Boarding Solutions

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Boarding Solutions Increase Profits by Ending
Gridlock Physician Name Date of Meeting
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Introduction to Physicians

• The Virginia College of Emergency Physicians
  developed this document to help members talk with
  their administrators about addressing boarding.
• You may customize this document for your
  hospitals unique situation.
• We included placeholders indicated with
  brackets throughout the document. For example,
  the cover slide has two placeholders that you
  should customize
• Physician Name
• Date of Meeting
• We also added speakers notes for some slides in
  the Notes View to help guide the conversation.
• Visit www.vacep.org/boardingtoolkit for more
  information on boarding, including in-depth
  presentations and documents you can use to
  customize this document.

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Contents

• Why Address Boarding
• Impact on patients
• Impact on bottom line
• State guidance
• Internal Scan Our Situation
• External Scan Whats Working in Virginia
• Bridge orders
• Admission units
• Rapid Intervention Treatment Zones and Results
  Waiting Areas
• Special situations mental health patients
• Recommendations
• Resources

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Why Address Boarding

• Addressing boarding reduces crowding
• ED crowding often occurs because no inpatient
  beds are available in the hospital, not because
  we have patients with non-urgent medical
  conditions
• Boarding means holding patients who have been
  admitted to the hospital in the ED, keeping them
  on gurneys or chairs in hallways and waiting
  areas
• Boarding has a negative effect on patient safety,
  comfort and satisfaction
• Boarding ties up emergency department resources
  resulting in fewer physicians and staff to care
  for patients and, ultimately, less revenue

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Patient Satisfaction
Source Press Ganey
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Quality Safety
Source Press Ganey
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2010 VDH Boarding Guidelines

• The Virginia College of Emergency Physicians
  helped design state guidelines on boarding with
  an eye toward making emergency department
  patients safer by
•  
• Quickly moving patients to inpatient floors
• Avoiding ambulance diversion
• Freeing up resources for patients who are in
  critical need of emergency care

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Internal Scan
Note to members adjust the table below to
include the data that will best illustrate the
severity of boarding at your hospital.
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What We Have Done in the ED

• Note to physicians insert examples of changes
  you have made inside the ED to address the
  problem.
•  
• Physician examples here
• One
• Two
• Three

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Collaboration is Vital
Emergency department crowding is an
institutional problem that goes well beyond the
emergency department. Only when all stakeholders
agree that the problem is systemic and
hospital-wide can solutions be implemented that
will improve patient flow from triage to
discharge and protect everyones access to
emergency care. 2008 Task Force Report on
Board American College of Emergency Physicians
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External Scan Whats Working in Virginia
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Solutions for Success

• Bridge orders
• Admission units
• Rapid Intervention Treatment Zones and Results
  Waiting Areas
• Special situations mental health patients

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Bridge Orders
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Bridge Orders Challenge

• HCA Henrico Doctors Hospital, Richmond, VA
• Hospitalists visited stabilized patients in the
  ED before admitting them to the
  hospital, which meant patients often had long
  waits for inpatient beds.
• Meanwhile, fewer new emergency department
  patients could be seen because stable
  patients were using ED beds while waiting for a
  hospitalist to admit them.

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Bridge Orders Solution

• Now ED physicians call the hospitalist to discuss
  the patients status, level of care, etc.
• If the hospitalist and the ED physician agree
  that the patient can be sent upstairs, the
  patient goes upstairs to a room and is admitted
  by the hospitalists on the appropriate floor.
• The ED physicians also complete a one-page bridge
  order outlining vitals, diet, etc.
• Goal after phone call to hospitalist, patient
  goes to appropriate floor within one hour.

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Bridge Orders Benefits

• Minimal cost
• Increased patient safety, comfort, satisfaction
• Decreased patient wait times
• Increased revenue

172.8
69.3
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Bridge Orders Steps for Implementation

• ED physicians, hospitalists and administrators
  meet to discuss.
• Set up a cross-functional team to implement.
• Develop a hand-off tool to ensure information
  exchange is thorough for patient.
• Establish measures.
• Once process is established, hold kick-off dinner
  to brief all parties on process.
• Start during a slow time (e.g., a summer
  Tuesday).

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Bridge Orders Considerations

• Trust across teams is critical.
• Patients that are typically good candidates for a
  bridge order include those with pneumonia,
  pancreatitis, etc.
• Patients should have stable vital signs.
• This works well in a facility where hospitalists
  admit the majority of patients.
• Avoid bridge orders when patients are unstable or
  if staff are debating about whether a patient
  meets the criteria for bridge orders.
• Pick one or two measures to focus on initially.

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Admission Units
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Admission Units Challenge

• Lynchburg General Hospital, Lynchburg, VA
• Staff recognized an opportunity to increase the
  efficiency of moving patients from the ED Bay to
  the inpatient unit.
• Many floor nurses anticipated long, dedicated
  periods of time for admission and therefore would
  wait until that specific period of time passed
  before they would report the bed was 'ready.
• Thus, the patient would remain in the ED Bay
  longer than necessary, clogging the system.

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Admission Units Solution

• We develop the Admission Unit a unit dedicated
  solely to the admissions process.
• Admission Unit nurses perform admissions duties
  quickly and efficiently, since their role is
  focused on admissions. They handle all logistics,
  checklists and initial orders so the floor nurses
  are no longer responsible for these tasks.
• In short, the Admission Unit nurses pull the
  admitted patients from the ED, then push them
  to the floor.

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Admission Units Benefits

• The Admission Unit improves flow in the emergency
  department. ED LOS is decreased significantly and
  the patient vacates the ED bay as soon as the
  doctor decides admission is warranted.
• Admission Unit staffers process admissions
  efficiently, since their it primary
  responsibility.
• The Admission Unit enhances patient safety.
• Admission Unit staffers take pride in their role.

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Admission Units Steps for Implementation

• Find a location for the admission unit.
• Learn from others we visited two hospitals to
  see their processes and tailored them for our
  needs.
• Determine goals for the admission unit (e.g.,
  time goals, etc.).
• Open the Admissions Unit with limited hours.
  Initially, we opened 12 hours/7 days, but later
  opened 24/7.
• Add staff as needed. For example, we added a
  medical records nurse who is solely responsible
  for obtaining accurate medical records. We also
  added a floating nurse who can capture admission
  histories.

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Admission Units Considerations

• Location can be a challenge think carefully
  about where to put the unit.
• Dedicate a specific manager to the units
  success.
• Strict criteria are important when deciding
  whether to send patients to the admissions unit
  criteria may vary by hospital.

• Sample Inclusion Criteria
• Medical/surgical patients
• OB patients (medical reasons)
• Telemetry patients
• Neurologic Intermediate Care Unit

• Sample Exclusion Criteria
• Pediatrics
• ICU patients
• Seizure patients
• Titratable drips
• Mother/baby patients
• Mental health
• 23-hour observation patients

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Rapid Intervention Treatment Zones and Results
Waiting Area
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RITZ and Results Waiting Area Challenge

• Sentara Potomac Hospital, Woodbridge, Virginia
• High incidence of ED boarding (hours and number
  of patients) and High LWOT
• No metrics
• Poor customer service scores
• Previous attempts focused on front end
• Needed to improve performance as new owners
  implemented key metrics including
• The agreed upon metric in which the door to
  discharge time for
• level 2s and 3s is lt 180 minutes is met 39 of
  the time
• levels 4s and 5s is lt75 minutes is met 25 of the
  time
• Percentage of patients to triage lt 15 min is met
  95 of the time

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RITZ and Results Waiting Area Solution

• The staff created a Rapid Intervention Treatment
  Zone. They also created a results waiting area
  for patients who can stay vertical. This allows
  another patient to be seen in the bed.

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Name of Initiative Benefits

• Minimal ED boarding
• Improvements involve front, middle and back end
• Clearly defined metrics
• Gains in customer service scores

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RITZ and Results Waiting Area Steps for
Implementation

• Use the right tool for the right job. Look at the
  resources you have
• Human resources / staffing
• Physical space
• Determine the best way to allocate the right
  people for the right jobs.
• Determine whether you have space for a results
  waiting area.
• Develop a plan in collaboration with
  administrators, nursing and support services.
• Rapid Cycle Test and Refine.

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RITZ and Results Waiting Area Considerations

• As you evaluate your situation, look for ways to
  keep horizontal patients horizontal and vertical
  patients vertical. In other words, if your
  patients dont need beds, dont leave them in
  beds (results waiting area helps with this).
• Focus on metrics and share the data. Transparency
  is critical for improvement.
• Celebrate successes and learn from failures.
• Share with and update administration and medical
  staff.

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Special Situations Mental Health Patients
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Mental Health Patients Challenge

• Carilion Clinic Roanoke Memorial Hospital,
  Roanoke
• Excessive length of stay for mental health
  patients and boarding of mental health admissions
  in the ED.

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Mental Health Patients Solution

• Improve intake
• All mental health patients Level 1 triage
• Standardized patient intake
• Created of dedicated ED Mental Health Unit
• Improve throughput and care in the ED
• Dedicated ED Psych Nursing Staff 1 fte RN, 1
  fte ED psych unit med tech
• Psych RN coordinators (Connect Team)
• Parallel evaluations (med clearance and Connect
  Team)
• ED Physician rounder on boarders (2hrs/day)
• Improve disposition and placement
• One Call for all Mental Health Patients
• Expanded weekend bed capacity
• 1-to-1 communication with ED physician and
  psychiatric team
• County/City Mental Health Coordination with
  Connect Team
• Automatic Psychiatry Consult for ED gt24 hrs
• Direct Facility Protocol Placement for Unique
  Patients

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Mental Health Patients Benefits
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Mental Health Patients Benefits
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Mental Health Patients Steps for Implementation

• Quantify the problem and map the process.
• Improve care and maximize efficiency within the
  ED first.
• Engage and collaborate across three key areas
• Law enforcement
• City and county services
• Inpatient and outpatient psychiatry
• Expand resources and eliminate redundancy
• Training, staffing, bed availability

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Mental Health Patients Considerations

• Expand the narrative make it a community issue
  and not an ED issue.
• Flow diagrams are critical to keeping everyone on
  the same page.
• Variations in practice must be eliminated.
• Relatively small upfront expenditures can have
  dramatic effects in LOS.

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Recommendations
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Opportunities

• Note to physicians insert examples of changes
  that you want to make in collaboration with
  people outside the hospital.
• Physician examples here
• One
• Two
• Three

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Resources
Dr. Tamera Barnes Henrico Doctors
Hospital 804-379-0444 804-432-0416 tcbarnes1_at_veriz
on.net Dr. Luis Eljaiek Sentara Potomac
Hospital 703-670-1283 703-670-1782 LFELJAIE_at_sentar
a.com Dr. Damon Kuehl Carilion Clinic Department
of Emergency Medicine 540-597-9153 drkuehl_at_carili
onclinic.org Dr. Chris Thomson Lynchburg General
Hospital 434-200-6858 434-401-7827 chris.thomson_at_c
entrahealth.com The Virginia College of
Emergency Physicians 757-220-4911 gwen_at_vacep.org
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