Our environment

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Our environment the silent issue

• Hospitals 1960 vs. now
• ED 1960 vs. now

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Crowding

• The cause
• The consequence
• The cure

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1. Whats NOT the cause?
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Inappropriate or unnecessary visits to the ED

• What are the results of the research?
• Sore throats
• Retrospectivitis
• Franacek
• What could be done about it?
• Education 5 decrease vs. 20 increase
• Does it matter?
• Excellent studies show that patients with minor
  problems to NOT impact on the waiting times for
  the seriously ill
• Therefore, any actions focused on this issue,
  if it is one, will NOT improve issues related to
  the boarding of admitted patients in the ED

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Money, not crowding, is the issue for these

• EMTALA
• Safety net

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The big gorilla

• Admitted patients, boarding in the ED, are THE
  major contributor to overcrowding and delays in
  care in the ED
• actual data!

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Finito!
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What causes ED overcrowding?

• Hospital overcrowding

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BoardingWhat are the consequences?
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Sick people have to wait too long to receive care
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Boarding increases TOTAL length of stay in the
hospital, further worsening access.

• 5 studies 1 day

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Boarding increases walkouts, some needing
admission
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Overcrowding increases medical errors
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JCAHO

• 50 of sentinel events occur in the ED
• 1/3 of these are related to overcrowding

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Overcrowding causes deaths

• .. beyond anecdote

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How big is the effect?

• Pneumonia 1.07
• Crowding 1.2 1.4
• Weekend admit 1.01 1.05

Group sizes
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Comparison

• 100 pneumonias save 7
• 100 crowding admits save 17 25
• (RR 1.2 1.34)

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The BIG question

• Does this problem kill more people than problems
  identified in other initiatives to improve
  outcomes of patients?

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Physicians are harmed
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25,000 patients

• Frequency of suits based on whether the patient
  waited less or more than 30 minutes to be seen
• lt 30 0.9
• gt 30 4.9

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Key points

• Crowding is caused by boarding

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Boarding increases harm to patients in the
following ways

• Waiting times
• Diversions
• Length of stay
• Medical errors
• Sentinel events
• MORTALITY

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Boarding increases harm to hospitals and doctors
in the following ways

• Financial losses to hospital and MD
• Malpractice claims

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How do we fix it?
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How do we currently deal with this problem?
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Itsy-bitsy ED
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Everything is filled to the brim
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Current model
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Current solution to HOSPITAL overcrowding

• Crowd one area

Space Staff Structure Expertise
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The question ..
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Which block in this diagram is LEAST capable of
surge? Which block in this diagram needs to be
MOST capable of surge?
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Radically new model redistribute the load
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nasty
nice
Move SOME boarders to the floors, even if it
means putting them in the hallway. The ED
CONTINUES to bear brunt of boarders
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The current status quo

• Too many admitted patients
• in the wrong space, in the wrong place, with the
  wrong staff
• is dangerous to our patients.

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The cure
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Why not divert ambulances?

• In most circumstances, it simply doesnt work
• If allowed
• other solutions are not sought
• Dangerous to the patient

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Summary ambulance diversion is

• Unsafe
• Ineffective
• Money loser

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Other lousy solutions

• Deferred care
• Safety?
• Effectiveness?
• MD at triage RN -gt MD

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The ONLY current solution known to work

• Move the admitted patients out!
• (The Full Capacity Protocol)

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Ask Four questions

• Space, load, expertise, and necessity

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Question 1 - Space

• Bad space

• Good space

If given both, where would you place the patient?
Obviously, in the good space. But, what if
there WAS no good space???? (see next question)
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Question 2 Load all units full

• Ten patient units A, B, C, D, E, F, G, H, I, J
• No good space on ANY unit

• 20 additional patients beyond good space
  capacity. How would you distribute them?

Action plan??
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Question 3 Expertise all units full

• Units B, C, D, E, F, G, H, I, J
• 6 nurses
• Needs 6
• Right expertise
• Right environment

• Unit A
• Understaffed
• 4 nurses
• Needs 6
• Wrong expertise
• Wrong environment

• 20 additional patients beyond good space
  capacity. How would you distribute them?

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Question 4 - Necessity

• Is your emergency department necessary?

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CURRENT answers

• 2 load up Unit A
• 3 load up Unit A
• 4 no, the ED is not necessary

This is NUTS! Worse than that, this is the way
we do things.
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Answer to questions 1-4

• Move the patient upstairs.

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The bold move by the NY State DOH
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DOH April 2002

• continuing issue of hospital overcrowding
• Emergency Departments must remain open
• Maintaining admitted patients within the ED is
  not acceptable
• the use of beds in solariums and hallways near
  nursing stations should be considered
• Regardless of location within the facility,
  staffing, services, privacy, infection control
  and confidentiality protections must be
  consistently in place

www.hospitalovercrowding.com
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Why? .

• Inpatient Units are less crowded, less noisy,
  less chaotic
• Inpatient Units provide appropriate clinical
  expertise (MDs, RNs)
• Emergency physicians are great at what they do.
  However, they are not cardiologists,
  pulmonologists, intensivists, etc. Once the
  patient is admitted, they deserve the appropriate
  specialty care
• Staging in an inpatient hallway will result in
  closer, therefore faster access to a room
• The ED can continue to fulfill its mission

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Full capacity Protocol How it Works

• Step 1 ED attending and ED charge nurse
  determine that the ED is close to full capacity,
  and thus, the care of the next patient is
  threatened
• Step 2 Bed coordinator evaluates the situation
  NEUTRAL party
• Step 2a Medical Director approves any decision.
  NEUTRAL party
• Step 3 Bed coordinator notifies Clinical
  Associate Directors
• Step 4 Units assigned hallway patients. No unit
  will receive more than 2 hallway patients.

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How many?
3190
12733 total
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Impact per boarded admission on ED
wait-to-be-seen times

• Typical impact under business as usual
• 15 minutes per boarded patient
• 8 boarders each patient waits an extra 2 hours
  to be seen
• FCP at Stony Brook
• 1 minute per boarded patient
• 8 boarders each patient waits an extra 8
  MINUTES to be seen (because of the
  decompression effect of the FCP)
• 2/3 of floor admissions qualify
• Experience with 2500 patients placed on floors
  to relieve crowding

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Impact

• Better care for all patients
• More timely treatment
• Fewer errors

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Why?

• Safety
• Decreased diversion, walkouts, delay, sentinel
  events, errors, deaths
• Easy
• Large work load redistributed across wide area,
  each area with very small increase in work load
• Costs
• Call bell, central telemetry, privacy screen
• NO extra staff, etc.
• Savings
• LOS
• Improve processes, ED AND inpatient
• MORE BUSINESS
• Fewer suits

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Why not?

• Cant vs. wont
• Refuse to consider
• Refusal to acknowledge safety issues
• Silo mentality (only MY area matters)
• Perfect and good are enemies
• Failure of leadership
• Fear of change

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Why Stony Brook?

• A true commitment to patient safety for EVERYONE,
  not just as viewed from the individual silo
• Willingness to succeed, and willingness to go the
  extra mile on behalf of the patient

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Who does it?

• Stony Brook
• Duke
• Wm. Beaumont
• EMTALA
• Yale
• St. Barnabus system
• NYU
• LOTS of places now
• Inside the Joint Commission
• JCAHO white paper and Best Practices

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Crowding is bad for hospital finances as well
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Move em out .

• Simple
• The helping hand is tiny
• Costs insignificant
• Makes money
• Increases safety
• Improves nurse/patient staffing ratios
• Improves processes
• No ambulance diversion

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Key points

• The ED continues to function
• Patients receive expert care in the area and by
  the people best suited to provide that care

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What is being asked?

• LOTS of people are being asked to do a LITTLE
  extra so that a small number of people can
  accomplish the difficult, rather than the
  impossible.
• It is being asked because this is the safest
  thing to do for the most patients.

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What is being asked? the practical version

• If the problem is more admissions than there are
  beds
• 250 people take care of the easy ½ of a problem
  while 15 people take care of the hard ½ of a
  problem.