No beds? ED sends patients upstairs
Patients are safer and happier
Are there any patients being held in your ED's hallway right now? How would you like for those patients to go directly to an inpatient hallway instead? That's exactly the policy that the ED at Stony Brook (NY) University Medical Center has in place.
Medical/surgical and telemetry patients are held in the ED's hallways only as a last resort, says Anna Rosenthal, RN, ED nurse manager. "I don't have a holding room here, and we find every nook and cranny to put somebody in first before we go to a hallway," she says. However, if those patients who don't have a room meet the criteria for the "hallway policy," they go upstairs right away — to an inpatient hallway.
Three nurses work as bed coordinators to facilitate inpatient flow, including placement to an available room or in a hallway. "If we have three patients waiting for a bed, they will automatically implement the hallway protocol and the patients go up," says Rosenthal. Previously, the hallway policy went into effect only when the ED was filled to capacity, but now all "hallway-eligible" patients go right upstairs, she says. Patients who are in severe pain, vomiting, in isolation, or confused are not eligible.
"Let's say I have two surgical and two medicine patients waiting to go up. The bed coordinator will divvy them out to the inpatient hallways. Later on in the day as we fill up, they'll take the next three or four patients who are waiting," explains Rosenthal.
This policy has decreased length of stay from 6.2 days for patients held in the ED, down to 5.4 days for patients admitted to an inpatient hallway, and is much better for patients, she says. "The policy is wonderful because the patient is placed on the unit that has the expertise to care for them," Rosenthal says. "It also takes 13 patients out of the ED — that is how many hallway spots we have — and that's a lot of patients."
Nurses use scripting and tell the patients, 'I'm sorry that we don't have a bed for you yet. You are going upstairs to the hallway, but you will get the next available bed. The staff is wonderful, and you will be given really good care."
Instead of being angry that they are sent to an upstairs hallway instead of an inpatient bed, most patients actually are relieved, according to Rosenthal. "They feel like they are going closer to where they are supposed to be," she says.
The hallway policy frees up space for incoming ED patients to be treated, says Carolyn Santora, MS, RN, CNAA-BC, associate director of critical care nursing at Stony Brook. "In the first year after the policy was implemented, we had a significant increase in patient satisfaction scores for ED patients," she says. Scores increased from the 35th percentile to the 80th percentile, she reports.
A "hallway protocol" is used when the ED at Harris Methodist Fort Worth Hospital is at full capacity, and typically it is used for patients who are less acutely ill. "They are able to receive concentrated nursing care and monitoring when they are on an inpatient floor," says Barbara Van Wart, RN, ED manager. "The hallway protocol moves the patient one step closer to a private patient room, still allowing them to receive one-on-one attention from a highly trained nurse."
At both Harris Methodist and Stony Brook, patients in hallways are given privacy screens and call bells so they can maintain their privacy and rest.
Harris Methodist patients that meet the criteria for the hallway protocol include telemetry and nontelemetry patients, excluding all ICU patients, patients at high risk for a cardiac event, ventilator-dependent patients, patients requiring isolation, and patients who have gastrointestinal bleeds or who are experiencing vomiting or diarrhea, says Van Wart. "Patients who are not eligible are sent to the next available private room in the hospital," she says.
Tips to obtain buy-in
To get the hospital to buy into the policy, the ED focused on the needs of the patient, asking the simple question "Where is the patient better off?" says Santora. "When the only alternatives are a crowded, noisy ED hallway or a quieter, less crowded inpatient hallway, where you have expert nurses in the care that patient is going to receive, the decision is obvious and easy," says Santora. "This did not become a matter of competing needs of the inpatient staff vs. the ED staff."
While a handful of EDs have implemented a similar hallway policy, some interviewed by ED Nursing reported problems with their state department of health. However, Santora says there are no rules or regulations that apply to inpatient hallways that do not also apply to ED hallways.
"They need to ask the right question, which is: 'If I have no alternative but to place a patient in a hallway — can I place them in an inpatient hallway vs. the ED hallway?'" advises Santora.
To obtain buy-in from inpatient nurses, the ED did a study and reported that patients received 3.87 of additional nursing care hours in inpatient hallways than they did when being held in the ED. "The difference was dramatic and completely supported the protocol," Santora says. "The inpatient nurses still don't like it, but they understand why the patient is there and agree that they can give the patient better care."
Sources
For more information about the ED's hallway policy, contact:
- Anna Rosenthal, RN, Nurse Manager, Emergency Department, Stony Brook University Medical Center, Nichols Road, Stony Brook, NY 11794-8501. Phone: (631) 444-8028. E-mail: [email protected].
- Carolyn Santora, MS, RN, CNAA-BC, Associate Director, Critical Care Nursing, Stony Brook University Medical Center, Nichols Road, Stony Brook, NY 11794-8501. Phone: (631) 444-2922. Fax: (631) 444-6298. E-mail: [email protected].
- Barbara Van Wart, RN, Manager, Emergency Department, Harris Methodist Fort Worth Hospital, 1301 Pennsylvania Ave., Fort Worth, TX 76104.
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