How can we fix this mess?

1. How can we fix this mess? Hospital Overcrowding

2. Answer • Simple • Costs nothing • Makes money • Increases safety • Improves nurse/patient staffing ratios • No ambulance diversion

3. The “undramatic” problems • Unreported bed • Uncleaned room • MD failure to discharge • Silos with full and empty beds • Weekend vs. weekday

4. Institutional perspective • Have one! • We must do the best thing for ALL of the patients, not the ED • ED is necessary • Inpatients don’t belong in the ED • ED provides LOUSY care of inpatients • The problem and the solution should be in the hands of the “right” people

5. x x x x x x x HUGE inpatient areas Itsy-bitsy ED x x x x x x x x x x x x x x x x Everything is filled to the brim

6. Current model x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

7. Current solution to HOSPITAL overcrowding Crowd the ED Space Staff Structure Expertise

8. Current model • Core measure: Timely administration of antibiotics • Core measure: Door to balloon time • Timely treatment of strokes • Patient satisfaction Inadequate staff Inadequate space Lots of meetings

9. Is this your ED model? x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

10. What are your SYSTEM incentives?

11. Our ED • Pre (25,000) • Incentives? • One Day Change • Bedside registration • NO patients wait in waiting room • Incentives?

12. 90 ………… 12

13. x x +/- Radically new model – 1970’s x x x x x x x x x x x x x x x x x nasty nice

14. WHY can’t we make it happen? • “Against the rules” • “DOH won’t allow” • OB OB OB • “That’s the way things are done” • Keep the chaos IN the ED • ED vs. rest of hospital • The problem is not admissions

15. Defining the real problem Too Many Admitted Patients In the wrong space, in the wrong place, with the wrong staff

16. A fateful day … in isolation

17. 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.viccellio.com/overcrowding.htm

18. What about ambulance diversion? • Simply Diverts to other overcrowded ED’s • Not good business • Can’t divert walk-ins • Works?

19. Our CQI Efforts • Meetings • Measures • Graphs • Memos • Repeat the above

20. Behavior is driven by incentives What are the incentives?

21. NO move to inpatient unit ED does admission paperwork ED gives treatment Day can be better organized Less total work Move to inpatient unit Decrease the number of patients to decrease the amount of work Discharges Clean beds Predict incentives ….

22. The Administrative Decision Focus on what is best for the patient How is being in the hallway better for the patient?

23. Four questions Space, load, expertise, and necessity

24. Good space Bad space Question 1 - Space Action plan??

25. Unit A No space 15 additional patients beyond “good” space capacity Interferes with prime function Units B, C, D, E, F, G, H, I, J No space No additional patients beyond “good” space Question 2 - Load Action plan??

26. Unit A 6 nurses Needs 11 Wrong expertise Wrong environment Units B, C, D, E, F, G, H, I, J 6 nurses Needs 6 Right expertise Right environment Question 3 - Expertise Action plan??

27. Question 4 - Necessity Is your emergency department necessary?

28. Answer to questions 1-4 • Move the patient upstairs.

29. Where leadership meets the road…. • Implementation of full capacity protocol • A hallway -> a hallway? • Leadership Concerns • Nobody does this • Not safe • Nurses will quit YOU are a leader EITHER WAY.

30. Why? …. • Inpatient Units are: less crowded, less noisy, less chaotic • Inpatient Units provide appropriate clinical expertise (MD’s, RN’s) • Staging in an inpatient hallway will result in closer, therefore faster access to a room • The ED can continue to fulfill its mission

31. Guess what!? Nurses are professionals. They can SEE what the best thing is for the patients. Where do you make them look?

32. Hospital overcrowding • Implementation of full capacity protocol • First three months www.viccellio.com/overcrowding.htm

33. What to do during difficult times ... Ask what’s best for the patient, and all the patients.

34. Full capacity Protocol: How it Works • Step 1 : ED attending and ED charge nurse • Step 2: Bed coordinator - NEUTRAL • Step 2a: Medical Director - NEUTRAL • Step 3: Bed coordinator notifies Clinical Associate Directors • Step 4: Units assigned hallway patients. No unit will receive more than 2 hallway patients.

35. Priority of Hallway placement • Non-telemetry patients with little or no co-morbidity • Non-telemetry patients with minimal or moderate co-morbidity • Telemetry patients as follows: • Little or no co-morbidity • Low index of suspicion for cardiac event • ED attending approval • Telemetry box availability and central monitoring slot Get them OFF tele

36. Exclusions to Hallway Placement • Patients requiring step-down or ICU • Rule-in MI or at high risk for cardiac event • Ventilator dependent patients • Patients requiring negative pressure or Isolation rooms • Patients requiring greater than 4 liters of O2 via nasal cannula

37. Changes in criteria • Hallway = hallway • Isolation patients • ICU patients !!! • Medical director not involved

38. Lessons Learned • Identify space and equipment issues prior to implementation • Sometimes “Just say No” • Floor overwhelmed • Include patients in recognition efforts Over time, the “issue” just ….. ….. dies.

39. What are the results? • Press-Ganey • ED • Inpatient • Memphis • Governor’s Workforce Award • LOS studies “It’s just too simple and obvious. You can’t expect us to believe this. Something must be wrong here.” Dan Sisto, NYHA

40. Results: Patient Satisfaction Press-Ganey

41. Results: Staff Satisfaction • ED Staff verbalize improved satisfaction in their work environment • Inpatient staff have not expressed impact on overall satisfaction related to hallway protocol Would you WANT them to like it?? What they don’t like – volume not issue

42. Patient opinions Take a guess

44. Results: Disposition Average patients > 1 hr= 10.3 hrs Average all patients = <5 hrs (16% of patients did not meet hallway criteria)

45. 03/04 Data • 2003: 161 patients placed in the hallway • 2004: 454 patients placed in the hallway • 2005: 600+ so far • Average ED stay prior to hallway placement: 213 minutes ( 3.5 hrs) • Average stay in hallway 454 minutes (7.5 hrs) <3% (12) spent 23hrs or> (longest 29hrs) 35% spent < 1 hr in hallway

46. Results: Patient Satisfaction Press Ganey

47. What about those other CQI efforts? Surprise surprise www.viccellio.com/overcrowding.htm

48. Transferring the chaos to the inpatient units?

49. Staffing ratios and patient safety • ED • Needs 15 (California: 19) • 12 for direct patient care • Has 10 (8 for direct patient care) • Added admitted load, needs 3.5 • Total RN need 18.5; available 10 (8) • Floors • Needs 6 for 30 • Has 6 for 30 • Redistribution (max 2 per unit) [8 patients to floor] • ED total RN needed 17; available 10 • Floor total RN needed 6.04 - 6.33; available 6 Direct patient care: 8 of 15.5 RN’s SPACE Question: which is safer???

50. Side-by-side: 1.70 RN vs. 1.05 RN Patient safety? ED Floor 6 (6) 10 (18.5) FCP FCP 10 (17) 6 (6.04 – 6.33) ED hold ≠ Hallway patient ED nurse ≠ Floor Nurse No space ≠ Space