Marian Conde University of Central Florida Leadership and Management Scope History Demand for Emergency Department services exceeds the available supply Inability to move patients to inpatient units ID: 357172
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Slide1
Overcapacity in the Emergency Department and Timely Throughput of Patients to Inpatient Units
Marian Conde
University of Central Florida
Leadership and ManagementSlide2
Scope: History
Demand for Emergency Department services exceeds the available supply
Inability
to move patients to inpatient units
"
Boarders" or "holds" (patients needing to stay in the ED due to no bed availability in inpatient units) that consume substantial amounts of resources and labor.
Unable
to bring patients back to the ED from the waiting
areas (Barrett, L., Ford, S., & Ward-Smith, P, 2012)
Ambulance
diversion due to over capacity
Emergency
department frequent users (ED-FU) visits multiple
times(
Bodenmann
, P.,2014)
Uninsured
or underinsured use ED as a primary care physician
50
% of hospital emergency departments are at over capacitySlide3
Scope: Impact
Negative impact on patient care
Patient
Safety: Patients need to be admitted to the in-patient units where caregiver competencies align with the patient's
condition
(Driscoll, M., Tobis, K., Gurka, D., Serafin, F., & Carlson, E., 2015).
Length
of stay
Cost
of care
Clinical
resource utilization
Patient
satisfaction
Physician
satisfaction
Nurse
satisfaction
Increase
of medical errors due to overcrowding and understaffing
Unnecessary
mortality
Access
block due to
overcrowding
(Khanna, S., Boyle, J., Lind, J., 2012). Slide4
Specific Problem
Over capacity in ED and Flow of Patients to Inpatient Unit in a timely manner.
Patients health outcomes & mortality are at risk due to the inability to move patients from the ED to in-patient units for their care in a timely manner and it plays a large role in patient dissatisfaction with their care
.Slide5
Nurse Leader Role
It is the responsibility of the nurse leader to work on a collaborative plan which will include all disciplines to ensure the correct placement and flow of patients from the ED to inpatient units.Slide6
Nursing Issue
Decrease time spent in ED to an inpatient bed correlates with improved mortality
outcomes (Barrett, L., Ford, S., & Ward-Smith, P., 2012).
Improved patient satisfaction.
Decrease time spent in ED for patient correlates with wait time for other patients to be seen which in turn correlates to improved revenue for hospital.
Transferring patients to inpatient beds correlates to a decrease in left without being seen by a physician and ambulance diversion.
Increase satisfaction for both physicians and nursing
teams.Slide7
Alternative Solutions
Daily Mission / Huddles with all involved disciplines to discuss potential discharges, surgical patients to be admitted, direct admits awaiting bed at home.
Teaching of the National Emergency Department Overcrowding Scale (NEDOCS) to all disciplines involved in the placement of patients and when each level of the plan would be initiated.
Private
rooms to be turned back to semi-private to enable patients in the ED to be moved to the proper level of care and decrease holds or boarders in the ED
.Slide8
Alternative Solutions
Bed management meetings to be called and held consistently if House Supervisor feels the hospital is moving into overcapacity.
Inpatient Managers, Assistant Nurse Managers and staff nurses to shadow ED nurses to have a better understanding of the flow and the importance of placing patients in inpatient beds in a timely manner by sharing data of why it is beneficial for both the patients and the hospital
.Slide9
Selected Solutions
Implementation of daily Bed Management meetings at 08:30 and
04:00.
All Stakeholders to attend Bed Management
meetings.
NEDOC Levels reviewed and decision of when to implement each
level (Weiss, S., Ernst, A., & Nick, T., 2006).
Bed ahead: each unit to have a nurse ready to accept patient and stretch assignment if needed to receive patient from ED.Slide10
Implementation of Plan
Bed management strategy was put in place by having all stakeholders involved in the transfer of patients from the ED to inpatient units.
Stakeholders at table were:
ED physicians, CNO, all Nursing Directors both ED and Inpatient,
all Nurse
Managers (ED & Inpatient), Assistant Nurse Managers
from all units
, representatives from Surgical Services,
Transportation
,
Environmental
Services, Dietary, laboratory, CT,
MRI
, Pharmacy and
Patient
Financial services.
All stakeholders attend the morning Mission Meeting were capacity and placement of patients is discussed. Discharges are reviewed, surgical patients to be admitted and direct admits. Staffing for both days and nights is reviewed and needs are reviewed for all areas of the hospital
.Slide11
Implementation of Plan
NEDOC Scale: was reviewed by all and when to implement each level of the plan was decided on with feedback from all of the stakeholders.
Shadow dates were set up for stakeholders to have a better understanding of the flow of the patients from the ED to inpatient units
.
Care Manager was placed in ED to facilitate proper placement of patients
.
Discharge area was developed and opened to facilitate the opening of inpatient beds by moving discharged patients waiting for rides to the discharge area.Slide12
Plan for Evaluation
Patient Satisfaction scores based on HCAPHSSlide13
Plan for Evaluation
ED matrix for
a
) time of arrival to see doctor
b
) time from arrival to
discharge
home
c
) time from arrival to
placement in
inpatient unit
bed
d
) number of patients that
left
the
ED
without being seen
e
) diversion of ambulances or
wait
time to unload
f
) amount of time from
decision
to
admit
to time
admitted
to bedSlide14
References
Barrett, L., Ford, S., & Ward-Smith, P. (2012). A bed management
strategy
for
overcrowding
in the emergency department.
Nursing
Economic$
,
30
(2), 82-86.
Bodenmann, P., Velonaki, V., Ruggeri, O., Hugli, O., Burnand, B.,
Wasserfallen
, J., & ... Daeppen, J. (2014). Case management
for
frequent users of the emergency department: study
protocol
of a randomized controlled trial.
BMC Health Services
Research
,
14
(1), 426-449. doi:10.1186/1472-6963-14-264
Driscoll, M., Tobis, K., Gurka, D., Serafin, F., & Carlson, E. (2015).
Breaking
down the
silos
to decrease internal diversions and
patient
flow delays.
Nursing
Administration
Quarterly
, (1). doi:
10.1097/NAQ.000000000000080Slide15
References
Hadley, M. (2009). Overcapacity protocols.
Alberta RN/ Alberta Association of Registered Nurses,
65 (2), 3.
Khanna, S., Boyle, J., Good, N., & Lind, J. (2012). Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block.
Emergency Medicine Australasia
,
24
(5), 510-517. doi:10.1111/j.1742-6723.2012.01587.x
Richards, J., Ozery, G., Notash, M., Sokolove, P., Derlet, R., & Panacek, E. (2011). Patients prefer boarding in inpatient hallways: Correlation with the national emergency department overcrowding score.
Emergency Medicine International
, 1-4. doi: 10.1155/2011/840459
Weiss, S., Ernst, A., & Nick, T. (2006). Comparison of the national emergency department overcrowding scale and the emergency department work index for quantifying emergency department crowding.
Academic Emergency Medicine
, 13 (5), 513-518. doi: 0.1197/j.aem.2005.12.009