ACEP's three low-cost solutions to boarding
The American College of Emergency Physicians (ACEP) has three "low-cost, high-impact" solutions to boarding, says Sandra M. Schneider, MD, FACEP, president-elect of ACEP; professor of emergency medicine at University of Rochester (NY) Medical Center; and a physician at Strong Memorial Hospital, also in Rochester. The "obvious answer for boarding is you just build more beds and hire more nurses. That's not going to happen; it's too expensive." So here are some non-cost-prohibitive answers.
The first solution ACEP offers is "what we call smoothing the operating schedule." Most significant OR cases are scheduled on Mondays and Tuesdays to allow patients three or four days of rehabilitation with physical therapists or social workers, who don't work on the weekend. And, she adds, most nursing homes don't take patients on the weekend. So ICUs are really full Monday and Tuesday, with more patients throughout the week. "Come Friday, things pretty much empty out on the surgical schedule," she says.
"The other fact is the emergency department basically admits the same number of people every day... whereas in the operating room, surgeons will admit maybe 10 times the number of patients on a Monday than they do on a Friday. And on Saturdays and Sundays, they may admit no one."
Smoothing flow, she says, includes trying to schedule OR cases at least six days a week, discharging patients seven days a week rather than just five.
The second tip is getting discharges out by noon, which she says can be difficult with physicians' rounding schedules. Most often patients leave at 4 or 5 p.m. and once beds are cleaned, most ICU rooms open at about 9 or 10 p.m., she says, while the ED's peak admitting time is about 11 a.m. to noon. "All of a sudden it's nine or 10 p.m., and we'll get four or five beds. It's kind of crazy," she says.
The third is a no-cost, "simple" technique, one used at Stony Brook (NY) University Hospital. "If you've got three people in the emergency department then you move them upstairs... it's called the full capacity protocol," she says. "If the patient is going to be in the hallway in the emergency department, you put them in the hallway on the floor and let the floor nurses take care of them."
She relates a story of a relative who was admitted for pneumonia. Though she continued to get worse, she was moved back from a floor to the ED. Schneider found out that there indeed was a bed available in the ICU but the hospital's policy was that ICU nurses only care for two patients at a time and because some nurses had called in sick, the remaining ones already were caring for the maximum number of patients. The nurse in the ED watching the pneumonia patient also was taking care of three ICU patients, three elderly admitted patients, and four emergency patients. Instead of having the ED nurse care for 10 patients, she says, the ICU nurses could have taken on one more apiece.
The dangers of boarding, crowding
ED crowding and boarding, especially the latter, present multiple patient safety risks that aren't "very well appreciated," Schneider says.
"We know, for example, that time to pain medicine goes up dramatically. We know that time to cath lab goes up." She has found that elderly patients who live at home and are boarded in the ED for four or more hours have a fourfold higher likelihood of going to a nursing home than those who go directly to a bed. And, of course, with overcrowding, the chance for medical errors increases.
(Editor's note: A full capacity protocol toolkit is available on the Robert Wood Johnson Foundation's website at http://www.rwjf.org/pr/product.jsp?id=56493.)
The American College of Emergency Physicians (ACEP) has three "low-cost, high-impact" solutions to boarding, says Sandra M. Schneider, MD, FACEP, president-elect of ACEP; professor of emergency medicine at University of Rochester (NY) Medical Center; and a physician at Strong Memorial Hospital, also in Rochester.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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