ED Decompression

July / August 2010

ED Decompression

Combating Emergency Department Overcrowding with Creative and Flexible Planning

To set the scene, imagine that it is a cold and rainy Friday evening in early January, and you are a nurse in the emergency department (ED) of the local hospital. Patients, with various complaints and levels of acuity, are being cared for in the ED’s 30 treatment rooms. Those who were determined, by the three triage nurses, to be too seriously ill or injured to wait in the lobby have been placed on stretchers inside the treatment rooms or the extra stretchers now encircling the nurse’s station. Among the patients, several are awaiting admission to inpatient units. To further complicate matters, there are 2 involuntarily committed psychiatric patients who are suicidal and awaiting transfer to other facilities. There are 14 patients who have been triaged and who are now registering for services. They are then being sent to wait in the lobby. Twelve others are in the cue awaiting an initial triage assessment.

This or similar scenarios are played out every day in EDs across the United States. Every day, the risk that critically ill or seriously injured patients are waiting in ED lobbies intensifies. The patients are not going away, their numbers are growing, and their conditions are not becoming any less critical. Savvy ED leaders must not only tap into new medical, diagnostic, and nursing-related facets of patient care, but we must also reach more deeply into ourselves and our resources and tap new, creative ways to deal with these pressing issues as well.

Indeed, EDs everywhere are bursting at the seams. As a result, patients are waiting longer to be seen by harried, rushed, and over-worked providers and clinical staff. The likelihood that assessments and subsequent care are being delayed for very ill or seriously injured patients is multiplied exponentially by the ED’s involuntarily assigned roles as primary care provider and inpatient medical and psychiatric holding units. Longer waits, aside from being potentially dangerous from a clinical perspective, wreak havoc in terms of patient satisfaction and overall safety. Subsequently, these ill or injured and dissatisfied patients, along with their tense and disgruntled family members, often use and abuse ED staff members and physicians for venting their frustrations. This can negatively impact morale and productivity, leading to burn-out and vacancies in staffing (Buerhaus et al., 2005). It is incumbent upon leaders then, to investigate, create and facilitate new and different was to manage resources to meet and conquer these multifaceted demands. To be successful in today’s emergency care environment, and to ensure patient safety, the status quo is no longer acceptable (Malloch & Porter-O’Grady, 2005).

Based on the layout and design of individual departments, various non-traditional options may exist. The goal here is to discuss creative solutions that have proven effective in decreasing wait times, increasing throughput, and thus, improving overall patient and staff satisfaction and safety. With that said, the challenges are renewed, compounded, and fluctuate daily. The proactive and imaginative approach, however, has yielded several means of decompression and allowed for better patient monitoring, thereby affording improved patient safety. Leadership in any facility may be able to use these ideas as a springboard and customize these principals to work in any setting.

Cohorting Patients
Based on presenting signs and symptoms, and at various stages of the ED treatment process, patients have certain intrinsic similarities. Capitalizing on these similarities can promote significant decompression. For example, instead of waiting for discharge inside a treatment space that could potentially accommodate the next patient, patients nearing the end of the treatment course can be moved to a single location and overseen by one nurse. Other patients, just beginning the assessment and treatment process, can now be assigned this newly vacated and infinitely valuable treatment space. The nurse responsible for the cohorted area is able to manage final medication administration and discharge teaching by calling individuals to a predetermined, private discharge area in, or in close proximity to, the cohort.

Other patients who may be appropriate for treatment resolution in the cohort area are those who, for instance, for whom the provider has ordered a round of intravenous fluids or antibiotics and then cleared for discharge. Basically, this area is appropriate for any patient who has completed the primary consultative and diagnostic portions of the visit and who are now merely in a “hold” or “wait” status until discharge.

If a “fast track” area is not already in use, or in order to expand a fast track’s capabilities, this principal can be used. Those patients who require simple and noninvasive treatments can receive care within the cohort. In essence, one may expand the ED’s capabilities within the confines of already occupied space.

Staffing the cohort usually requires only one nurse, possibly a non-licensed clinical or clerical staff member to assist, and a provider who is already on-duty. This makes for an easy “sell” in terms of allocating or acquiring funding for this kind of initiative. Operationalizing this principal is quite simple and can be accomplished in multiple ways. In my hospital’s case, one fairly large treatment room and a contiguous smaller room are used. The larger of the two rooms is outfitted with comfortable, medical-grade recliners. Screens are placed between them to provide necessary patient privacy. As a distraction, a large-screen television is angled so that it can be viewed from each recliner. Patients are moved into this area as appropriate with the explanation that they are moving toward discharge.

Those sent to the cohort before evaluation by a provider are told that, although non-traditional in nature, this is the most expedient treatment option. The smaller treatment room mentioned above is used for the provider’s examination, consultation, and assessment. Then the patient is brought back to the cohorted area to complete his or her treatment course. These two rooms are used to see and treat six to eight patients simultaneously, in the same space, and with the same staff, normally needed to treat only two patients. This organization’s cost to establish this process was less than $10,000.

The ability of leadership to be creative is somewhat contingent on each individual department’s configuration and location within the larger facility. Proximity to other departments is an option to consider for possible temporary expansion. In the case of this hospital’s ED, it is contiguous to a separate treatment and waiting area. During regular business hours, this space is used as an Occupational Health Clinic and for minor in-house workers’ compensation injuries. However, after 5:00 p.m. and on weekends, this space provides valuable decompression for the ED, thus the term “subletting.” Again, the resources needed to activate the space are minimal. A nurse, a non-licensed assistive clinical or clerical staff member and a provider can, in a matter of a few minutes, be up and running.
Not only can this be valuable in terms of additional treatment space, but in terms of waiting room space as well. Contagious patients and their families can be separated from the general population. Potentially volatile situations, such as those surrounding the treatment of gang or domestic violence-related injuries, can be managed more safely if separation is possible. Incidences involving multiple victims and families can also be managed in this separate area. Having and using this space allows for both departmental decompression and situational de-escalation.

ED Boarding of Inpatients
This issue has, and will continue to plague EDs for the foreseeable future. There are no easy solutions to this ever-growing problem, but the ability to segregate this population and manage it as a cohort can provide a workable, if temporary, solution in sublet space. For instance, in this region of the country, mental health reform has significantly decreased the number of available inpatient beds both in this facility and in the surrounding counties. Mentally ill patients are boarding in the ED while awaiting placement to both our inpatient psychiatric unit as well as units in our area. When other clinical areas of the organization are full to capacity there is no recourse but to board all sorts of patients in the ED. Cohorting can also facilitate the acquisition of staff from the patient’s intended unit to come and provide care until such time that space on that unit is available and the patient can be moved. This promotes continuity of care and allows for regular ED staff to concentrate on those patients more appropriate to their skill sets and expertise.

Cohorting patients within the ED and subletting areas outside the ED proper, can mean the difference between throughput and virtual standstill. Leaders who are able to think creatively and act “outside-the-box” will be those who are successful in meeting the demands of today’s ever growing and ever changing patient demands. This creativity may also prove to be the key to bolstering ED staff and physician morale during these arduous and uncertain times and may prevent attrition and burnout.

Van Haygood is administrator for emergency/express, post-procedural care & direct admission services at Catawba Valley Medical Center in Hickory, North Carolina. He may be contacted at vhaygood@catawbavalleymc.org.

Buerhaus, P. I., Donelan, K., Ulrich, B. T. Norman, L., Williams, M., & Dittus, R., (2005). Hospital RNs and CNOs perceptions of the impact of the nursing shortage on the quality of care. Nursing Economic$, 23(5), 214-221

Malloch, K. & Porter-O’Grady, T. (2005). The quantum leader: Application for the new world of work. Sudbury, MA: Jones and Bartlett.