1

How can we fix this mess?

Hospital Overcrowding

2

Answer

Simple Costs nothing Makes money Increases safety Improves

nurse/patient staffing ratios

No ambulance diversion

3

The “undramatic” problems

Unreported bedUncleaned roomMD failure to dischargeSilos with full and empty bedsWeekend vs. weekday

4

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

EDED provides LOUSY care of

inpatients The problem and the solution

should be in the hands of the “right” people

5

xx

xx

x

xx

xx

x

xx

xx

x

xx

xx

xx

xx

Everything is filled to the brim

Itsy-bitsy ED HUGE inpatient areas

6

xx

xx

x

xx

xx

x

xx

xxx

xx

xx

xx

xx

xx

x

xx

xxx

xx

x

Current model

7

Current solution to HOSPITAL overcrowding

Crowd the EDSpaceStaffStructureExpertise

8

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

9

xx

xx

x

xx

xx

x

xx

xxx

xx

xx

xx

xx

xx

x

xx

xxx

xx

x Is this your ED model?

10

What are your SYSTEM incentives?

11

Our ED

Pre (25,000)Incentives?

One Day ChangeBedside registrationNO patients wait in waiting

roomIncentives?

12

90 ………… 12

13

Xxxxxxxxxxxxxxxxxxxxxxxxxxx

x x x x x

x x x x x x

x

xx xxxxxx

xx

x

xx

xxx

xx

x

+/- Radically new model – 1970’s

nice

nasty

14

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 EDED vs. rest of hospitalThe problem is not admissions

15

Defining the real problem

Too

Many

Admitted

Patients

In the wrong space, in the wrong place, with the wrong staff

16

A fateful day

… in isolation

17

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

18

What about ambulance diversion?

Simply Diverts to other overcrowded ED’s

Not good business Can’t divert walk-

ins Works?

19

Our CQI Efforts

• Meetings• Measures• Graphs• Memos• Repeat the above

20

Behavior is driven by incentives

What are the incentives?

21

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

22

The Administrative Decision

Focus on what is best for the patient

How is being in the hallway better for the patient?

23

Four questions

Space, load, expertise, and necessity

24

Question 1 - Space

Good space Bad space

Action plan??

25

Question 2 - Load

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??

26

Question 3 - Expertise

Unit A 6 nurses Needs 11 Wrong expertise Wrong

environment

Units B, C, D, E, F, G, H, I, J

6 nurses Needs 6 Right expertise Right

environment

Action plan??

27

Question 4 - Necessity

Is your emergency department necessary?

28

Answer to questions 1-4

Move the patient upstairs.

29

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.

30

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

Why? ….

31

Guess what!?

Nurses are professionals. They can SEE what the best thing is

for the patients.

Where do you make them look?

32

Hospital overcrowding

Implementation of full capacity protocol

First three months

www.viccellio.com/overcrowding.htm

33

What to do during difficult times ...

Ask what’s best for the patient, and all the patients.

34

Full capacity Protocol: How it Works

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.

35

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

Get them OFF tele

36

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

37

Changes in criteria

Hallway = hallwayIsolation patientsICU patients !!!Medical director not

involved

38

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.

39

What are the results?

Press-Ganey 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

40

Results: Patient Satisfaction

Press-Ganey

41

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

42

Patient opinions

Take a guess

LOS: ED vs. Floor Hallway

6.2

5.4

5

5.2

5.4

5.6

5.8

6

6.2

6.4

ED Hallway Floor Hallway

LOS

44

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%

45

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

46

Results: Patient Satisfaction

Press Ganey

47

What about those other CQI efforts?

Surprise surprise

www.viccellio.com/overcrowding.htm

48

Transferring the chaos to the inpatient units?

49

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

50

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

51

Side-by-side: NOT ED VS. FLOOR

Patient safety?

10 (18.5)

10 (17) 6 (6.04 – 6.33)

6 (6)UNIT A UNIT B

FCP FCP

52

Itsy bitsy trauma room

RN:PT Ratio = 4-5:1

53

ICU

What if??????????

2 : 1 becomes 2.3 : 1

54

What about ratios & NCH in the ICU?

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????????

55

What if…?

Something bad happens to a patient?Unique to hallway?Compare to ED?

A patient complains?Something doesn’t go

perfectly?

56

Why?

SafePatientStaffPatient not yet seen

Easy Costs

LOSDiversionImprove processes

57

Why not?

Can’t vs. won’tCOMBPerfect and good are

enemiesLeadership“belongs in the ED”

58

Who does it?

Stony Brook Duke Wm. Beaumont

EMTALA Yale St. Barnabus system NYU LOTS of places now “Inside the Joint Commission” JCAHO white paper and “Best Practices”

59

Key points

The ED is essential Admitted patients are a hospital problem Patients need experts for their care

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