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Our environment – the silent issue

Hospitals 1960 vs. now

ED 1960 vs. now

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Crowding

The cause

The consequence

The cure

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1. What’s NOT the cause?

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Inappropriate or “unnecessary” visits to the ED

What are the results of the research?Sore throatsRetrospectivitis*****Franacek*****

What could be done about it?Education: 5% decrease vs. 20% increase

Does it matter?Excellent studies show that patients with minor

problems to NOT impact on the waiting times for the seriously ill

Therefore, any actions focused on this “issue”, if it is one, will NOT improve issues related to the boarding of admitted patients in the ED

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Money, not crowding, is the issue for these:

EMTALASafety net

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The big gorilla

Admitted patients, boarding in the ED, are THE major contributor to overcrowding and delays in care in the ED actual data!

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8

9Finito!

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What causes ED overcrowding?

Hospital overcrowding

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Boarding:What are the consequences?

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Sick people have to wait too long to receive care

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Boarding increases TOTAL length of stay in the hospital, further worsening access.

5 + studies – 1 day

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Boarding increases walkouts, some needing admission

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Overcrowding increases medical errors

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JCAHO

50% of sentinel events occur in the ED

1/3 of these are related to overcrowding

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Overcrowding causes deaths

….. beyond anecdote

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How big is the effect?

Pneumonia 1.07Crowding 1.2 – 1.4Weekend admit 1.01 – 1.05

Group sizes

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Comparison

100 pneumonias: save 7100 “crowding” admits: save 17

– 25(RR 1.2 – 1.34)

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The BIG question

Does this problem kill more people than problems identified

in other initiatives to improve outcomes of patients?

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Physicians are harmed

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25,000 patients

Frequency of suits based on whether the patient waited less or more than 30 minutes to be seen:< 30 = 0.9> 30 = 4.9

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Key points

Crowding is caused by boarding

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Boarding increases harm to patients in the following ways:

Waiting timesDiversionsLength of stayMedical errorsSentinel eventsMORTALITY

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Boarding increases harm to hospitals and doctors in the following ways:

Financial losses to hospital and MD

Malpractice claims

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How do we fix it?

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How do we currently deal with this problem?

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xxxxx

xxxx

x

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Everything is filled to the brim

Itsy-bitsy ED

HUGE inpatient areas

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xxxxx

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xxxxx

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Current model

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Current solution to HOSPITAL overcrowding

Crowd one areaSpaceStaffStructureExpertise

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xxxxx

xxxx

x

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x

Which block in this diagram is LEAST capable of surge?Which block in this diagram needs to be MOST capable of surge?

The question …..

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Xxxxxxxxxxxxxxxxxxxxxxxxxxx

x x x x x

x x x x x x

x

xxxxxxx

x

xxx

xxxxx

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x

“Radically” new model – redistribute the load

nice

nasty

Move SOME boarders to the floors, even if it means putting them in the hallway. The ED CONTINUES to bear brunt of boarders

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The current status quo

Too many admitted patientsin the wrong space, in the wrong

place, with the wrong staffis dangerous to our patients.

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The cure

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Why not divert ambulances?

In most circumstances, it simply doesn’t work

If allowed:other solutions are not sought

Dangerous to the patient

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Summary: ambulance diversion is:

Unsafe IneffectiveMoney loser

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Other lousy solutions

Deferred careSafety?Effectiveness?

MD at triage; RN -> MD

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The ONLY current solution known to work:

Move the admitted patients out!

(The Full Capacity Protocol)

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Ask Four questions

Space, load, expertise, and necessity

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Question 1 - Space

Good space Bad space

If given both, where would you place the patient? Obviously, in the “good” space. But, what if there WAS no good space???? (see next question)

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Question 2 – Load – all units full

Ten patient units: A, B, C, D, E, F, G, H, I, J

No “good” space on ANY unit

Action plan??

20 additional patients beyond “good” space capacity. How would you distribute them?

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Question 3 – Expertise – all units full

Unit A Understaffed

4 nursesNeeds 6

Wrong expertise Wrong

environment

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

6 nurses Needs 6 Right expertise Right

environment

20 additional patients beyond “good” space capacity. How would you distribute them?

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Question 4 - Necessity

Is your emergency department necessary?

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CURRENT answers

#2: load up Unit A#3: load up Unit A#4: no, the ED is not necessary

This is NUTS! Worse than that, this is “the way we do things.”

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Answer to questions 1-4

Move the patient upstairs.

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The bold move by the NY State DOH:

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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.hospitalovercrowding.com

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Inpatient Units are: less crowded, less noisy, less chaotic

Inpatient Units provide appropriate clinical expertise (MD’s, RN’s)Emergency physicians are great at what they do.

However, they are not cardiologists, pulmonologists, intensivists, etc. Once the patient is admitted, they deserve the appropriate specialty care

Staging in an inpatient hallway will result in closer, therefore faster access to a room

The ED can continue to fulfill its mission

Why? ….

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Full capacity Protocol: How it Works

Step 1 : ED attending and ED charge nurse determine that the ED is close to full capacity, and thus, the care of the next patient is threatened

Step 2: Bed coordinator evaluates the situation – NEUTRAL party

Step 2a: Medical Director approves any decision. NEUTRAL party

Step 3: Bed coordinator notifies Clinical Associate Directors

Step 4: Units assigned hallway patients. No unit will receive more than 2 hallway patients.

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How many?

PICU

Burn

SICUCV ICU

Floor9543

66.6% FCPeligible

Peds

MICUCCUNeuro

ED

12733 total3190

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Impact per boarded admission on ED wait-to-be-seen times:

Typical impact under “business as usual”: 15 minutes per boarded patient8 boarders: each patient waits an extra 2 hours to be

seen FCP at Stony Brook:

1 minute per boarded patient8 boarders: each patient waits an extra 8 MINUTES to be

seen (because of the “decompression” effect of the FCP)2/3 of floor admissions qualifyExperience with 2500+ patients placed on floors to

relieve crowding

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Impact

Better care for all patientsMore timely treatmentFewer errors

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Why? Safety

Decreased diversion, walkouts, delay, sentinel events, errors, deaths

EasyLarge work load redistributed across wide area, each area with

very small increase in work load Costs

Call bell, central telemetry, privacy screenNO extra staff, etc.

SavingsLOS Improve processes, ED AND inpatientMORE BUSINESSFewer suits

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Why not?

Can’t vs. won’tRefuse to considerRefusal to acknowledge safety issuesSilo mentality (only MY area matters)

Perfect and good are enemiesFailure of leadership

Fear of change

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Why Stony Brook?

A true commitment to patient safety for EVERYONE, not just as viewed from the individual silo

Willingness to succeed, and willingness to go the extra mile on behalf of the patient

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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”

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Crowding is bad for hospital finances as well

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Move ‘em out ….

SimpleThe helping hand is tiny

Costs insignificant Makes money Increases safety Improves nurse/patient staffing ratios Improves processes No ambulance diversion

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Key points

The ED continues to function Patients receive expert care in the area

and by the people best suited to provide that care

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What is being asked?

LOTS of people are being asked to do a LITTLE extra so that a small number of people can accomplish the difficult, rather than the impossible.

It is being asked because this is the safest thing to do for the most patients.

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What is being asked? – the practical version

If the problem is more admissions than there are beds:

250 people take care of the easy ½ of a problem while 15 people take care of the hard ½ of a problem.