A recent study published in the Annals of Emergency Medicine (Sun, 2012) performed a retrospective cohort analysis of patients admitted in 2007 via the emergency departments (ED) of acute care hospitals in California. The researchers studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5 percent greater odds of inpatient death.
Crowding is a crisis that results from the practice of “boarding” or holding in the ED emergency patients who have been admitted to the hospital. Crowding occurs when no inpatient beds are available in the hospital. These boarded patients wait, sometimes for days, for inpatient beds in a chaotic and unpredictable environment (ACEP, 2008).
This issue must be recognized as an institutional one. Gridlock in the ED can only be solved by the involvement of all stakeholders so that systemic and hospital-wide solutions may be implemented.
On the news last evening, it was reported that a hospital had opened “a large tent” on its property to manage the increased patients seen in its ED due to the flu season. Many EDs are already overcrowded and unable to respond to day-to-day emergencies, let alone disasters, epidemics, or acts of terrorism.
This is a situation in which nursing can be part of the solution. Nurses are most knowledgeable about the process of patient care. While collaborating with involved healthcare professionals throughout the organization, strategies can be explored and implemented to address this overcrowding, which we now know affects patient mortality.
Where to begin?
Most organizations have an Emergency Department Committee; here the stakeholders can utilize the Quality Improvement Process to address the problem. The committee needs to explore barriers to timely patient admission, look at best-practices as reported in the literature, make recommendations, trial the actions, and evaluate the effects.
Here are some helpful solutions:
- Coordinate the timely discharge of inpatients: In our organization, a Daily Bed Round meeting was conducted. The brief meeting was held at 11:00 a.m. each morning after the unit managers conducted their own unit rounds with involved nursing staff. Each manager would report the status of patients to be discharged. Discharge planning staff would also attend and were available to address any identified barriers to discharge. Participation by all clinical units was expected. No other department meetings were held in the morning, since the critical role of nursing participation and contribution was recognized and appreciated.
- Ensure that all beds are available in a timely manner: Walking rounds were conducted daily around 2:00 p.m. to 3:00 p.m. to identify the status of all anticipated discharge beds. The participants included the Director of Admitting and the VP of support services. This was done to ensure that all beds were accurately reported, cleaned, and ready for the new admission. Any barriers were identified and managed at the time.
- Carefully evaluate the current staffing levels in relation to patient census patterns: We listened to our nursing staff and jointly evaluated staffing levels and added staggered shifts in relation to the patient census pattern. In collaboration with our professional nursing union, we implemented a four-hour work shift to handle peaks in volume. This was attractive to some nurses with child care issues, who could now work part of a full shift.
- Evaluate current process of triage to discharge: The use of an “admissions nurse” was suggested by staff. This RN was assigned to the ED and completed the admission assessment and implementation of MD orders for every patient admitted to an inpatient bed. When the receiving RN accepted the patient from the ED, this time-consuming component of care would be reviewed and resulted in a reduction in time delays to accept the patient. The feedback from nursing was so positive that we later implemented a night admission nurse.
- Evaluate the process for transfer of the patient to the assigned nursing unit: Our standard goal was that all patients would be accepted within 30 minutes of the call from admitting. If not, the nursing supervisor would evaluate the situation. Delays were identified and managed from both ED and inpatient sides. This continues to be a work in progress.
The above suggestions emphasize the vital role of the first-line staff RN in managing this systemic issue of ED overcrowding. Additional solutions may include bedside registration, fast track units, and observation units. However, periods of high ED crowding are associated with increased inpatient mortality. Yet again, nursing is in a position to promote a safe patient care environment.
- Sun. B. (2012) Effect of Emergency Department Crowding on Outcomes of
Admitted Patients. Annals of Emergency Medicine. Elsevier.
- ACEP Task Force Report on Boarding. (2008) Emergency Department Crowding: High- Impact Solutions. American College of Physicians