Surge capacity: What can we do now?
Surge capacity?
Do we need a disaster to make it happen?
The morning report vs. ED holds
Answer
Simple Costs nothing Makes money Increases
safety Improves
nurse/patient staffing ratios
Not …
Why did this happen?Why did this happen to the ED?
Properly categorize the problem EMTALA the poor the safety net The unnecessary visit – who else
complains? Subtext – the poor SHOOT THE MESSENGER What’s the SCIENCE??
Temporary problems
… or …..
Too many inpatients in the ED !!!!
Strategies for the fix and the blame Ambulance diversion Transfer Triage out
EMTALA, the poor, the safety net
The unnecessary visit Temporary problems
Data data data
Send our business away
Strategy of victimization, race, and tragic heroes
Strategy of ignoring the problem
Strategy of beating the problem to death
Rules of the road It should help ALL of the patients, not the ED Operating principle: ED is necessary ED CANNOT bear brunt of the deficiencies of
the entire health care industry Inpatients don’t belong in the ED
ED provides LOUSY care of inpatients– The insecurity-driven scam
The problem and the solution should be moved out of the ED
Implementing the rules of the road
Fix the problems you canNo excuses from problems you
can’t
The ED is currently PREVENTING the solution to the problem
Discharge planningBed availability
“Safety” ≠ “Happy”Leadership COUNTS
An ED designed with monitors by each bed because of the unpredictable needs of incoming patients does not mean it is automatically an ICU or telemetry inpatient
unit. The willingness of emergency physicians to cope with just about anything is not a virtue if this situation is the result.
Mark Henry
What your ED does for you
AD Little community survey 5 vs. 40 Keep the hospital full Financial
1 moreTrauma center
With bad service, who leaves?
What your ED REALLY does for you
Defining the problem
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Everything is filled to the brim
Itsy-bitsy ED HUGE inpatient areas
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Current model
Current model
Core measure: Timely administration of antibiotics
Core measure: Door to balloon time Timely treatment of strokes Patient satisfaction
Inadequate staffInadequate space
Lots of meetings
Current solution to HOSPITAL overcrowding
Crowd the EDSpaceStaffStructureExpertise
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+/- Radically new model – 1970’s
nice
nasty
WHY can’t we make it happen?
“Against the rules”
– “DOH won’t allow”
– OB OB OB ED ED ED “That’s the way things are done”
Generational indoctrinationReinforcement via the fire extinguisher
Keep the chaos IN the ED
Defining the real problem
Too
Many
Admitted
Patients
A fateful day
… in isolation
DOH April 2002
“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
What about ambulance diversion?
Simply Diverts to other overcrowded ED’s
Not good business Can’t divert walk-ins
Solutions:
Move patients upstairs
Can’t do that???
Hospital overcrowding
Implementation of full capacity protocol First three months
www.viccellio.com/overcrowding.htm
Initial reaction
•DOH will not allow
•Not in the patient’s best interest
•ED needs to deal with this without impacting in-patient units
Our CQI Efforts
• Meetings• Measures• Graphs• Memos• Repeat the above
Where leadership meets the road….
Implementation of full capacity protocol A hallway -> a hallway?
Leadership Concerns Nobody does this Not safe Nurses will quit
YOU are a leader EITHER WAY.
The Real Solution
Move the patient upstairs.
The Administrative Decision
Focus on what is best for the patient
How is being in the hallway better for the patient?
But do we have to???????
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
Yes, Because……..
The Golden Rule of Health Care
If it were your Mother…….
Operating assumptions
The ED MUST remain openCritically ill patients MUST be
cared forWe act in the best interest of
the PATIENTS, not the ED
Process
Interdisciplinary Group Develop clear guidelines Communicate,
communicate, communicate
Development of Policy : Key Points
Identify applicable units Identify individual roles &
responsibilities Limit in-house hallway bed placement Prioritize “real” bed admissions :
hallway, ICU downgrade List criteria for hallway placement
Keys to Success:
“One Song, One Voice”*
*Drum Line
Keys to Success:
Identify a neutral party to make decisionsAnd communicate process
Keys to Success:
Support from The top
Keys to Success:
Don’t make this into a Big thing
Full capacity Protocol: How it Works Step 1 : ED attending in collaboration
with ED charge nurse identify need for protocol to bed coordinator
Step 2: Bed coordinator gains approval from Medical Director or designee
Step 3: Bed coordinator notifies Clinical Associate Directors and the Inpatient Units that Full Capacity Protocol is being implemented
Step 4: Units assigned hallway patients. No unit will receive mote than 2 hallway patients.
Priority of Hallway placement
1. Non-telemetry patients with little or no co-morbidity
2. Non-telemetry patients with minimal or moderate co-morbidity
3. 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
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
The Impact of Calling Full Capacity Protocol?
Expedited mobilization of resources to discharge patients
Nursing influence results in physician practice change
Improved communication between departments
Those areas not subject to FCP continue the same inability to improve
Lessons Learned
Identify space and equipment issues prior to implementation
Sometimes “Just say No” Floor overwhelmed
Include patients in recognition efforts
What are the results?
Press-Ganey 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
Results: Patient Satisfaction
Press-Ganey
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??
Results: LOS
ED HallwayFloor Hallway
LOS
6.2
5.4
5
5.2
5.4
5.6
5.8
6
6.2
LOS: ED vs. Floor Hallway
LOS
Results: Disposition
Average patients > 1 hr= 10.3 hrsAverage all patients = <5 hrs
(16% of patients did not meet hallway criteria)
Immediate Room Room < 1 hr Room > 1hr
28% 25% 46%
Patient in Hallway
•Late Rounding by MD’s•Disjointed Discharge Practices•Lack of Discharge Planning•Inefficient Room Turnaround Time•Lack of Med/Surg Beds, Specialty Beds•Overuse of Isolation•ICU Staffing•Poor Communication with bed control•No one has complete picture
Patient in Appropriate Room
The Problem/The Goal
Seeing is believing
Seeing is believing
… unless you refuse to look
And the truth is………..
Is better than……………
WAIT!!
Transferring the chaos to the inpatient units?
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 3.5Total RN need 18.5; available 10 (8)
FloorsNeeds 6 for 30Has 6 for 30
Redistribution (max 2 per unit) [8 patients to floor]
ED total RN needed 17; available 10Floor total RN needed 6.04 - 6.33; available 6
Question: which is safer???
Direct patient care: 8 of 15.5
RN’s
SPACE
Side-by-side: 1.70 RN vs. 1.05 RN
Patient safety?
ED nurse ≠ Floor Nurse
ED hold ≠ Hallway patient
10 (18.5)
10 (17) 6 (6.04 – 6.33)
6 (6)ED Floor
FCP FCP
No space ≠ Space
Key points
The ED is essential Admitted patients are a hospital
problem Acknowledge the obvious 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
What if…?
Something bad happens to a patient?Unique to hallway?Compare to ED?
A patient complains? Something doesn’t go perfectly?
Why?
SafePatientStaffPatient not yet seen
Easy Costs
LOSDiversionImprove processes
Why not?
Can’t vs. won’t COMB Perfect and good are enemies Leadership “belongs in the ED”
Summary
Identify THE problem and stick with it
Stop perpetuating the myth of the EVERYman
Place the problem in the lap of the person who must fix it
Stop ambulance diversion
Who does it?
Stony Brook Duke Wm. Beaumont
EMTALA
Yale St. Barnabus system “Inside the Joint Commission” JCAHO white paper and “Best
Practices”
And the truth is……….
….this
Is better than this………………
Chaos
No chaos
Bad care
Better care
Hard
Easy
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Everything is filled to the brim
Itsy-bitsy ED HUGE inpatient areas
How would you solve this as a NEW problem?
The future
Move them up anyway? Bad solution – expand the ED to
accomodate
John Rowles
“Safety” ≠ “Happy”
…. or
www.viccellio.com/overcrowding.htm