Marian Conde University of Central Florida Leadership and Management Overcapacity in the Emergency Department and Timely Throughput of Patients to Inpatient Units Marian Conde University of Central Florida Leadership and Management

Scope: History Demand for Emergency Department services exceeds the available supply Inability to move patients to inpatient units "Boarders" or "holds" (patients needing to stay in the ED due to no bed availability in inpatient units) that consume substantial amounts of resources and labor. Unable to bring patients back to the ED from the waiting areas (Barrett, L., Ford, S., & Ward-Smith, P, 2012) Ambulance diversion due to over capacity Emergency department frequent users (ED-FU) visits multiple times(Bodenmann, P.,2014) Uninsured or underinsured use ED as a primary care physician 50% of hospital emergency departments are at over capacity

Scope: Impact Negative impact on patient care Patient Safety: Patients need to be admitted to the in-patient units where caregiver competencies align with the patient's condition (Driscoll, M., Tobis, K., Gurka, D., Serafin, F., & Carlson, E., 2015). Length of stay Cost of care Clinical resource utilization Patient satisfaction Physician satisfaction Nurse satisfaction Increase of medical errors due to overcrowding and understaffing Unnecessary mortality Access block due to overcrowding (Khanna, S., Boyle, J., Lind, J., 2012).

Specific Problem Over capacity in ED and Flow of Patients to Inpatient Unit in a timely manner. Patients health outcomes & mortality are at risk due to the inability to move patients from the ED to in-patient units for their care in a timely manner and it plays a large role in patient dissatisfaction with their care.

Nurse Leader Role It is the responsibility of the nurse leader to work on a collaborative plan which will include all disciplines to ensure the correct placement and flow of patients from the ED to inpatient units.

Nursing Issue Decrease time spent in ED to an inpatient bed correlates with improved mortality outcomes (Barrett, L., Ford, S., & Ward- Smith, P., 2012). Improved patient satisfaction. Decrease time spent in ED for patient correlates with wait time for other patients to be seen which in turn correlates to improved revenue for hospital. Transferring patients to inpatient beds correlates to a decrease in left without being seen by a physician and ambulance diversion. Increase satisfaction for both physicians and nursing teams.

Alternative Solutions Daily Mission / Huddles with all involved disciplines to discuss potential discharges, surgical patients to be admitted, direct admits awaiting bed at home. Teaching of the National Emergency Department Overcrowding Scale (NEDOCS) to all disciplines involved in the placement of patients and when each level of the plan would be initiated. Private rooms to be turned back to semi-private to enable patients in the ED to be moved to the proper level of care and decrease holds or boarders in the ED.

Alternative Solutions Bed management meetings to be called and held consistently if House Supervisor feels the hospital is moving into overcapacity. Inpatient Managers, Assistant Nurse Managers and staff nurses to shadow ED nurses to have a better understanding of the flow and the importance of placing patients in inpatient beds in a timely manner by sharing data of why it is beneficial for both the patients and the hospital.

Selected Solutions Implementation of daily Bed Management meetings at 08:30 and 04:00. All Stakeholders to attend Bed Management meetings. NEDOC Levels reviewed and decision of when to implement each level (Weiss, S., Ernst, A., & Nick, T., 2006). Bed ahead: each unit to have a nurse ready to accept patient and stretch assignment if needed to receive patient from ED.

Implementation of Plan Bed management strategy was put in place by having all stakeholders involved in the transfer of patients from the ED to inpatient units. Stakeholders at table were: ED physicians, CNO, all Nursing Directors both ED and Inpatient, all Nurse Managers (ED & Inpatient), Assistant Nurse Managers from all units, representatives from Surgical Services, Transportation, Environmental Services, Dietary, laboratory, CT, MRI, Pharmacy and Patient Financial services. All stakeholders attend the morning Mission Meeting were capacity and placement of patients is discussed. Discharges are reviewed, surgical patients to be admitted and direct admits. Staffing for both days and nights is reviewed and needs are reviewed for all areas of the hospital.

Implementation of Plan NEDOC Scale: was reviewed by all and when to implement each level of the plan was decided on with feedback from all of the stakeholders. Shadow dates were set up for stakeholders to have a better understanding of the flow of the patients from the ED to inpatient units. Care Manager was placed in ED to facilitate proper placement of patients. Discharge area was developed and opened to facilitate the opening of inpatient beds by moving discharged patients waiting for rides to the discharge area.

Plan for Evaluation Patient Satisfaction scores based on HCAPHS

Plan for Evaluation ED matrix for a) time of arrival to see doctor b) time from arrival to discharge home c) time from arrival to placement in inpatient unit bed d) number of patients that left the ED without being seen e) diversion of ambulances or wait time to unload f) amount of time from decision to admit to time admitted to bed

References Barrett, L., Ford, S., & Ward-Smith, P. (2012). A bed management strategy for overcrowding in the emergency department. Nursing Economic$, 30(2), 82-86. Bodenmann, P., Velonaki, V., Ruggeri, O., Hugli, O., Burnand, B., Wasserfallen, J., & ... Daeppen, J. (2014). Case management for frequent users of the emergency department: study protocol of a randomized controlled trial. BMC Health Services Research, 14(1), 426-449. doi:10.1186/1472-6963-14-264 Driscoll, M., Tobis, K., Gurka, D., Serafin, F., & Carlson, E. (2015). Breaking down the silos to decrease internal diversions and patient flow delays. Nursing Administration Quarterly, (1). doi: 10.1097/NAQ.000000000000080

References Hadley, M. (2009). Overcapacity protocols. Alberta RN/ Alberta Association of Registered Nurses, 65 (2), 3. Khanna, S., Boyle, J., Good, N., & Lind, J. (2012). Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emergency Medicine Australasia, 24(5), 510-517. doi:10.1111/j.1742-6723.2012.01587.x Richards, J., Ozery, G., Notash, M., Sokolove, P., Derlet, R., & Panacek, E. (2011). Patients prefer boarding in inpatient hallways: Correlation with the national emergency department overcrowding score. Emergency Medicine International, 1-4. doi: 10.1155/2011/840459 Weiss, S., Ernst, A., & Nick, T. (2006). Comparison of the national emergency department overcrowding scale and the emergency department work index for quantifying emergency department crowding. Academic Emergency Medicine, 13 (5), 513-518. doi: 0.1197/j.aem.2005.12.009