Benchmarking Success Code Purple’ mode relieves ED bottlenecks
Are you often worried about patients being put at risk by overcrowding in your ED? Would you like to reduce bottlenecks caused by patients being held in the ED until inpatient beds become available? The ED at William Beaumont Hospital in Royal Oak, MI, has done just that, by implementing an innovative "Code Purple" mini-disaster mode.
The ED is an busy Level One trauma center with 110,000 annual visits, according to Val Gokenbach, RN, MBA, CAN, director of emergency services and observation. "Tremendous growth has created many systems and operational problems," she says. "As a result, the ED is unable to expeditiously move patients through the process."
It is not uncommon for the triage area to have 50 patients waiting to be seen, patients waiting in hall spaces, and 20 patients waiting to be admitted, says Gokenbach. "This level of activity can precipitate an unsafe environment for some patients," she notes.
Despite efforts to increase staffing levels and physician coverage, lack of treatment spaces and available beds prevent elimination of the bottleneck, says Gokenbach. That’s where "Code Purple" comes in. The system allows the ED to function in a "disaster mode" but without the associated support that would be received during an actual disaster.
The inpatient side is the root of the bottleneck problem, stresses Gokenbach. "In many institutions, an out-of-sight, out-of-mind’ philosophy exists in regard to the patients waiting in the ED," she says.
Patterns in discharging, medical education, and nursing care result in the patients being discharged in the afternoon hours, she says. "This is curiously the exact time that the peak influx of patients is occurring in the ED," Gokenbach says.
To address scenarios such as peak patient loads, a multidisciplinary team developed the Code Purple system. The team included representatives from all areas that impact the flow of patients through the ED: nursing, housekeeping, transportation, radiology, registration, and care management. Here are key points of the Code Purple system:
• Code Purple policy is housed in the disaster manual and treated as an official safety code.
• Code Purple is called via beeper to all members of the Code Purple alert team.
• When a Code Purple is called, the inpatient units create short-term hall spots and begin accepting patients awaiting beds.
• All pending discharge patients are moved to the unit lounges to wait for their transportation.
• The administrative hospital supervisor, and representatives from radiology, housekeeping, transportation, and continuing care report to the ED.
• Radiology holds the completion of non-stat, diagnostic studies until the ones from the ED patients have been completed.
• The transportation supervisor assigns staff to complete transfers in an order that will expedite the movement of ED patients.
• The environmental supervisor dispatches housekeeping staff to the areas that will benefit the movement of ED patients.
• The continuing care coordination staff makes rounds on the units and communicate with physicians in cases in which the patients may be discharged.
• Staff from the inpatient areas may be directed to report to the ED to pick up their patients for admission to their units if possible.
• A registration representative reports to the ED with the most recent list of bed availability.
• To maintain positive customer service, a script and service recovery program are used, to help patients understand why they might need to spend some time in a hallway on a unit rather than their room.
Whenever the Code Purple is called overhead, patients ask what is going on, Gokenbach explains. "We respond by telling them that the ED is very busy, and to provide a quality service to the patient we formally call on the help of the whole institution," she says.
The service recovery program is used to make patients feel better about bad experiences that they may have, Gokenbach explains. "ED managers and staff are empowered to give coupons that may be used for food, the hospital gift shop, and parking," she says.
When the activity and acuity in the ED reaches an uncomfortable level, the Code Purple is initiated by the charge nurse clinician in the ED, in coordination with the administrative emergency physician. On the day shift, ED administration and nursing administration will coordinate efforts to decide if the call should be placed. On off shifts and weekends, the charge nurse clinician and the ED physician notify the administrative supervisor to assess the need for added support. If the decision at that time is to use the Code Purple, ED administration are notified at home of the final decision.
Code Purple is called only when the environment may place patients at risk, says Gokenbach. "However, due to the variable nature of the scenarios that present in the ED, it was impossible to set rigid, quantifiable guidelines," she notes.
Code Purple drills are conducted in the same format as disaster drills to assess the effectiveness and to make recommendations to the program, notes Gokenbach.
Code Purple is called only about two or three times a month, when the ED is completely overwhelmed, according to Andrew G. Wilson, MD, FACEP, chairman of the department of emergency medicine. A typical scenario is as follows: All stretcher spots and hall spots are full, about 40 patients are at triage, and five patients are expected from a car accident, he says. Altogether, there are about 110 patients in a 55-bed ED, with patients who could be moved up to beds upstairs and imaging studies pending on other patients who could subsequently be discharged, Wilson explains.
In this type of scenario, Code Purple is a "mini-disaster process" that allows the ED to acquire short-term help from the inpatient units, Gokenbach explains. "This relays the serious nature of the problem, and to send a message that the entire institution is in support of the process," she says.
Sources
For more information about Code Purple, contact:
• Val Gokenbach, RN, MBA, CAN, Emergency Services and Observation, William Beaumont Hospital, 3601 W. Thirteen Mile Road, Royal Oak, MI 48073. Telephone: (248) 551-1995. Fax: (248) 551-2017. E-mail: [email protected].
• Andrew G. Wilson, MD, FACEP, Chairman, Department of Emergency Medicine, William Beaumont Hospital, 3601 W. Thirteen Mile Road, Royal Oak, MI 48073. Telephone: (248) 551-1969. Fax: (248) 551-2017. E-mail: [email protected].
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