Discharged ED patients boarded
Ready for discharge, awaiting paperwork
To address patient flow EDs across the country are employing different variations around boarding inpatients in upstairs hallways. Staff members at St. Vincent Hospital in Boston are trying something a little different: In a recently introduced policy, they are only boarding ED patients who have been discharged or who are about to be discharged, and only with their permission. The end result is that more ED beds available for incoming patients and those patients who need ongoing clinical care.
"The policy is hospitalwide and enables us to expedite patients out of the ED," explains Octavio Diaz, MD, MPH, the hospital's chief medical officer. Diaz is a board-certified emergency physician and former chief of emergency medicine who still practices. "It's not the standard, 'take-the-sick-patients-out-and-put-them-in-hallways-upstairs' approach," he says. "We took a secondary approach."
Thus, for example, the policy might apply for patients who were ready to be discharged but the physician is waiting to determine if they can tolerate food orally, or who were waiting for their final dose of antibiotics. Or, they might be elderly patients who need dictation to be completed before calling an ambulance to return them to a nursing home.
This option was the first one the hospital leaders looked at, explains Diaz, noting that those patients may be moved to hallway beds. However, he adds, patients can be discharged only with the patients' and physician's permission.
William Sullivan, DO, JD, who is the director of emergency services at St. Mary's Hospital in Streator, IL, and a practicing attorney, sees no legal problems with this policy. "Having discharged patients wait in hallways or even wait in waiting rooms is entirely appropriate and is commonly practiced," he says. "During busy periods, our hospital will often have discharged patients wait in the waiting room for discharge instructions and/or prescriptions."
There isn't a legal duty to keep discharged patients in a room until they leave the premises, Sullivan maintains. "If a patient is deemed stable enough for discharge, there is no 'emergency medical condition,' and EMTALA no longer applies," he says. "If the hospital needs a bed for an incoming ambulance run, having stable patients wait in other areas of the emergency department is medically appropriate."
So far, the new policy has been implemented only a handful of times, but Paul Mackinnon, PhD, RN, FNP, the hospital's chief nursing officer, who also has run a Level I trauma center and two EDs, says it's been met with approval by patients and most nurses. "We asked one gentleman what he thought, and he gave us accolades," he reports. The ED nurses welcomed it, Mackinnon says. "Several are very happy that the organization had taken a stance to do what's best for the patients," he says.
Sometimes effective patient flow strategies also can contribute to improved patient care, adds Sullivan. Not only does the St. Vincent policy effectively free up space, but it would be difficult to medically justify leaving a critically ill patient waiting in an ambulance for a bed to open up so that staff could focus on discharging a patient who came for treatment of a hangnail, he says.
"We have to stabilize patients first, and we can't do it if there is someone receiving a dose of antibiotics that is sitting in the bed," he explains.
ED policy spurs other improvements A new policy at St. Vincent Hospital in Boston to combat overcrowding by boarding, when necessary, ED patients who have been discharged or who are about to be discharged has spurred other process improvement initiatives, and this reaction was by design, says Octavio Diaz, MD, MPH, the hospital's chief medical officer. "By creating a policy such as this, we put the entire hospital on notice that they were going to have to rely on very significant measures to improve throughput, so lo and behold at the same time, we dramatically improved turnaround time by its mere presence," he notes. But that was not the only improvement, adds Paul Mackinnon, PhD, RN, FNP, the hospital's chief nursing officer. "We looked at the whole process in throughput, revamped our entire triage process, had multiple process improvement projects, including processes upstairs," he says. "For example, we instituted a 30-minute limit for getting admitted patients to a floor." In the revamped triage process, all patients now get a quick registration immediately so labs can be initiated right away. There also is a quick bedding process: If a bed is available in the back, the patient bypasses triage, and triage is completed inside the department. These improvements were made possible through the creation of a multidisciplined flow team, MacKinnon says. The team included Mackinnon, the ED chair, vice president of quality, chief medical officer, vice president of radiology, cleaning services, the laboratory, several inpatient directors, the admitting director, ED managers, several quality clinicians, the case management director, the hospitalist director, the chief resident, and bed control. The team "directed processes back at what was best for the patient." For example, a flex unit was created to expand and contract based on volume. The unit, located upstairs, has a total of 32 beds, half of which are telemetry beds. When telemetry capacity in the institution is maximized, the unit is opened up in blocks of five beds. A "flow pool" of staff members who wish to pick up extra time is enlisted when the unit needs to be opened. It takes a couple of hours to get the unit up and running, according to Mackinnon. They changed overcrowding from an ED issue to a hospitalwide issue, Mackinnon explains. "We created a color-coded system, and twice a day we will page out what the ED looks like and what the hospital looks like in terms of crowding," he says. For each step of the system, extra responsibilities fall upon various departments. When the hospital is at code red, for example, it is an "all-hands-on-deck" situation, including doctors, nurses, dietary staff, etc. "There may be additional lab people sent to the ED, or additional people working the discharge process," says Mackinnon. "Directors of the inpatient units get involved in discharge, for example." |
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