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The Emergency Department sees approximately 35,000 patients yearly with an admissions rate of 24%. The national average admission rate is reported at 17% to 18%. This may suggest the acuity at Desert Springs Hospital is greater than the average ED. This higher than average admission rate coupled with inefficiencies in patient flow, shortage of ICU beds and staff, has caused the ED to back up, necessitating the need for the ambulance service to divert patients to other facilities. The number of hours on emergency divert has increased from 18% to 32% and from 31% to 77% for critical care divert. The following recommendations are suggested to streamline the admission process and decrease the length of stay of admitted patients in the Emergency Department, thereby reducing the number of hours on divert:
A. Facility recommendations.
1. Expand critical care by 12 beds. Project to be complete and operational by Dec. 1, 2000.
2. Utilize outpatient holding area for post-percutaneous transluminal coronary angioplasty (PTCA) recovery to allow additional capacity in Intermediate Care. Intermediate Care currently has 22 beds, and many of them are utilized for post-PTCA patients.
3. Utilize lounge chairs in pre-op for discharged patients waiting for transportation.
4. Utilize the flow behind the back section of the ED for overflow, mental health, and inebriated patients.
B. Patient flow recommendations.
1. Divert Avoidance Response Team (DART) to be activated prior to the ED necessitating divert. Criteria: 3 ICU/CCU holds and/or 10 admitted holds in any level of care combination. DART includes administrator on call, medical director, nursing supervisor, admit nurse, housekeeping supervisor, case manager, ED manager and/or ED physician. The goal of DART is to take a proactive approach to divert avoidance and change the culture of diverting first and then attempting to alleviate the backlog.
2. Develop a standardized short order sheet for initial orders to allow for quick initiation of the admission process. Currently, the time difference between the decision to admit the patient and actually completing the initial orders is 60-75 minutes. The admission process begins once the initial admission orders are recorded, NOT when the ED physician decides to admit the patient.
3. Work with managed care companies to expedite the admission process. Patients are currently held for several hours in the ED waiting for admission assessment by the managed care physician.
4. Implement a nurse/transporter team to facilitate the admission from the ED to the nursing unit. This team would transport the patient, perform initial orders, and perform the orientation of the room and nursing unit to the patient. This process would eliminate delays due to staff nurse unavailability at the time the admission is required.
5. Implement protocols to expedite routine testing to begin at point of triage.
6. Identify a gatekeeper to meet and greet ambulance upon arrival.
7. Implement bedside registration with short form registration for ED patients to expedite initial assessment process.
8. Enforce ICU/CCU and Intermediate Care admission criteria to assure appropriate patient placement.
9. Radiology to transport patients from the ED instead of ED staff.
10. Laboratory to draw patients in Radiology instead of waiting for return to ED to expedite processing of lab tests.
C. Equipment recommendation.
1. Rent monitors and ventilators to prevent unavailability experienced last year.
D. Staffing recommendations:
1. The nursing/tech schedule in the ED has traditionally been static with no swing shifts coinciding with busier times in the department. Schedules are being restructured with additional swing shifts to increase staffing during busier hours.
2. Continue to recruit RNs and CNAs to meet staffing standards.
3. Work with statewide nursing recruitment task force to change regulations to allow paramedics to function in the ED.
Source: Desert Springs Hospital, Las Vegas.