JCAHO wants to know your solutions for ED crowding
Dissatisfied patients. Longer wait times. Patients being treated in the hallways. If you needed any more ammunition that overcrowding must be addressed in your ED, now you have it: The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has proposed standards that require you to develop strategies to combat ED overcrowding.
"The Joint Commission has now said what all of us in the EDs already knew," says Kathy Hendershot, RN, MSN, CS, director of clinical operations for the emergency medicine and trauma center at Methodist Hospital in Indianapolis. "ED overcrowding is usually not an ED problem; it is a hospital capacity problem."
Use the Joint Commission proposed standards, which are expected to become effective January 2004, to obtain buy-in for effective process improvements, recommends Hendershot. "It has been a great motivator for multidisciplinary teams to work on the solutions and has helped me justify the need for additional staff and space," she says.
At Methodist Hospital’s ED, volume, acuity, and admission rates have increased and resulted in longer wait times, says Hendershot.
"We are doing more intensive and time consuming work-ups in the ED, which make our patients stays longer," she adds.
This reflects problems reported by EDs nationwide, but making strategic changes, you can have a dramatic impact on ED overcrowding, says Hendershot. "There is no magic here," she says. "The goal is to fix processes until you see results."
To reduce ED overcrowding, use these effective solutions:
• Critically examine your staffing.
"Old ratios are being thrown out the window," Hendershot says. "We are all moving toward a system based on acuity and length of stay to staff our EDs." [For information on a staffing best practices tool and guidelines developed by the Des Plaines, IL-based Emergency Nurses Association (ENA), see "New tool will change the way you staff your ED," ED Nursing, April 2003, p. 74.]
If you are holding admitted patients, Joint Commission surveyors want to see that they receive the same level of nursing care in the ED as they would as inpatients, says Hendershot. "Now we must convince our administrators of this, as this will be an increase in the staffing cost never seen on our budget before," she says.
• Add extra triage staff.
Due to longer wait times, an additional triage nurse was added for 12 hours a day, says Hendershot. "I now have two nurses, two ancillary staff, a visitor representative, and a volunteer at triage," she says.
The nursing staff ratio also has increased compared with technicians, Hendershot notes. "I have always had a mixed nurse and technical support staff, but I am slowing increasing the professional model," she adds. "I usually ran a 60% nurse and 40% technical mix, but I am aiming for an 85% nurse and 15% tech staff."
The 85%/15% mix is recommended by the ENA’s staffing model, which addresses acuity and assessment requirements, says Hendershot. "With this ratio, hopefully there will be less waiting for nursing assessments and interventions, which will improve throughput," she says.
• Use "no-delay" reporting.
Delays in bed requests for patients being held in the ED are monitored closely, says Hendershot. An electronic tracking program developed in house tracks the time of a bed request, the time it was assigned, and the time the ED is notified, she says.
"This helps us track which unit has difficulties taking patients or which units may have staffing issues to address," says Hendershot. A report is generated and given to each director as a "dashboard indicator" of their unit, she explains.
If the receiving floor nurse is unavailable when a bed becomes available, the charge nurse immediately takes report and relays information to the nurse receiving the patient, she explains. "If the charge nurse is busy, the patient is transported with a written report," she says. "This has really improved some of the delays we were having."
This takes the frustration out of the process for the sending and receiving units, she says. "We now know that we can call report at anytime now," says Hendershot, estimating that delays in placing patients in an inpatient bed have been reduced by 35 minutes.
• Open a discharge service center.
At St. Francis Hospital and Health Centers in Indianapolis, a discharge service center was opened near the ED, with the goal of freeing inpatient beds so the ED doesn’t get backed up by holding admitted patients, says Sharla D. Anderson, Director of Emergency Services. An ED nurse assists floor nurses in determining which patients are eligible to be placed in the center while waiting for transportation home, she explains.
There are six comfortable chairs with ottomans in the center, with one nurse and one technician who feed patients, work with case managers, coordinate transportation, review written discharge instructions with the patient, and administer intravenous antibiotics, fluids, and medications, says Anderson.
"When the patient is informed that they are being moved to the discharge center, there often is suddenly a ride available much earlier than previously anticipated," notes Anderson. "This can be up to a four-hour decrease in wait time."
Patients are sent to the discharge service center unless they are in isolation, require one-to-one supervision, are going to leave the hospital on a continuous monitor, are totally incontinent, have received blood products within two hours, are on a ventilator, or have open or draining wounds, she says.
• To free beds, ask physicians to round on least critical patients first.
Medical staff has been asked to "think 11," which means to get the patients out by 11 a.m, says Anderson.
Previously, the physicians would round on the most critical patients first, then get to those most likely to be discharged, says Anderson. "The physicians have been asked to round on their least critical patients first," she says. "That way, their discharges can be expedited." [For more information on overcrowding, see "Are you putting patients at risk with dangerously high diversion rates?" ED Nursing, April 2001, p. 73. The publisher of EDN, American Health Consultants, also publishes ED Management (EDM). EDM stories on overcrowding include "Reports say diversion on the rise: Use technology to overhaul patient flow," EDM, March 2002, p. 25; and "Report: ED visits on the rise," EDM, July 2002, p. 80. Back issues of EDN and EDM are available for purchase on the American Health Consultants web site (www.ahcpub.com). Click on "e-solutions." Under "AHC Online," click on "online activation." Where it says, "Please select an archive," select the newsletter, then the year, and then the month. Select the story you want to purchase.]
Sources and Resources
For more information on ED overcrowding, contact:
- Sharla D. Anderson, Director, Emergency Services, 1600 Albany St., Beech Grove, IN 46107. Telephone: (317) 783-8245. E-mail: [email protected].
- Kathy Hendershot, RN, MSN, CS, Director of Clinical Operations, Emergency Medicine and Trauma Center, Methodist Hospital, I-65 at 21st St., P.O. Box 1367, Indianapolis, IN 46206-1367. Telephone: (317) 962-8939. Fax: (317) 962-2306. E-mail: [email protected].
The Joint Commission on Accreditation of Healthcare Organizations issued draft standards for emergency department overcrowding on May 9, 2003. The draft standards can be accessed free at www.jcaho.org. Click on "Accredited Organizations," "Hospitals," "Standards," "Draft Standards," and "Emergency Department Overcrowding Standards."
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