ED Overcrowding: Successful

Action Plans of a Southern California

Community Hospital

C L I N I C A L

Authors: Gillian Doxzon, RN, BSN, MAM, and JanetHoward-Ducsay, RN, BA, BSN, Redlands, Calif

Gillian Doxzon, Inland Empire Chapter, is Director of Critical Careand Emergency Services, and Janet Howard-Ducsay, Inland EmpireChapter, is Clinical Staff Educator Emergency Department, RedlandsCommunity Hospital, Redlands, Calif

For reprints, write: Janet Howard-Ducsay, RN, BA, BSN, RedlandsCommunity Hospital, 350 Terracina Blvd, Redlands, California 92374;E-mail: JYH@redlandshospital.org.

J Emerg Nurs 2004;30:325-9.

0099-1767/$30.00

doi:10.1016/j.jen.2004.06.009

August 2004 30:4

Overcrowded emergency departments threaten

access to emergency care for everyone. In the

last 12 years, US ED visits have risen from 89.8

million to 110.2 million, more than a 22% increase.1 The

Centers for Disease Control and Prevention cites an

increase of 2.7 million visits from 2001 to 2002, despite

reduced hospital resources. In turn, hospitals operate fewer

inpatient beds. Between 1990 and 1999, hospitals lost

103,000 staffed beds and 7800 medical/surgical intensive

care unit beds.1 Many clinical specialties in health care are

facing dramatic shortages, with one of the most serious

being nursing. Enrollment in California nursing schools is

limited, primarily due to 2 factors: state budget cuts and a

shortage of qualified nursing instructors. And the average

age of the nursing workforce is 48 years. With these

startling figures, there is no end in sight to today’s health

care crisis, and it probably has not reached its pinnacle. In

addition, a steady increase in population throughout the

country is occurring, particularly in the western region of

the country.

Gathering the data

In 2003, Redlands Community Hospital, a 172-bed

Southern California facility, responded to the JCAHO

standard in the Hospital Accreditation Manual (LD 3.4.

JCAHO), which requests that hospital leaders develop and

implement plans to identify and mitigate situations that

result in ED overcrowding. We reviewed pertinent hospi-

tal data and identified areas of concern as follows: (1)

overall ED visit census for the past 4 years had increased

38.4% (Figure 1); (2) the 68-minute ‘‘door to doc’’ time

JOURNAL OF EMERGENCY NURSING 325

FIGURE 1

Redlands Community Hospital ED visits.FIGURE 2

The total number of patients per year who left withoutbeing seen. The number in each histogram represents the %of total number of patients and the % of patients for thatyear. The decreasing figure in 2003 is the result of the PA atTriage program.

CLINICAL /Doxzon and Howard -Ducsay

was longer than the California Emergency Physicians

standard of 30 minutes as reported in their May 2003

Monthly Practice Management Report (A copy can be

obtained from Med America Analysis Reporting System,

2010 Webster St, Suite 1770, Oakland, CA 94612.); and

(3) hospital administration understood the impact of these

data not only affected the efficiency of the emergency

department and its staff, but also had an impact on the

depletion of the resources in the hospital.

We further examined specific data to help identify the

overcrowding situation in our 21-bed emergency depart-

ment, (14 beds and 7 hallway stretchers). The overall

number of patients, as well as the percentage of patients

left without being seen, was increasing dramatically. In

May 2003, with the introduction of a Physician Assistant

(PA) at Triage program, we achieved an improvement,

because the PA at Triage was providing care to 20% of

our census with a resulting rapid turnaround for these

patients.2 Since May 2003, the percentage of patients left

without being seen decreased to 1.8% from 3.5%, sup-

porting the overall effectiveness of the program (Figure 2).

The data on admitted patients were carefully exam-

ined, and we found that 90% of the medical admissions to

our community hospital arrive via the emergency depart-

ment. The percentage of admissions from the ED census

remained between 14% and 15% between 2000 and 2003,

but the overall increase in ED visits pushed the number of

admissions from 3726 to 5031 over 4 years, a 35%

326 JOURNAL OF EMERGENCY NURSING 30:4 August 200

increase (Figure 3). The acuity of admitted patients also

increased. Twenty percent of admissions were to critical

care beds and greater than 40% were to telemetry beds.

These figures are similar to those cited in a 2002 study

which found that the number of critically ill people

visiting California emergency departments increased by

59% over the past decade.3

The increase in admitted patients and the unavailabil-

ity of inpatient beds from 2001 to 2003 resulted in a 71%

increase in the hours of ED holds (Figure 4). With the

daily hold hours averaging approximately 90 hours per

day, the emergency department was saturated anywhere

from 8 to 20 hours per day.

According to the ED Policy Manual at Redlands

Community Hospital, saturation is reached when the

ED acuity and/or volume has reached maximum levels.

At saturation level, ED staffing is maximized with current

patient loads and patient care could be compromised by

accepting additional ambulance traffic. Our local commu-

nity’s annual growth rate is 3.5% with a steady growth in

the elderly population. The results of our customer/patient

surveys documented the following patient concerns: (1)

lengthy wait times, (2) delays in nonurgent treatments, (3)

perception of our lack of caring during their stay, (4) poor

4

FIGURE 3

The total number of patients admitted per year. Thenumber in each histogram represents the % of the yearlycensus admitted.

FIGURE 4

Hours of ED holds annually in Redlands CommunityHospital emergency department.

CLINICAL /Doxzon and Howard -Ducsay

updates about delays in procedures, and (5) lengthy

throughput times for discharges and admissions.

Designing the process

With these data and administrative support, a draft design

for patient flow process management was created. The

design was developed with input from many staff mem-

bers. The patient care coordinator (PCC) of the emergency

department provided input for the staffing and RN/LVN

coverage. The paramedic liaison nurse provided input on

the effect of ambulance traffic, diversion, and ED satura-

tion on the levels of the plan. The ED educator addressed

staff competency needs for additional training of tempo-

rary staff. The medical director addressed the availability of

providers and additional service hours and productivity.

The director of critical care addressed the impact of the

critical care hold patients on the ICU, direct observation

unit, and house census as well as staffing to stability level.

The next step of the process was to conduct ED

leadership meetings with our charge nurses, physician

assistants, and physicians. Brainstorming sessions were held

monthly. Through these interactive meetings, ideas, obser-

vations, and suggestions from various participants helped

to identify the areas affected in terms of daily patient care.

The consensus of the groups was to focus on (1) availability

of inpatient beds, (2) distribution of hold hours averaging

2400+ hours/month, (3) turnaround times for laboratory

August 2004 30:4

and radiology procedures, (4) nursing shortages, and (5)

‘‘door to doc’’ time. We felt that focusing on these specific

issues would contribute to the success of handling the

problems of ED overcrowding and patient throughput.

From February 2003 to February 2004, for example, the

average ‘‘door to doc’’ time improved greatly, from the

previous 68 minutes to 46 minutes, with 49% of those

visits taking less than 30 minutes. This improvement was

the positive result of our PA at Triage program developed

in May 2003.

Levels of response

After identifying the factors contributing to ED delays, 4

response levels were initially developed (Table 1) in

September 2003. These response levels identified elements

of the ED work conditions and the delay in patient

throughput. It showed the demand of services for other

ancillary departments based on the census. Levels 2, 3, and

4 were the descriptive codes to equate ED overcrowding.

Once the descriptive codes were in place, action plans

were created for each response level. Initially, the action

plans were started at the unit level beginning with the

emergency department. The action plans were labeled

411, 611, and 911, because these numbers were conve-

nient, easily recognized, and user friendly to notify ap-

propriate administrative staff. Departments such as lab,

radiology, post-anesthesia care unit, operating unit, case

management, and each nursing unit were asked to create

JOURNAL OF EMERGENCY NURSING 327

TABLE 1

ED status for activation of response levels

Level 1

1. ED flow is handling patient care2. There are no excessive delays3. All ancillary departments’ work flow is smooth4. Inpatient beds are available in all departments

Level 2 (consider calling 411)1. Increase in ambulance traffic and staging in hallway >10

minutes2. Patient arrival to MSE time >45 minutes3. >5 patients waiting for triage4. Three patients are ED holds for >2 hours5. All monitored beds in the emergency department are

occupied

Level 3 (consider calling 611)1. Increase in ambulance traffic and staging in hallway >20

minutes2. Patient arrival to MSE >60 minutes3. >8 patients waiting for triage4. Six patients are ED holds for >4 hours5. Monitored beds, hallway, and routine beds are all

occupied6. No inpatient beds are available

Level 4 (consider calling 911)1. Multi-casualty incident victims arriving via ambulance2. Patient arrival time to MSE >90 minutes3. >12 patients waiting for triage4. Ten patients are ED holds for >6 hours5. >3 ICU critical 1:1 ED patients6. No inpatient beds are available7. No available surgery add on time

MSE, Medical screening examination.

CLINICAL /Doxzon and Howard -Ducsay

their own unit response to various ED overcrowding

situations. Level 411 is an information update that the

emergency department is handling patient flow, but the

census is high and patient throughput is slowing down.

Level 611 is notification that there are system problems

and potentially unsafe conditions may begin to develop,

and Level 911 implies that all available resources are

maximized, routine diversion/saturation efforts are inef-

fective, and patient safety may be a serious risk.

While each department has individual unit-specific

ways to assist, common key elements exist at each level.

With the 411 level alert, similar responses include assessing

staffing availability and patient stability levels to initiate

potential transfers, downgrades, or discharges. Ancillary

and support departments typically mobilize needed

328

supplies such as beds and services to facilitate the flow.

At the 611 level, unit administrators act as liaisons between

the ED charge nurse and their units to mobilize patients to

inpatient beds. For non-affected units such as labor and

delivery and neonatal ICU, staff assists with patient care

and admission assessments. Ancillary departments, such as

lab, do batch testing and prioritize stats, and radiology will

reschedule outpatient exams. No in-house staff is flexed

home. At the 911 level response, administrators from all

departments are in direct contact with their units. If a 911

is called during off hours, the PCC is called and often will

return to the hospital and respond directly to the emer-

gency department. If necessary, all PCCs, educators, and

directors assist in triage, assessment, patient care, and

transfers. Medical staff is notified to triage inpatients for

possible changes in their level of care.

Activating the process

The emergency department uses an electronic ED tracker

to show the present patient census, pending admissions,

status events, wait lists, and hours of hold status. This is

centralized on a large monitor screen in the department

and on each ED computer so the criteria level response

information is readily available. Documentation of the

number of holds and length of stay for holds is quickly

made to evaluate what systems are contributing to the

delay in throughput time. Other information documented

includes (1) delays due to physician activities such as no

orders received, or need consult; (2) lack of bed availability

on specific units; (3) delay in lab or radiology; and/or (4)

delay due to a domino effect of transfers. The time of

action plan initiation is documented and the action plan

status is then sent to designated staff by text pagers.

When a level 611 or 911 plan is activated, the ED

charge nurse is the coordinator of the response team. He or

she assigns staff to begin patient assessments, discharge

patients, and/or transfer patients to the floor. Unit RN/

LVN may staff and open a holding area for pending

admissions in order to free up ED beds so we can move

patients from the waiting room. Lab, respiratory therapy,

and radiograph are stationed in the emergency department

for rapid response. Unit PCCs are facilitating downgrades

JOURNAL OF EMERGENCY NURSING 30:4 August 2004

CLINICAL /Doxzon and Howard -Ducsay

and potential discharges. The action plan may be in place

for only a few hours, which is frequently enough time to

‘‘unclog’’ the emergency department. Evaluation is contin-

uous until the action plan response is canceled, at which

point staff return to their units.

Conclusion

The department will continue to evaluate the effectiveness

of this program and make changes based on additional

data. The entire hospital contributes to the successful flow

of patients through the emergency department. Collabo-

rative efforts by various staff and departments make the

system work. ED overcrowding is not just an ED problem.

ED overcrowding is a systems problem requiring a sys-

tematic facility-wide multidisciplinary response.

Additional notes

During the hospital’s recent JCAHO survey, from March

8 to 11, 2004, the nurse surveyor requested a copy of the

implemented plan for ED overcrowding. The Patient Flow

Process Management Action Plan was presented during

the surveyors’ visit, and the plan, as it happened, was well

received and recommended as a Best Practice response to

the JCAHO Standard LD 3.49.

The action plan was also presented as a Best Practice

at CALENA State meeting by Gillian Doxzon, RN, in

Sacramento, CA, March 16 to 18, 2004. For in-depth

action plan responses, please request a document from

the authors.

REFERENCES

1. Centers for Disease Control and Prevention, Department ofHealth and Human Services. Data and Statistics. Availablefrom: URL: http://www.cdc.gov

2. Howard-Ducsay J. (2003, September) Use of Physician Assistantsat Triage in the Emergency Department. ENA Connection,2003;27(7):18.

3. Lambe S, Washington DL, Fink A, Herbst K, Liu H, Fosse JS,et al. Trends in the use and capacity of California’s emergencydepartments, 1990-1999. Ann Emerg Med 2002;39:389-96.

August 2004 30:4 JOURNAL OF EMERGENCY NURSING 329