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!

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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

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

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17 Boarding increases walkouts, some needing admission

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19 Overcrowding increases medical errors

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

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23 Overcrowding causes deaths ….. beyond anecdote

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

37 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 xx x x x Current model

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

39 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 xx 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? The question …..

40 Xxxxxxxxx xxxxxxxxx xxxxxxxxx xxxxx xxxxxx x x x x x x x x x x x x x x x xx x x x “Radically” new model – redistribute the load nice nasty 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

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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)

51 Ask Four questions Space, load, expertise, and necessity

52 Question 1 - Space Good space Bad 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)

53 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 Action plan?? 20 additional patients beyond “good” space capacity. How would you distribute them?

54 Question 3 – Expertise – all units full Unit A Understaffed 4 nurses Needs 6 Wrong expertise Wrong environment Units B, C, D, E, F, G, H, I, J 6 nurses Needs 6 Right expertise Right environment 20 additional patients beyond “good” space capacity. How would you distribute them?

55 Question 4 - Necessity Is your emergency department necessary?

56 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.”

57 Answer to questions 1-4 Move the patient upstairs.

58 The bold move by the NY State DOH:

59 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”

60  Inpatient Units are: less crowded, less noisy, less chaotic  Inpatient Units provide appropriate clinical expertise (MD’s, RN’s)  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 Why? ….

61 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.

62 How many? ED MICU CCU Neuro Peds Floor % FCP eligible SICU CV ICU BurnPICU total 3190

63 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 patients placed on floors to relieve crowding

64 Impact Better care for all patients More timely treatment Fewer errors

65 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

66 Why not? Can’t vs. won’t 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

67 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

68 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”

69 Crowding is bad for hospital finances as well

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73 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

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

75 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.

76 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.