Overcapacity in the Emergency Department and Timely Through - PowerPoint Presentation

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