nurses
will quit
YOU are a leader EITHER WAY.
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Why? ….
 Inpatient
Units are: less crowded, less
noisy, less chaotic
 Inpatient Units provide appropriate
clinical expertise (MD’s, RN’s)
 Staging in an inpatient hallway will result
in closer, therefore faster access to a
room
 The ED can continue to fulfill its mission
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Guess what!?
Nurses are professionals. They
can SEE what the best thing is
for the patients.
Where do you make them look?
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Hospital overcrowding
 Implementation
of full
capacity protocol
 First three months
www.viccellio.com/overcrowding.htm
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What to do during difficult times ...
Ask what’s best for the patient,
and all the patients.
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Full capacity Protocol: How it Works
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Step 1 : ED attending and ED charge
nurse
Step 2: Bed coordinator - NEUTRAL
Step 2a: Medical Director - NEUTRAL
Step 3: Bed coordinator notifies
Clinical Associate Directors
Step 4: Units assigned hallway
patients. No unit will receive more
than 2 hallway patients.
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Priority of Hallway placement
1.
2.
3.
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Non-telemetry patients with little or no comorbidity
Non-telemetry patients with minimal or
moderate co-morbidity
Telemetry patients as follows:
Little or no co-morbidity
Low index of suspicion for cardiac event
ED attending approval
Telemetry box availability and central
monitoring slot
Get them OFF tele
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Exclusions to Hallway Placement
Patients requiring step-down or ICU
 Rule-in MI or at high risk for cardiac
event
 Ventilator dependent patients
 Patients requiring negative pressure
or Isolation rooms
 Patients requiring greater than 4 liters
of O2 via nasal cannula

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Changes in criteria
 Hallway
= hallway
 Isolation patients
 ICU patients !!!
 Medical director not
involved
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Lessons Learned


Identify space and equipment
issues prior to
implementation
Sometimes “Just say No”

Floor overwhelmed
Include patients in
recognition efforts
Over time, the “issue” just …..
….. dies.
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What are the results?

Press-Ganey
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ED
Inpatient
Memphis
Governor’s Workforce Award
LOS studies
“It’s just too simple and
obvious. You can’t expect us
to believe this. Something
must be wrong here.” Dan
Sisto, NYHA
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Results: Patient Satisfaction
Press-Ganey
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Results: Staff Satisfaction

ED Staff verbalize improved
satisfaction in their work
environment

Inpatient staff have not expressed
impact on overall satisfaction
related to hallway protocol
Would you WANT them to like it??
What they don’t like – volume not issue
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Patient opinions
Take a guess
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LOS: ED vs. Floor Hallway
6.4
6.2
6.2
6
5.8
LOS
5.6
5.4
5.4
5.2
5
ED Hallway
Floor Hallway
Results: Disposition
Immediate Room
Room < 1 hr
Room > 1hr
28%
25%
46%
Average patients > 1 hr= 10.3 hrs
Average all patients = <5 hrs
(16% of patients did not meet hallway
criteria)
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03/04 Data
2003: 161 patients placed in the hallway
 2004: 454 patients placed in the hallway
 2005: 600+ so far
 Average ED stay prior to hallway placement:
213 minutes ( 3.5 hrs)
 Average stay in hallway
454 minutes (7.5 hrs)
<3% (12) spent 23hrs or>
(longest 29hrs)
35% spent < 1 hr in hallway
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Results: Patient Satisfaction
Press Ganey
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What about those other CQI
efforts?
Surprise surprise
www.viccellio.com/overcrowding.htm
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Transferring the chaos to the
inpatient units?
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Staffing ratios and patient safety

ED

Needs 15 (California: 19)
– 12 for direct patient care
Has 10 (8 for direct patient care)
 Added admitted load, needs 3.5
 Total RN need 18.5; available 10 (8)

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Direct patient
care: 8 of 15.5
RN’s
Floors
Needs 6 for 30
 Has 6 for 30

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Redistribution (max 2 per unit) [8 patients to floor]
ED total RN needed 17; available 10
 Floor total RN needed 6.04 - 6.33; available 6

SPACE
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Question: which is safer???
Side-by-side: 1.70 RN vs. 1.05 RN
Patient safety?
ED
Floor
10 (18.5)
6 (6)
FCP
10 (17)
FCP
6 (6.04 – 6.33)
ED hold ≠ Hallway patient
ED nurse ≠ Floor Nurse
No space ≠ Space
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Side-by-side: NOT ED VS. FLOOR
Patient safety?
UNIT A
10 (18.5)
FCP
10 (17)
UNIT B
6 (6)
FCP
6 (6.04 – 6.33)
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Itsy bitsy trauma room
RN:PT Ratio = 4-5:1
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What if??????????
ICU
2 : 1 becomes 2.3 : 1
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What about ratios & NCH in the ICU?
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ED
Needs 3RN
Has 3
Holding 2 patients: add 1 RN
Total need = 4 (-1.0)
Floor
Needs 6 for 12
Has 6 for 12
Redistribute (1)
ED total RN need 4; available 3 (-1)
Inpatient ICU need 7; available 6 (-1)
Impact ON HPPD per inpatient :
ED missing 12 hppd/ICU hold or each TR
Pt receives 6 NCHPPD
ICU missing 0.9 hppd/ICU pt or each ICU
Pt receives 11.07NCHPPD
Which is safer????????
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What if…?
 Something
bad happens to a
patient?
 Unique
to hallway?
 Compare to ED?
A
patient complains?
 Something doesn’t go
perfectly?
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Why?
 Safe
 Patient
 Staff
 Patient
not yet seen
 Easy
 Costs
 LOS
 Diversion
 Improve
processes
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Why not?
 Can’t
vs. won’t
 COMB
 Perfect and good are
enemies
 Leadership
 “belongs in the ED”
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Who does it?
Stony Brook
 Duke
 Wm. Beaumont
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 EMTALA
Yale
 St. Barnabus system
 NYU
 LOTS of places now
 “Inside the Joint Commission”
 JCAHO white paper and “Best Practices”
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Key points
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The ED is essential
Admitted patients are a hospital problem
Patients need experts for their care
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The ED is not a replacement part for everything
The ED is NOT an effective back-up unit
Place the problem in the lap of the person
who must fix it
Stop ambulance diversion
Clarify with your DOH
OB OB OB
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