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 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 !!!!

4 The “undramatic” problems Unreported bed Uncleaned room MD failure to discharge Silos with full and empty beds Weekend vs. weekday

5 Strategies for the fix and the blame Send our business away Ambulance diversion Transfer Triage out Blame someone who can’t defend themselves EMTALA, the poor, the safety net Ignore it The unnecessary visit Temporary problems Study it to death Data data data

6 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 ED ED provides LOUSY care of inpatients The problem and the solution should be in the hands of the “right” people

7 My enemy - me Wrong problem Wrong fix Willingness to bear the burden “…. Just as soon as we can. Let’s meet! …..”

8 x x x x x x x x x x x x x x x x x x x x x x x Everything is filled to the brim Itsy-bitsy ED HUGE inpatient areas

9 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x xx x x x Current model

10 Current solution to HOSPITAL overcrowding Crowd the ED Space Staff Structure Expertise

11 Current model Core measure: Timely administration of antibiotics Core measure: Door to balloon time Timely treatment of strokes Patient satisfaction Inadequate staff Inadequate space Lots of meetings

12 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x xx x x x Is this your ED model?

13 What are your SYSTEM incentives?

14 Our ED Pre (25,000) Incentives? One Day Change Bedside registration NO patients wait in waiting room Incentives?

15 90 ………… 12

16 Xxxxxxxxx xxxxxxxxx xxxxxxxxx xxxxx xxxxxx x x x x x x x x x x x x x x x xx x x x +/- Radically new model – 1970’s nice nasty

17 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 ED ED vs. rest of hospital The problem is not admissions

18 Defining the real problem Too Many Admitted Patients In the wrong space, in the wrong place, with the wrong staff

19 A fateful day … in isolation

20 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”

21 What about ambulance diversion? Simply Diverts to other overcrowded ED’s Not good business Can’t divert walk- ins Works?

22 Our CQI Efforts Meetings Measures Graphs Memos Repeat the above

23 Behavior is driven by incentives What are the incentives?

24 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

25 The Administrative Decision Focus on what is best for the patient How is being in the hallway better for the patient?

26 Four questions Space, load, expertise, and necessity

27 Question 1 - Space Good space Bad space Action plan??

28 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??

29 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??

30 Question 4 - Necessity Is your emergency department necessary?

31 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.

32 Answer to questions 1-4 Move the patient upstairs.

33  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? ….

34 Guess what!? Nurses are professionals. They can see what the best thing is for the patients.

35 Hospital overcrowding Implementation of full capacity protocol First three months

36 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

37 Keys to Success: “One Song, One Voice”* *Drum Line

38 What to do during difficult times... Ask what’s best for the patient, and all the patients.

39 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.

40 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

41 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

42 Changes in criteria Hallway = hallway Isolation patients ICU patients !!! Medical director not involved

43 Itsy bitsy trauma room RN:PT Ratio = 4-5:1

44 ICU What if?????????? 2 : 1 becomes 2.3 : 1

45 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????????

46 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.

47 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

48 Results: Patient Satisfaction Press-Ganey

49 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

50 Patient opinions Take a guess

52 Results: Disposition Average patients > 1 hr= 10.3 hrs Average all patients = <5 hrs (16% of patients did not meet hallway criteria) Immediate RoomRoom < 1 hrRoom > 1hr 28%25%46%

53 03/04 Data 2003: 161 patients placed in the hallway 2004: 454 patients placed in the hallway Average ED stay prior to hallway placement: 213 minutes ( 3.5 hrs) Average stay in hallway 454 minutes (7.5 hrs) (longest 29hrs) 35% spent < 1 hr in hallway

54 Results: Patient Satisfaction Press Ganey

55 What about those other CQI efforts? Surprise surprise

56 Seeing is believing

57 And the truth is………..

58 Is better than……………

59 If you were scared …….

60 Transferring the chaos to the inpatient units?

61 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 3.5 Total RN need 18.5; available 10 (8) Floors Needs 6 for 30 Has 6 for 30 Redistribution (max 2 per unit) [8 patients to floor] ED total RN needed 17; available 10 Floor total RN needed ; available 6 Question: which is safer??? Direct patient care: 8 of 15.5 RN’s SPACE

62 Side-by-side: 1.70 RN vs 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 No space ≠ Space

63 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

64 What if…? Something bad happens to a patient? Unique to hallway? Compare to ED? A patient complains? Something doesn’t go perfectly?

65 Why? Safe Patient Staff Patient not yet seen Easy Costs LOS Diversion Improve processes

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

67 The 9 – 5 weekday hospital

68 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”

69 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