Critical Path Network
Initiatives address ED overcrowding, diversion
Solution includes ED observation unit
Faced with an increase in emergency department visits and a rising inpatient census, the chief executive officers at Massachusetts General Hospital in Boston made ED overcrowding a major quality and safety initiative of the hospital starting in 2006 and took a systemwide approach to addressing the problem.
"It was the perfect storm. We had too many people in the emergency department and the inpatient census was up, making it difficult to move patients from the emergency department. Patients and staff were starting to complain. We knew we had an overcrowding issue and were concerned about quality and safety. There were space issues and process issues," recalls Laura Huber, RN, BSN, case management team manager.
Massachusetts General Hospital is a 907-bed tertiary care hospital with a 49-bed Level I trauma center. The ED had 80,823 patient visits in 2007.
Results from the initiative
Following the initiative, the hospital ED experienced a 57.4% decrease in the number of hours on diversion from 2005 to 2007 despite a 2.3% increase in ED visits from 2006 to 2007.
The hospital worked with a consultant to study the ED processes and determine where the team could make improvements.
Some of the solutions to overcrowding included reconfiguring the ED space, developing an ED observation unit, and moving admitted patients to beds before all of their test results became available.
A multidisciplinary team of staff from Massa-chusetts General and the hospital system's post-acute providers collaborated on a process that admits appropriate patients directly to post-acute care, bypassing an acute care admission.
The hospital redesigned its physical space, adding more examination rooms to the ED so work-ups could begin sooner, reconfigured an area to accommodate more stretchers in the hall, and enlarged the sitting area where patient work-ups could be started.
In addition, a 14-bed ED observation unit was added to accommodate patients who don't need to be admitted as inpatients but need to become medically stabilized. Their stay is billed as an ED visit.
Case managers staff the observation unit Monday through Friday from 8 a.m. to 6:30 p.m.
The average ED observation unit length of stay is 16 hours from the time patients come into the ED until they are discharged.
"This is a long time to have a patient take up a bed when there are emergent patients coming in. We are able to improve quality and safety by having these patients who need more focused discharge planning in a separate unit," Huber explains.
Some may transition to inpatient status but the vast majority is discharged to home or an alternative setting, she says.
After the observation unit was opened, the number of patients admitted to inpatient beds from the ED decreased by 6,267 from FY 2006 to 2007.
The team looked at the processes involved in getting the patients signed in, triaged, how long it took the physicians to see the patients, delays in diagnostic testing, delays in asking for beds, delays in patients being moved to beds, and patient discharges. They conducted time studies and tracking to identify where the delays were occurring, along with length of stay in the ED and barriers that delayed inpatient admission.
"We wanted to determine how to move the patient through the continuum efficiently and what roadblocks were delaying patient throughput," Huber says.
They developed a tracking system to determine the length of time patients were staying in the ED, the time a bed was requested, the time the bed was assigned, the time the bed was ready, the time of the physician and nursing handoff, and the time that the patient actually leaves the ED.
ED delays
The team found that the ED was delayed in asking for an inpatient bed even though they knew patients were going to be admitted because the diagnostic work-up had not been completed.
In many instances, patients were staying in the ED while they waited for radiology procedures because the clinical staff weren't putting in for an inpatient bed until the patient's scans were completed.
The team recommended that patients move to the inpatient bed but stay in the ED radiology queue and be transferred to radiology when their turn comes.
The team set a goal that patients with "ready" inpatient beds would leave the ED within one hour.
To improve access for primary care for patients who were not being admitted, the team created a list of open appointments in the hospital's primary care clinics so the patients who do not have a primary care provider can get timely follow-up appointment. The hospital also created the role
of a primary care access coordinator who could facilitate appointments in nonaffiliated community clinics.
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