1 how can we fix this mess? hospital overcrowding
TRANSCRIPT
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How can we fix this mess?
Hospital Overcrowding
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Answer
Simple Costs nothing Makes money Increases safety Improves
nurse/patient staffing ratios
No ambulance diversion
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The “undramatic” problems
Unreported bedUncleaned roomMD failure to dischargeSilos with full and empty bedsWeekend vs. weekday
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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
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Everything is filled to the brim
Itsy-bitsy ED HUGE inpatient areas
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Current model
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Current solution to HOSPITAL overcrowding
Crowd the EDSpaceStaffStructureExpertise
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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
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What are your SYSTEM incentives?
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Our ED
Pre (25,000)Incentives?
One Day ChangeBedside registrationNO patients wait in waiting
roomIncentives?
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90 ………… 12
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Xxxxxxxxxxxxxxxxxxxxxxxxxxx
x x x x x
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+/- Radically new model – 1970’s
nice
nasty
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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
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Defining the real problem
Too
Many
Admitted
Patients
In the wrong space, in the wrong place, with the wrong staff
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A fateful day
… in isolation
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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.viccellio.com/overcrowding.htm
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What about ambulance diversion?
Simply Diverts to other overcrowded ED’s
Not good business Can’t divert walk-
ins Works?
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Our CQI Efforts
• Meetings• Measures• Graphs• Memos• Repeat the above
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Behavior is driven by incentives
What are the incentives?
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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
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The Administrative Decision
Focus on what is best for the patient
How is being in the hallway better for the patient?
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Four questions
Space, load, expertise, and necessity
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Question 1 - Space
Good space Bad space
Action plan??
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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??
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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??
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Question 4 - Necessity
Is your emergency department necessary?
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Answer to questions 1-4
Move the patient upstairs.
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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.
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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? ….
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Guess what!?
Nurses are professionals. They can SEE what the best thing is
for the patients.
Where do you make them look?
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Hospital overcrowding
Implementation of full capacity protocol
First three months
www.viccellio.com/overcrowding.htm
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What to do during difficult times ...
Ask what’s best for the patient, and all the patients.
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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.
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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
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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
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Changes in criteria
Hallway = hallwayIsolation patientsICU patients !!!Medical director not
involved
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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.
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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
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Results: Patient Satisfaction
Press-Ganey
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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
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Patient opinions
Take a guess
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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
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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%
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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
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Results: Patient Satisfaction
Press Ganey
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What about those other CQI efforts?
Surprise surprise
www.viccellio.com/overcrowding.htm
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Transferring the chaos to the inpatient units?
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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
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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
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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
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Itsy bitsy trauma room
RN:PT Ratio = 4-5:1
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ICU
What if??????????
2 : 1 becomes 2.3 : 1
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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????????
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What if…?
Something bad happens to a patient?Unique to hallway?Compare to ED?
A patient complains?Something doesn’t go
perfectly?
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Why?
SafePatientStaffPatient not yet seen
Easy Costs
LOSDiversionImprove processes
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Why not?
Can’t vs. won’tCOMBPerfect and good are
enemiesLeadership“belongs in the ED”
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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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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