If ED physicians are waiting for the overcrowding problem to go away, they'll have a long wait, say the experts: Things are bad and getting worse. On the bright side, they add, some strategies have proven to be effective in lightening the load for the ED – which physicians know all too well bears the brunt of the burden for what is often a hospital-wide problem.
It's not getting better, and I think it will get worse because there's a supply/demand mismatch," says Jim
Williams, DO, former Chief of staff at Methodist Specialty and Transplant Hospital in San Antonio, TX, and an ED physician.
"The ED is just the canary in the coal mine &#mdash; the front door of healthcare," he continues. "There is a nursing and doctor shortage, an increasing number of baby boomers living longer, increased severity of illnesses with which they present, and a lack of insurance."
This comes as no surprise to ED physicians, says Williams, "Because we live them every day, but in order to really understand things you have to frame it as just one symptom of a much bigger disease. We doctors are frustrated because we are at the mercy of third-party payers – Medicare, Medicaid, and the privates. We have a contract with the hospital to provide care, and we want to have a relationship with the hospital, so if we scream too much about lack of bed availability or poor nurses it creates tension, so we have to walk a tightrope."
Bret Nicks, MD, Assistant Medical Director of the ED at Wake Forest University Baptist Medical Center agrees. "All ED physicians will be able to relate to the fact that it's not necessarily an isolated ED issue, but speaks to systems issues," he says, "But the majority of hospitals and administrators have been relatively reticent to change the processes by which patients are admitted and discharged over time."
There are strategies ED physicians can use effectively, says Nicks, "but it requires buy-in from the hospital and those departments that are 'inheriting' our patients."
Nicks says you have to create some means of efficiently disposing of patients, for example, a 90-minute window for consulting time, "But if there are not beds in the hospital it does not matter; you'll have boarding, and a continuous trickle-down effect."
Getting patents out of the ED
One strategy that has been used with some success involves moving patients out of the ED and placing them in beds in upstairs hallways. "Even if they are in a hallway bed, you're getting them upstairs where they can have more continuity of care," says Williams.
However, Nicks is not so sure. "We've gone through that; it requires a major change in 'mantra,' plus a shuffling of care entities," he says. "Can you put them up in the hallway if there is no oxygen, no appropriate monitoring, or you are in violation of the fire code?" Still, facilities such as the hospital at State University of New York at Stony Brook have used such a strategy quite effectively.
Another approach involves changing processes to improve flow. "For example," says Williams, "You can develop parallel processes as opposed to the more traditional linear processes." In other words, instead of handling the patient one step at a time – registration, history, blood draws, and so on, you can readjust your protocols so that several activities can be taking place at once – i.e., bedside registration, or point-of-care testing. "It decreases the time each patient requires, but it does not decrease quality of care," Williams asserts.
"Some emergency departments have identified discharge units," adds Nicks. "Once a patient is in the process of being discharged, they actually leave their room and go to another, larger room and sit on a chair [until they are completely discharged] to free up those beds." If there is space that can be identified for such a use, he says, "This is definitely a great idea."
Another effective strategy for offsetting overcrowding is the observation unit. "'Obs' is a terrific timesaver," says Williams. "It takes and holds these patients who in all likelihood would be inpatients." Obs is primarily used for three diagnoses, he explains – chest pain, CHF, and asthma. "These patients do not need to be boarded, and may not even need an inpatient bed; they can be treated within a 24-hour window and sent home," he adds.
Nicks' department takes this approach one step farther. "We use ours as a hybrid – a relatively new term – because we use it for two purposes," he explains. "First, we identify patients too sick to go home but who do not need to be admitted, and we give them expedited care. These patients have the potential to go home but need 8-23 hours of additional care. Then, we also place ED patients in there who have been evaluated and had their care process started but who will require an extended period of time before it is completed because of an elongated workup. We know what we need to do in terms of the workup and labs, but we can't do them quickly so the patient can't go home yet." This "hybrid" approach, says Nicks, "Maximizes your census capacity by using available beds in the obs unit for ED patients."
Another effective strategy, says Williams, involves discharging inpatients in the morning when things are slow in the ED and admitting ED patients in the afternoon. "Also, you should work to match staffing with needs, and smooth out your surgery schedule so there are no peaks and troughs," he advises. A hospital bed coordinator is also invaluable, as he or she can seek available beds all over the hospital.
Of course, this requires buy-in from other departments, as does this strategy suggested by Nicks: "A lot of ED physicians have implemented an approach with administration through which they come to a consensus on what ED overcrowding is and what the critical patient mass is for the department," he explains. "Once that critical mass is reached and agreed upon, a process should be implemented whereby the CMO [chief medical officer] will send a page out to the departments, as well as the hospitalist team or whoever is on call, to say you have reached a critical mass, and that they need to identify other patients who can be expedited for moving home or to another area of the hospital." This approach, he emphasizes, "needs buy-in on all levels."
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