Deluged with inpatient holds? Avoid violations
Are you giving admitted patients being held in your ED patients the same level of care they would receive in the critical care units? If not, you are violating standards from the Joint Commission on Accreditation of Healthcare Organizations that require the same standard of care be provided.
Caring for critical care inpatients in the ED presents many risks, says Karen Clark, RN, MSN, CCRN, an ED and critical care nurse for Adventist Health Care System in Silver Spring, MD.
"EDs are designed to assess, stabilize, admit, transfer, or release — not to manage ongoing plans of care," she explains. To safely manage inpatients held in your ED, you must overhaul the way you provide care, says Clark. "We must change the way we practice and deliver care. This is not an easy objective," she adds.
According to a study that surveyed directors of EDs and critical care services in hospitals in six mid-Atlantic states, admission orders often are delayed while patients are held in EDs.1 This could lead to adverse outcomes and also Type 1 recommendations from the Joint Com-mission, Clark says, the study’s principal investigator.
Here are key findings of the study:
- Of the EDs that responded, 71.6% did not have processes or committees to address critical care patients held in the ED.
- Nearly 59% reported difficulties in getting critical care patients out of EDs into critical care beds.
- More than half said there was inadequate staff to complete important admission orders for tests of admitted patients held in the ED.
Here are effective strategies to improve consistency of care for critical care inpatients held in the ED:
• Access the resources of your facility.
All the resources of your facility must be shared with the ED, Clark emphasizes. "The goal is to include the ED as if it is an inpatient unit," she says.
The patients being held in the ED must receive the same support from radiology, laboratory, pharmacy, and ancillary staff as if they were occupying an inpatient bed, Clark explains.
Staffing changes based on fluctuations in inpatient census also should include ED volumes, according to the study’s co-investigator, Loretta Brush Normile, PhD, RN, assistant professor at the College of Nursing and Health Science at George Mason University in Fairfax, VA.
"This would facilitate implementation of inpatient admission orders as if the patient occupied an inpatient bed," she says. "This also decreases the length of stay by implementing plans of care earlier rather than later."
• Have a dedicated role to manage inpatients.
Hospitalists or intensivists could manage the inpatient population more effectively in the ED, Clark suggests. They could facilitate rapid-sequence triage protocols that would accelerate patient flow, she says.
"They would manage admitted patients, thus relieving ED physicians of unexpected crisis and interventions," she explains.
• Provide telemetry monitoring in the ED.
Consider training your entire staff in telemetry monitoring, Clark advises. "The goal is to provide telemetry monitoring throughout the hospital regardless of where," she says. Many cardiac monitoring systems are equipped with specific alarms to indicate the degree of severity and type of arrhythmia, Clark says. "However, these alarms are for the most part ignored in the ED setting and in some instances disabled," she says. "There is so much noise in an ED at times, that everyone is on sensory overload."
She gives this solution: Train all ED nurses and ED techs in arrhythmia recognition and provide a monitor technician, especially during periods of high census. This would lessen the chance of missing malignant arrhythmias such as life-threatening bradycardia, she says.
"I have personally witnessed runs of v. tach and brady rhythms not printed out by the monitoring system because the alarms were disabled, and I just happened to walk by," Clark reports. She has seen this scenario occur in EDs and critical care units. "With the increasing acuity and severity of illness we are seeing in EDs, implementing the monitor tech role, though initially costly, would improve outcomes," she argues.
By recognizing changes as they occur and intervening, critical events could be avoided that increase length of stay, morbidity, and cost, Clark explains. Training should involve all staff in the ED including technicians, and two weeks of training should be provided, she recommends.
"Our standard of care would be closer to meeting the standard of care the patient would receive in the critical care setting," she says.
• Train ED nurses in critical care.
To ensure ED nurses are comfortable managing critical care patients, give nurses direct exposure to the inpatient areas, Clark advises. Rotate ED nurses to the critical care unit for a specified period of time, she recommends. "Both specialties share common knowledge, but manage patients differently," she explains.
Rotating ED nurses and critical care nurses in both areas would improve patient outcomes, says Normile. "Critical care nurses would be more comfortable managing critical care patients in the ED, once exposed sufficiently to the setting," she says.
Similarly, training ED nurses in the critical care units would improve care of complicated patients held in the ED, adds Clark. "Giving ED nurses the chance to put into practice what they learn in the classroom would benefit all concerned," she says.
Reference
1. Clark K, Normile LB. Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-Atlantic states. J Emerg Nurs 2002; 28:489-495.
Sources
For more on caring for inpatients in the ED, contact:
• Karen Clark, RN, MSN, CCRN, 10881 Kipe Drive, Waynesboro, PA. 17268. E-mail: [email protected].
• Loretta Brush Normile, PhD, RN, Assistant Professor, George Mason University, College of Nursing and Health Science, Mail Stop 3C2, Fairfax, VA 22030-4444. Telephone: (703) 993-1945. Fax: (703) 993-1964. E-mail: [email protected].
Are you giving admitted patients being held in your ED patients the same level of care they would receive in the critical care units? If not, you are violating standards from the Joint Commission on Accreditation of Healthcare Organizations that require the same standard of care be provided.
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