1. Surge capacity: What can we do now?

2. Surge capacity? Do we need a disaster to make it happen? The morning report vs. ED holds

3. Answer Simple Costs nothing Makes money Increases safety Improves nurse/patient staffing ratios

4. Not …

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

7. Properly categorize the problem EMTALA the poor the safety net The unnecessary visit – who else complains? Subtext – the poor SHOOT THE MESSENGER Whats the SCIENCE?? Temporary problems … or ….. Too many inpatients in the ED !!!!

8. 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

9. 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 dont 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

10. Implementing the rules of the road Fix the problems you can No excuses from problems you cant The ED is currently PREVENTING the solution to the problem Discharge planning Bed availability Safety Happy Leadership COUNTS

11. 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

12. What your ED does for you AD Little community survey 5 vs. 40 Keep the hospital full Financial 1 more Trauma center With bad service, who leaves?

13. What your ED REALLY does for you

14. Defining the problem

15. 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

17. 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

18. 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

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

22. 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 – 1970s nice nasty

23. WHY cant we make it happen? Against the rules –DOH wont allow –OB OB OB ED ED ED Thats the way things are done Generational indoctrination Reinforcement via the fire extinguisher Keep the chaos IN the ED

24. Defining the real problem Too Many Admitted Patients

26. A fateful day … in isolation

27. 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

28. What about ambulance diversion? Simply Diverts to other overcrowded EDs Not good business Cant divert walk-ins

29. Solutions: Move patients upstairs Cant do that???

30. Hospital overcrowding Implementation of full capacity protocol First three months www.viccellio.com/overcrowding.htm

32. Initial reaction DOH will not allow Not in the patients best interest ED needs to deal with this without impacting in-patient units

33. Our CQI Efforts Meetings Measures Graphs Memos Repeat the above

34. 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.

35. The Real Solution Move the patient upstairs.

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

37. But do we have to???????

38. Inpatient Units are: less crowded, less noisy, less chaotic Inpatient Units provide appropriate clinical expertise (MDs, RNs) Staging in an inpatient hallway will result in closer, therefore faster access to a room Yes, Because……..

39. The Golden Rule of Health Care If it were your Mother …….

40. Operating assumptions The ED MUST remain open Critically ill patients MUST be cared for We act in the best interest of the PATIENTS, not the ED

41. Process Interdisciplinary Group Develop clear guidelines Communicate, communicate, communicate

42. 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

43. Keys to Success: One Song, One Voice* *Drum Line

44. Keys to Success: Identify a neutral party to make decisions And communicate process

45. Keys to Success: Support from The top

46. Keys to Success: Dont make this into a Big thing

47. 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.

48. 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

49. 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

50. 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

51. Lessons Learned Identify space and equipment issues prior to implementation Sometimes Just say No Floor overwhelmed Include patients in recognition efforts

52. What are the results? Press-Ganey Governors Workforce Award LOS studies Its just too simple and obvious. You cant expect us to believe this. Something must be wrong here. Dan Sisto, NYHA

53. Results: Patient Satisfaction Press-Ganey

54. 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??

55. Results: LOS

56. 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%

57. Patient in Hallway Late Rounding by MDs 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

58. Seeing is believing

59. … unless you refuse to look

60. And the truth is………..

61. Is better than……………

62. WAIT!!

63. Transferring the chaos to the inpatient units?

64. 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 6.04 - 6.33; available 6 Question: which is safer??? Direct patient care: 8 of 15.5 RNs SPACE

65. 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 No space Space

66. 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

67. What if…? Something bad happens to a patient? Unique to hallway? Compare to ED? A patient complains? Something doesnt go perfectly?

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

69. Why not? Cant vs. wont COMB Perfect and good are enemies Leadership belongs in the ED

70. 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

71. Who does it? Stony Brook Duke Wm. Beaumont EMTALA Yale St. Barnabus system Inside the Joint Commission JCAHO white paper and Best Practices

72. And the truth is………. ….this

73. Is better than this………………

74. Chaos

75. No chaos

76. Bad care

77. Better care

78. Hard

79. Easy

80. 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 How would you solve this as a NEW problem?

81. The future Move them up anyway? Bad solution – expand the ED to accomodate

82. John Rowles Safety Happy

83. …. or www.viccellio.com/overcrowding.htm