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If you want to avoid diversion, you need to move admitted patients upstairs quicker, urges Alan C. Woodward, MD, chief of emergency services at Emerson Hospital in Concord, MA. "Patients are coming to us sicker and need to be admitted, but there are insufficient beds," he says. "We are now bedded and staffed for the valleys. The norms are a stretch, and the peaks are unattainable."
The ED acts as a "buffer" for many of the busiest units of the hospital, says James J. Augustine, MD, FACEP, CEO of Premier Health Care Services, a Dayton, OH-based physician management group that provides ED staffing and consulting. "The ED staff manage the patients and do rapid decision making for patients who need services when that unit of the hospital is tied up," he adds. "We hold and manage patients waiting for an open operating room, critical care bed, dialysis unit, cardiac cath lab, invasive radiology intervention room, or CT scanner."
Here are ways to reduce overcrowding and avoid diversion:
• Bring solutions to administration. Step forward and take the opportunity to solve the problems of "tight bed flow" in the upstairs units, advises Augustine. "ED patients are best served when we can rapidly evaluate and then send the patient to an appropriate unit with an open bed," he says. "ED leaders are often masters at efficiency and major incident planning. The hospital will benefit from the addition of these skill sets."
• Act promptly when the ED is backlogged. At Valley Hospital in Las Vegas, a Divert Activation Response Team (DART) is called in when the ED is overcrowded, reports Edwin Homansky, MD, FACEP, the ED’s chief of staff. The team includes a representative from nursing administration, the administrator on call, the admitting supervisor, housekeeping supervisor, and the ED charge nurse, he says. (See "Desert Springs Hospital diversion plan 2000-2001," in this issue.)
The team does the following:
It’s key to act as soon as you see a problem developing, says Homansky. "If the ED is heating up at 3 on Friday afternoon, then by 7 that night you’re going to have a real problem," he stresses. "You need to start addressing that soon."
• Start the admission process earlier. At Valley Hospital, the admission process is started as soon as it’s determined that a patient will be admitted, which saves 30 to 45 minutes, says Homansky. "For example, we will start admission procedure on an obvious unstable angina patient before any tests are back, knowing from the history and EKG that this patient is going to be an admit," he explains.
• Build flexibility into other departments. Develop a consistent method of communication between the unit coordinator in the ED and areas such as the OR and the ICUs, urges Dennis Allin, MD, medical director of the Kansas City Emergency Medical Services system and director of emergency medicine at the University of Kansas Medical Center. At University of Kansas, there are separate medicine, pediatric, neurosurgery, and surgery ICUs, along with a intensive care burn unit, he says.
"The unit coordinators on these units will communicate and cooperate with each other, allowing us to stay open," Allin says. For example, the medicine ICU might be full, but a sick patient can be placed in any of the other ICUs, he explains. "We can do this because our critical care nurses are all trained in the same core competencies," he says.
• Immediately move patients out of the ED when the ED is overcrowded. Key policy makers must be able to open up closed units, move patients expediently out of critical care beds to step-down or general units, cancel elective cases, and communicate with medical staff members, says Augustine. "You need to do this at the instant when bed resources become tight," he adds.