Surge capacity: What can we do now?

Surge capacity?

Do we need a disaster to make it happen?

The morning report vs. ED holds

Answer

Simple Costs nothing Makes money Increases

safety Improves

nurse/patient staffing ratios

Not …

Why did this happen?Why did this happen to the ED?

Properly categorize the problem EMTALA the poor the safety net The unnecessary visit – who else

complains? Subtext – the poor SHOOT THE MESSENGER What’s the SCIENCE??

Temporary problems

… or …..

Too many inpatients in the ED !!!!

Strategies for the fix and the blame Ambulance diversion Transfer Triage out

EMTALA, the poor, the safety net

The unnecessary visit Temporary problems

Data data data

Send our business away

Strategy of victimization, race, and tragic heroes

Strategy of ignoring the problem

Strategy of beating the problem to death

Rules of the road It should help ALL of the patients, not the ED Operating principle: ED is necessary ED CANNOT bear brunt of the deficiencies of

the entire health care industry Inpatients don’t belong in the ED

ED provides LOUSY care of inpatients– The insecurity-driven scam

The problem and the solution should be moved out of the ED

Implementing the rules of the road

Fix the problems you canNo excuses from problems you

can’t

The ED is currently PREVENTING the solution to the problem

Discharge planningBed availability

“Safety” ≠ “Happy”Leadership COUNTS

An ED designed with monitors by each bed because of the unpredictable needs of incoming patients does not mean it is automatically an ICU or telemetry inpatient

unit. The willingness of emergency physicians to cope with just about anything is not a virtue if this situation is the result.

Mark Henry

What your ED does for you

AD Little community survey 5 vs. 40 Keep the hospital full Financial

1 moreTrauma center

With bad service, who leaves?

What your ED REALLY does for you

Defining the problem

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Everything is filled to the brim

Itsy-bitsy ED HUGE inpatient areas

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Current model

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

Current solution to HOSPITAL overcrowding

Crowd the EDSpaceStaffStructureExpertise

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+/- Radically new model – 1970’s

nice

nasty

WHY can’t we make it happen?

“Against the rules”

– “DOH won’t allow”

– OB OB OB ED ED ED “That’s the way things are done”

Generational indoctrinationReinforcement via the fire extinguisher

Keep the chaos IN the ED

Defining the real problem

Too

Many

Admitted

Patients

A fateful day

… in isolation

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

What about ambulance diversion?

Simply Diverts to other overcrowded ED’s

Not good business Can’t divert walk-ins

Solutions:

Move patients upstairs

Can’t do that???

Hospital overcrowding

Implementation of full capacity protocol First three months

www.viccellio.com/overcrowding.htm

Initial reaction

•DOH will not allow

•Not in the patient’s best interest

•ED needs to deal with this without impacting in-patient units

Our CQI Efforts

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

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.

The Real Solution

Move the patient upstairs.

The Administrative Decision

Focus on what is best for the patient

How is being in the hallway better for the patient?

But do we have to???????

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

Yes, Because……..

The Golden Rule of Health Care

If it were your Mother…….

Operating assumptions

The ED MUST remain openCritically ill patients MUST be

cared forWe act in the best interest of

the PATIENTS, not the ED

Process

Interdisciplinary Group Develop clear guidelines Communicate,

communicate, communicate

Development of Policy : Key Points

Identify applicable units Identify individual roles &

responsibilities Limit in-house hallway bed placement Prioritize “real” bed admissions :

hallway, ICU downgrade List criteria for hallway placement

Keys to Success:

“One Song, One Voice”*

*Drum Line

Keys to Success:

Identify a neutral party to make decisionsAnd communicate process

Keys to Success:

Support from The top

Keys to Success:

Don’t make this into a Big thing

Full capacity Protocol: How it Works Step 1 : ED attending in collaboration

with ED charge nurse identify need for protocol to bed coordinator

Step 2: Bed coordinator gains approval from Medical Director or designee

Step 3: Bed coordinator notifies Clinical Associate Directors and the Inpatient Units that Full Capacity Protocol is being implemented

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

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

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

The Impact of Calling Full Capacity Protocol?

Expedited mobilization of resources to discharge patients

Nursing influence results in physician practice change

Improved communication between departments

Those areas not subject to FCP continue the same inability to improve

Lessons Learned

Identify space and equipment issues prior to implementation

Sometimes “Just say No” Floor overwhelmed

Include patients in recognition efforts

What are the results?

Press-Ganey 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

Results: Patient Satisfaction

Press-Ganey

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??

Results: LOS

ED HallwayFloor Hallway

LOS

6.2

5.4

5

5.2

5.4

5.6

5.8

6

6.2

LOS: ED vs. Floor Hallway

LOS

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%

Patient in Hallway

•Late Rounding by MD’s•Disjointed Discharge Practices•Lack of Discharge Planning•Inefficient Room Turnaround Time•Lack of Med/Surg Beds, Specialty Beds•Overuse of Isolation•ICU Staffing•Poor Communication with bed control•No one has complete picture

Patient in Appropriate Room

The Problem/The Goal

Seeing is believing

Seeing is believing

… unless you refuse to look

And the truth is………..

Is better than……………

WAIT!!

Transferring the chaos to the inpatient units?

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

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

Key points

The ED is essential Admitted patients are a hospital

problem Acknowledge the obvious 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

What if…?

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

A patient complains? Something doesn’t go perfectly?

Why?

SafePatientStaffPatient not yet seen

Easy Costs

LOSDiversionImprove processes

Why not?

Can’t vs. won’t COMB Perfect and good are enemies Leadership “belongs in the ED”

Summary

Identify THE problem and stick with it

Stop perpetuating the myth of the EVERYman

Place the problem in the lap of the person who must fix it

Stop ambulance diversion

Who does it?

Stony Brook Duke Wm. Beaumont

EMTALA

Yale St. Barnabus system “Inside the Joint Commission” JCAHO white paper and “Best

Practices”

And the truth is……….

….this

Is better than this………………

Chaos

No chaos

Bad care

Better care

Hard

Easy

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Everything is filled to the brim

Itsy-bitsy ED HUGE inpatient areas

How would you solve this as a NEW problem?

The future

Move them up anyway? Bad solution – expand the ED to

accomodate

John Rowles

“Safety” ≠ “Happy”

…. or

www.viccellio.com/overcrowding.htm