So you say overcrowding is an issue at your hospital. Your ED is regularly filled with admitted holds (patients admitted to the hospital waiting for beds, for those non-emergency affiliated readers). Your emergency nursing staff is burdened with inpatient care that they are not familiar with providing and/or documenting. Your ED docs are forced to see patients in hallways, lobbies, ambulance bays, waiting areas, wherever space allows. It is a highly inefficient, demoralizing and undignified way to provide care. Your patients are very unhappy. You are unhappy. Weekdays maybe you get some beds but Fridays and weekends are filled with staff call-outs, and having to close units. Do you have a headache yet?
So what is or are the solutions? Well, there is no magic pill. The Vicciellio concept is one: place the admitted holds one on each unit in the hallway upstairs on the floors. While this has been accepted by many state departments of health, it is put to little practical use by hospitals. Nursing unions do not like it, and short of forcing the issue by taking a patient up to a floor yourself and leaving them in a hallway against your administrations wishes, risks your job and probably your groups contract.
So what else? Well you could try and push for state legislation to provide disincentives for hospitals that continue this practice. This would take a while, in our state it could take years. So is it possible to fix the overcrowding situation? Yes (in this case I am an optimist). No one person however, is capable of making this drastic change. It involves changing the hospital culture to recognize that the ED for many places is the front door for their admitted patients, and therefore the ED should be treated as one of the hospital’s best customers. It involves every department of the hospital making sure the ED and floors have staffing and supplies they need to operate at full capacity 24 hours a day, or at least at peak volumes hours, compared to the current 9am-5pm model that most hospitals operate under now. For instance, if a low risk patient is placed in 24 hour observation on a Friday night to receive an MRI during the stay but your MRI unit is closed on Saturdays, then you won’t get the patient out in time. Money will be lost. It involves pushing your medical staff to recognize their own inefficiencies. Rounding once per day on inpatients is not enough. Patients need to be discharged as soon as possible, waiting until the next morning is no longer an option if they are ready to go at 5pm the day before. Case managers, social workers in the ED watching admitted patients from the ED to discharge is a necessity. Nursing homes must accept discharged patients at least 12 hours per day, I say 7a-7p, not just until 4pm, like many practice. If your hospital does not have a VP of quality along with a VPMA then you are behind. Finally, the ED docs, and nursing need to have a central reporting structure within administration. The time for nurses in the ED to only report to theVP of nursing and the docs to someone else is over. Our goals as docs and nurses in the ED are the same. There needs to be a commitment from administration to make this work at all levels; they need to acknowledge that admitted holds are not good for patient care. Finally, you need metrics. Measure every aspect of the patient moving through the entire hospital; from the time they walk through the ED to the time they are discharged. We need to look for prediction models of staffing, volume and throughput. Do you know what happens 24 hours after your hospital’s length of stay increases by 0.5 days? I don’t, but I would bet the number of holds in my ED will be going up. Imagine if you could staff for that ahead of time. Well there is a lot to swallow here. Our hospital is striving for many of these points, and I will keep you abreast of how the process proceeds.
Emergency Department Crowding