Is your ED overcrowded? Reduce risks with these aggressive tactics
Delays caused by overcrowding may present significant liability
Overcrowding may be a way of life in many EDs these days, but that doesn’t mean ED managers have to live with it. You can—and should—take action to ease the burden on your staff and patients, Gregory Henry, MD, FACEP, and other experts contacted by ED Management say.
All agree that overcrowding is potentially dangerous. The inherent delays can lead to poor outcomes and increased liability risks. Yet the problem doesn’t have to be overwhelming. In fact, it should be viewed as a challenge, says Henry, vice president of risk management at Emergency Physicians Medical Group in Ann Arbor, MI. "I don’t know any other industry that would complain about having too much business," he says. "If you went to a restaurant and wanted a table for eight instead of four, they would accommodate you. This is a numbers game, and people coming to us only adds to the power of emergency medicine."
The causes are varied. In large EDs, overcrowding is a consistent and dangerous problem, says Robert Hockberger, MD, FACEP, chair of the department of emergency medicine at Harbor-UCLA Medical Center in Torrance, CA. "As a large, public teaching hospital in Los Angeles, we have an ED that provides all levels of care, including follow-up care. Since it can often take weeks or months for patients to be seen in a clinic, patients choose to come to the ED, and we are always overcrowded," he reports.
Overcrowding often results from sick patients being housed in the ED for hours [while] waiting to be admitted because there are not enough inpatient beds for them, notes Hockberger. "Also, many of our patients just want access to care when the doctor’s offices and clinics aren’t open," he says. "The EMTALA federal guidelines basically preclude us from turning anyone away."
Other scenarios can result in an overwhelmed ED, such as local hospitals going out of business. "We’ve had a couple of large HMOs go out of business, and those patients who temporarily don’t have a physician tend to use the ED instead," says Sue Dill Calloway, BA, BSN, RN, MSN, JD, director of risk management at Ohio Hospital Association in Columbus, OH. "We are also experiencing a significant nursing shortage, which is starting to create a problem."
During a recent flu epidemic, Columbus EDs reported record delays and overcrowding. "Like many other states, you couldn’t pick up a newspaper without reading how bad it was," says Dill. "Some hospitals were reporting eight-hour delays. We had three times the usual amount of patients coming in the door, which presented major liability risks."
Another factor is that the typical ED patient has become more complex, partly due to the "greying" of Americans, with a higher percentage of patients older than age 50. "It takes a lot longer to work up an 82-year-old patient who is dizzy than a 12-year-old who cut his finger," Henry notes.
Also, admitted patients are receiving their first hours of intensive care in the ED, and patients are being treated in the ED with more intensive treatments and sophisticated interventions, which prolong ED stays, Henry says. "There is a push to have more patients seen and discharged as opposed to admitted. That is changing the scope and dynamics of emergency medicine and increasing delays."
Often, long delays are unnecessary, Henry asserts. "You need senior people who can make clinical decisions promptly. Care delayed is care denied. Some patients need to be admitted before the work-up is done," he says. "When it comes to this issue, people tend to do a lot more whining than creative thinking."
Rather than whine, Henry offers the following creative ideas to help ED managers cope with overcrowding:
Switch to disaster mode. "We need to call disaster mode more often," argues Henry. "A disaster isn’t just a train wreck or an airplane crash. It’s any time your resources are overwhelmed, whenever you can’t handle the patients in front of you. At those times when you need to deal with greater volumes, you need some reserve capacity so more personnel are thrown at the problem."
Increase pace of work. "Too often, there is a mindset on the part of doctors and nurses, particularly in city or county hospitals, of saying, This is all I do, I do this much and not any more: When the ED is overcrowded, that attitude is unacceptable," Henry says.
The physician mindset has to change in overcrowded situations, he says. "We have three speeds for working. We have the usual and customary speed, which includes banter and some interactive time. Then we have what I call the hustle mode,’ when we’re moving from bed to bed and have very little fun time. The last one is warp speed,’ in which you’re doing only what is necessary to get people moving in the system."
When confronted with a glut of patients, staff must increase their pace accordingly, Henry stresses. "If 22 people are brought in by ambulance, you need to decide in a minute what you are doing with each patient," he says. "You need to practice [at different speeds] depending on how badly you’re overwhelmed."
In most cases, ED clinicians are not flexible enough, he says. "A lot of physicians have no ability to alter their speed of seeing patients, which is wrong. Every other profession does it. Restaurants have slow and busy nights, and so does the ED."
Have physicians do triage. "Doctor triage is not an unreasonable proposition in big hospitals," Henry suggests. "That way, the patient gets [all of his or her labs] going before they are seen in the back. [The physician in this position] can do lots of things, so when the patient actually shows up back [in the treatment room], all the work is done."
Create a holding area for patients. At Mount Carmel Medical Center in Columbus, OH, a holding area was created to reduce delays caused by overcrowding. "As soon as we decided a patient would be admitted, we take the patient to a holding area so beds [in the ED] would be open sooner," Dill recalls. "Now if I have a patient and find out they’re being admitted, I make arrangements to have the history and physical done [after that happens]. Now instead of having six beds tied up for an hour [by patients waiting to be admitted], we put those six patients in the holding area."
Hire a float nurse. At Mount Carmel Medical Center, a float nurse facilitates treatment and discharge of ED patients. "Otherwise, the patient might sit there for 10 minutes waiting for his or her discharge instructions because the nurse was starting an IV or transporting a patient," says Dill.
Document overcrowded status on charts. "When you are backed up, I think it’s perfectly appropriate to dictate right on the chart we are in a delayed or disaster mode.’ You can’t pretend you are giving out care you’re not providing," Henry suggests. "Instead, state up front, we are in an overcrowded, overloaded situation.’"
Doing this can reduce legal risks later, says Henry. "In court, everything is played out as if you saw one person at a time and had all the time in the world," he explains. "We need to demonstrate that’s not how we do business. Nobody in court trials mentions the other 28 patients you saw that shift."
Enlist the help of other departments. The ED should get help from other departments as needed, says Henry. "There are people upstairs who are not overwhelmed. We tend to think of ourselves as lone cowboys, but we’re not. Frequently, long delays occur because you can’t get patients up to the floors," he notes.
Often other departments aren’t supportive of emergency medicine, Henry argues. "Lab and x-ray need to be truly supportive to us, and not keep to themselves," he says. "They function without regard to patient wait time and outcome, which is ridiculous."
When your ED is overwhelmed, other departments, including admitting services, need to station staff in the ED to help out, Henry says. "We need to get bodies out before we get new ones in. Because it’s dispositioning the patients, not seeing the patients, that holds things up."
Use observation units. "We are not utilizing observation medicine techniques to the greatest degree," says Henry. "There ought to be units where patients can be admitted directly that have nothing to do with floor services. That way, proper observation services can be done by the ED physician, and then we can get the patient out the door."
There should be standard work-up protocols on those patients, so they never have to go upstairs, says Henry. "The trend is toward having less and less inpatient beds and more rapid decision treatment centers, where we work up complex diseases and get patients out the door."
Start labs while patients wait. Even if delays are increased because of overcrowding, labs can be started while patients wait, Henry suggests. "Patients believe their wait time ends when they get started in the process, so sometimes that can be speeded up [by starting labs while they wait]."
Inform patients of expected wait times. At Harbor-UCLA, a sign is posted stating "No patients are denied care. All patients are seen in order of their medical acuity. Currently, patients without life or limb threatening problems will need to wait X’ hours."
At triage, patients are informed of the approximate wait time. "There have been studies showing that patients are more likely to wait that long, and be satisfied, if in fact you are honest with them up front," says Hockberger. "We tell them we’re not going to turn you away, and we would rather not refer you for an appointment for tomorrow. If you get sicker while you’re waiting, please give us an opportunity to look at you again. And if you decide to leave, please come back to the triage nurse so we can make sure you’re OK."’
Get buy-in from administrators. "Explain that the faster you [see] patients, the less chance there is that patients will sign out AMA (against medical advice), and you will recoup a lot more revenues," says Dill. "We were fortunate we had an administration which understood that patients are our customers and were willing to invest in reducing delays."
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