Our environment – the silent issue

1. Our environment – the silent issue Hospitals 1960 vs. now ED 1960 vs. now

2. Crowding The cause The consequence The cure

3. 1. What’s NOT the cause?

4. 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

5. Money, not crowding, is the issue for these: • EMTALA • Safety net

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

9. Finito!

10. What causes ED overcrowding? Hospital overcrowding

11. Boarding:What are the consequences?

12. Sick people have to wait too long to receive care

14. Boarding increases TOTAL length of stay in the hospital, further worsening access. 5 + studies – 1 day

17. Boarding increases walkouts, some needing admission

19. Overcrowding increases medical errors

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

23. Overcrowding causes deaths ….. beyond anecdote

26. How big is the effect? • Pneumonia 1.07 • Crowding 1.2 – 1.4 • Weekend admit 1.01 – 1.05 Group sizes

27. Comparison • 100 pneumonias: save 7 • 100 “crowding” admits: save 17 – 25 • (RR 1.2 – 1.34)

28. The BIG question Does this problem kill more people than problems identified in other initiatives to improve outcomes of patients?

29. Physicians are harmed

30. 25,000 patients • Frequency of suits based on whether the patient waited less or more than 30 minutes to be seen: • < 30 = 0.9 • > 30 = 4.9

31. Key points Crowding is caused by boarding

32. Boarding increases harm to patients in the following ways: • Waiting times • Diversions • Length of stay • Medical errors • Sentinel events • MORTALITY

33. Boarding increases harm to hospitals and doctors in the following ways: • Financial losses to hospital and MD • Malpractice claims

34. How do we fix it?

35. How do we currently deal with this problem?

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

37. 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

38. Current solution to HOSPITAL overcrowding Crowd one area Space Staff Structure Expertise

39. The question ….. 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 Which block in this diagram is LEAST capable of surge? Which block in this diagram needs to be MOST capable of surge?

40. x x x x x “Radically” new model – redistribute the load x x x x x x x x x x x x x x 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

41. 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.

42. The cure

43. Why not divert ambulances? • In most circumstances, it simply doesn’t work • If allowed: • other solutions are not sought • Dangerous to the patient

48. Summary: ambulance diversion is: • Unsafe • Ineffective • Money loser

49. Other lousy solutions • Deferred care • Safety? • Effectiveness? • MD at triage; RN -> MD

50. The ONLY current solution known to work: Move the admitted patients out! (The Full Capacity Protocol)