An Admissions Unit Accelerates ED Flow, Helping Upper Floors Better Manage Incoming Patients
October 1, 2023 5 minutes read
By Dorothy Brooks
Amid capacity challenges on upper floors, along with extended boarding times and rising leave-without-being-seen rates in the ED, administrators at UnityPoint Health - Meriter Hospital in Madison, WI, considered how they could most effectively speed up throughput while preserving quality care.
Liz Nelson, MSN, BSN, director of patient care at the hospital, says facility leaders had to consider more than just patients requiring admissions from their own ED. “We have a joint operating agreement with UW Health, [the health system of the University of Wisconsin-Madison],” Nelson explains. “In addition to our ED here in our facility at Meriter, we also admit patients from two UW Health EDs. Further, as a system of care, we are trying to support admissions from our clinics that typically get sent to an already-busy ED.”
To address the throughput logjam, administrators decided to create a separate unit where ED patients destined for admission could be placed while waiting for an inpatient bed upstairs. Opened in early July 2023 on a pilot basis, the aptly called “admissions unit” currently sees four to eight patients at a time, but has the space to accommodate as many as 14. “We really feel that an admissions unit will help us efficiently use the beds we have vs. trying to [use the space] to run a small, distinct hospital unit, which is hard to operationalize and have it be fiscally successful,” Nelson says.
The new unit is staffed by float pool nurses who are trained to the hospital’s critical care track.
“They are assigned to do a lot of admissions for the hospital. They also tend to know the best landing places for patients in the hospital because they work on so many different units,” Nelson says.
Thus, in collaboration with a hospitalist or surgeon who is overseeing these patients, Nelson notes the float nurses who staff the unit can initiate care while the patients are waiting for an inpatient bed and help ensure they are directed to the right unit and the right level of care.
Nelson observes many patients who require intermediate-care beds come through the ED, but it can be difficult in the emergency setting to treat their electrolytes or address their blood pressures — measures that could enable the patients to be placed in a general level of care bed. However, when the appropriate care is initiated in the admissions unit, many of these patients can be placed in general-care beds, helping the hospital preserve intermediate-care beds for patients need them.
To determine who will be placed in the admissions unit, the health system operates a “unified access center” that places patients for all three of the hospitals included in the joint operating agreement that UnityPoint Health - Meriter Hospital has with UW Health. “Our nursing administrative coordinators and our supervisors collaborate with the access center,” Nelson says. “Our priority is to have ... intermediate-care and general-care patients go through the [admissions] unit.”
Similar to what other EDs face, the end of the day is busy, when outpatient clinics start to close, and this is when the hospital might face a flurry of admissions and discharges. Through the new unit, Nelson says staff can plan for both. “This gives our environmental services department, which is strapped just like everyone else, time to clean those inpatient beds,” Nelson adds.
Further, the admissions unit helps smooth the workload nurses on the inpatient units face in the evening when all the new admissions are brought to their floors.
“Typically, our bigger units will get 13 to 17 admissions on a PM shift, and now they’re getting about half of those admissions directly [from the ED] and half of them from the admissions unit, which is more like a transfer,” Nelson says. “Admissions orders are started in the admissions unit, so hopefully some of the issues have been addressed by the time these patients get to their designated inpatient units.”
While the admissions unit accelerates ED flow, it does not affect the volume of patients coming to the hospital from other EDs. However, Nelson notes one result administrators did not anticipate is that the care provided in the admissions unit is enabling some patients to be discharged from the unit to home, about six per week, on average. “Their length of stay on the unit might be a little longer, from 12 to 20 hours, but we are able to get them home,” Nelson reports.
Further, multiple patients who were to be placed into intermediate-care beds can be placed into general-care beds following four-hour stays in the admissions unit.
“We are tightest for beds at the intermediate-care level, and that makes sense, but we’re really wanting to be efficient with [this resource],” Nelson says.
The admissions unit also assists emergency general surgery patients, such as those requiring an appendectomy who presented off-hours. “Typically, these patients would be held in the ED until the OR opens up, but now we can bring them to the admissions unit, prep them, and get them to the procedure area without these patients needing an inpatient bed,” Nelson adds.
While the admissions unit is in the pilot phase, administrators are aiming to keep the census in the four to eight patient range. Typically, the unit is staffed by two or three nurses, depending on the required level of patient care.
However, Nelson’s goal for the unit is to see if it can grow to the point where 50% of admissions to the hospital come through this area.
“I think we can also help our perioperative service lines, especially in the emergency general surgery realm, where we have challenges with patients waiting for their procedures,” Nelson says.
Meanwhile, emergency clinicians have expressed satisfaction with the admissions unit’s progress thus far.
“I would say we still have one day a week where everything is kind of blowing up and hitting the fan ... so they have really high expectations for us,” Nelson observes. “But overall, our providers are really appreciating being able to send, especially, their borderline patients to the admissions unit to provide a little bit of bandwidth to figure things out without holding up ED workflows.”
Also, the feedback from ED patients who go to the admissions unit has been extremely positive. “Their care is being initiated and something is happening vs. the perception of waiting,” Nelson says.
This early in the process, there are details to be worked through, but the secret might be in the way the admissions unit is staffed. “We use staff who excel at and enjoy doing admissions,” Nelson notes.
Administrators at a Wisconsin hospital created a separate unit where ED patients destined for admission could be placed while waiting for an inpatient bed upstairs. The new unit is staffed by float pool nurses who initiate care while the patients are waiting and help ensure they are directed to the right unit and the right level of care.
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