Making room for more patients
A 'whole-hospital' approach and hospitalist involvement open beds and clear halls
From the February ACP Hospitalist, copyright © 2007 by the American College of Physicians.
By Jessica Berthold
Peter Viccellio, MD, still remembers the day, month and year when he had an epiphany that changed his hospital.
It was a Thursday in November 1999, and he was working in the emergency department of New York's Stony Brook University Medical Center. All the inpatient beds were full, and eight isolation patients lay in the hallway as staff rushed around.
Bed huddles can improve communication among hospital staff.
Surveying the scene, Dr. Viccellio wondered yet again why there was a rule against moving hallway-bound emergency patients to the halls of less-crowded floors.
Exasperated, he called a friend in the state health department to find out.
"His response was that there was no such rule," said Dr. Viccellio, now clinical director of the ED. "It had been an urban myth for years that you couldn't do this."
So Dr. Viccellio started a campaign to cut down on "boarding"-keeping admitted patients in the emergency department while they wait for an inpatient bed-by distributing those patients in halls throughout the hospital.
"We move them from our crowded ED hallways, which are noisy, brightly lit, understaffed … to areas where there are much better nurse-patient ratios, and where they have the appropriate specialties to take care of them," Dr. Viccellio said.
Dubbed the "Full Capacity Protocol," the practice helped, and has since been adopted by hundreds of hospitals.
Yet boarding, which occupies space, staff and equipment that could be used for arriving patients, is still a problem for emergency departments, with half of the nation's medical directors saying they have to board patients for four or more hours every day, according to the American College of Emergency Physicians.
It's not difficult to see why. Patient volume in U.S. emergency departments swelled by 26% from 1993 to 2003, while the nation lost 425 emergency rooms, according to a 2006 report by the Institute of Medicine of the National Academies. And a lack of inpatient beds, especially in the intensive care unit, means ED patients can't be moved: 90% of level I trauma centers and hospitals with 300 or more beds operate at or above capacity, a 2002 Lewin Group survey found.
The supply-demand balance is systemic, experts say. The population is aging. EDs are the only place uninsured people are guaranteed care. Cash-strapped hospitals shut their doors or become specialty facilities to capture the better compensation rates.
Hospitals need help from the federal government and individual communities to solve these problems, experts say, but that will take time. Meantime, many are taking measures to clear hallways and waiting rooms on their own.
A 'whole-hospital' solution
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"Many hospitals have failed to take an institutional approach; the problem is walled off on the ground floor." — Arthur L. Kellermann, FACP |
The key to reducing boarding and overcrowding in the emergency department is to frame the issue as a whole-hospital problem-meaning everyone in the hospital should strive for more efficient care. The faster the discharge, the more beds are freed up-and the faster ED patients can be moved.
"Many hospitals have failed to take an institutional approach; the problem is walled off on the ground floor," said Arthur L. Kellermann, FACP, chair of emergency medicine at Emory University in Georgia. "There has to be a commitment from the whole hospital to function more efficiently."
Communication between units is key, he said. Some hospitals have "bed czars" who track which beds in the facility are full, empty or about to become free. Others have inpatient staff page emergency staff when beds are about to open up.
Shore Health System hospitals in Cambridge and Easton, Md., have "bed huddles" three times a day, where staff from several units crowd into a tiny room to discuss how many ED admissions there are, how many inpatient beds will soon be free and how many staff are working.
The huddles are a low-cost way of maximizing staff resources and treating patients more efficiently, said Donna Prahl, RN, manager for case management at Shore Health. Based on huddle reports, nurses may switch around to relieve busy units, or hospitalists may take a second look at discharging patients.
The intimate nature of the huddles-as opposed to electronic bed boards-may account for their success: The hospital can now predict 80% of its discharges, versus 30% two years ago, Ms. Prahl said.
"By looking at a computer screen you don't hear the stress in a manager's voice about how crazy an emergency department is," Ms. Prahl said. "It's not just about the information; it's about feeling each other's pain."
The hospital also recently implemented "bridge orders," which allow ED patients to move upstairs with a basic set of care orders when a bed becomes free. Previously, the admitting doctor would have done an evaluation and written orders before the patient could move, Ms. Prahl said.
Meanwhile, Dr. Viccellio's Full Capacity Protocol inspires staff to free up beds faster, he said.
"Once we started doing this, a third to a quarter of patients we sent upstairs never made it to the hallway. Magically a bed was found as they were on the way up," Dr. Viccellio said. "Another 25% were in the hallway for an hour or less, and then a bed was made."
The practice is a hit with patients, but hospital administrators and employees are often resistant to it, citing safety concerns and increased workload, said Frederick Blum, MD, immediate past president of the American College of Emergency Physicians.
"Some administrators would rather confine the boarding problem to the ED to protect their other units," Dr. Blum said.
At Detroit's 903-bed Henry Ford Hospital, the Full Capacity Protocol was discussed but nixed after a nearby hospital tried it and got "enormous pushback" from staff on non-ED floors, said Gerard Martin, MD, a senior physician in Henry Ford's emergency department.
"It'd be nice if you could get buy-in from the other floors," said Dr. Martin. "But the truth is, they don't always care what happens in the ER."
Faster discharges, fewer admissions
Some hospitals are looking outside their own walls to ease boarding and overcrowding. When Ms. Prahl of Shore Health realized that the admission policies of her community's nursing homes were prolonging hospital stays, she had a talk with them.
"You can only move patients if you have adequate openings downstream," Ms. Prahl said. "Some of these homes wouldn't take patients after 1 p.m., or on weekends. We started giving them data about the numbers of patients they were accepting, and about the high cost of keeping those patients in the hospital. Things changed."
The University of Michigan's 550-bed University Hospital pares down admissions by having a nurse practitioner or social worker screen patients to see if follow-up can be done via home visits. Shore Health System, meanwhile, sends some of its ED patients for follow-up care to a local physician's office if they are determined to not need admission, helping patients establish primary care in a more appropriate setting. Several hospitals also report using observation units to avoid admitting patients who don't need it.
The Bronx's Montefiore Medical Center separates the sickest patients from the less sick in separate waiting rooms, and has a five-level triage system to determine where and when patients should be seen-a strategy that has cut arrival-to-discharge time by 30%, said Peter Semczuk, DDS, MPH, the hospital's vice president of clinical services.
When possible, Montefiore collects patients' medical history and vital signs at the bedside, instead of at an intermediate triage desk. So does Spectrum Health-Grand Rapids in Michigan.
"We get only their name, chief complaint and date of birth, then they go straight to a room and everything else is done there," said Jim Schweigert, MD, medical director of emergency services at Spectrum Health-Grand Rapids. "It avoids duplication."
Hospitalists, data analysis can help
Staff can be a big help. Administrators said that their hospitalists made it easier to spot patient bottlenecks and delays in service.
"They aren't just rounding once a day, but are watching things constantly," Dr. Schweigert said. "Hospitalists help improve patient flow."
At Montefiore, hospitalists noticed a trend of patients staying extra days solely because they needed tests for which there were no weekend staff. Now, ancillary services are available six or seven days a week instead of five, Dr. Semczuk said.
"Becoming a seven-day hospital was instrumental for improving our discharge process," Dr. Semczuk said. "We have seen a direct correlation between the numbers of hospitalists and a decline in the average length of stay."
Ultimately, the kind of fixes a hospital should implement depends on the facility, Dr. Blum said.
"The combination of problems that lead to boarding at a given institute are all different and require a different approach," Dr. Blum said.
Collecting and analyzing data can help narrow down what a hospital's individual solutions should be, said Margaret VanAmringe, MHS, vice president for Public Policy and Government Relations for the Joint Commission.
Grand Rapids Hospital, for example, uses data to more evenly distribute when elective surgeries are scheduled.
"We also analyze data to find out when patients are arriving and leaving, when they are having to wait, etc., and then match that so we have the right amount of staff," Dr. Schweigert said.
Patient data can also help convince reluctant hospital staff to make changes, Ms. VanAmringe noted.
"Nothing smacks people in the head quite as much as some hard data," she said.
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