Stony Brook University Hospital: ED Overcrowding: Redefining the Problem with a Full Capacity Protocol Problem to Be Resolved: Boarding patients in the emergency department Hospital: Location: Stony Brook University Hospital 101 Nicolls Road Stony Brook, NY 11794 Categories: Output Key Words: Full Capacity Protocol Capacity Management Boarder Hospital Metrics: (Taken from the FY2005 AHA Annual Survey) 2005 ED Volume: 52,524 Hospital Beds: 504 Ownership: Public Trauma level: 1 Teaching status: Yes Tools Provided: Full Capacity Protocol A four page document containing hospital policies and procedures for implementing the Full Capacity Protocol. Strategy Description Under the Full Capacity Protocol, when the ED is no longer able to evaluate and treat patients in a timely fashion due to lack of space, patients awaiting admission are transferred to acute care hallway beds on inpatient units. This protocol is implemented by the hospital Bed Coordinator with approval by the hospital Medical Director. The Impetus for Change The emergency department (ED) at Stony Brook University Hospital received a Press Ganey rating in the bottom 1 st percentile for patient satisfaction in July 1999. Based on these scores, hospital administration charged the ED with improving patient satisfaction. To address the impact of ED crowding on patient satisfaction, a CQI steering committee led by Peter Viccellio, MD, FACEP, Vice Chairman, Department of Emergency Medicine, and Carolyn Santora, RN, MS, CAAN-BC, Associate director for Heart, Trauma, and Emergency Services, implemented the Full Capacity Protocol (See the Full Capacity Protocol). Under this protocol, when the ED is no longer able to evaluate and treat patients in a timely fashion due to lack of space, patients awaiting admission are transferred to acute care hallway beds on inpatient units. Additional information on ED crowding and the Full Capacity Protocol can be found at www.hospitalovercrowding.com. Buy-In and Implementation According to Carolyn Santora, RN, MS, Associate Director for Heart, Trauma and Emergency Services, obtaining buy-in for the new protocol meant overcoming objections by staff including the perception that boarding patients in the hallway of acute care units was against the rules and would be bad for the patients. Dr. Viccellio and Ms. Santora looked at the differences in nurse to patient staffing ratios when
boarding patients in the ED versus boarding patients on inpatient units and were able to make a compelling argument for the new protocol. While ED staff identified the need to initiate the protocol based on ED crowding, the hospital Bed Coordinator was responsible for implementing the protocol with the approval of the Medical Director. This chain of command helped to shift the view of the problem of patients awaiting admission from the ED to a broader institutional view, and requiring a broader institutional solution. The protocol clearly identified the types of patients that would be eligible for acute care hallway beds (no patients requiring step-down or ICU), the types of units that could accept patients, and a limit to the number of patients boarding in each unit (no more than two patients per unit). Lessons Learned Implementing the Full Capacity Protocol meant changing the culture of the entire hospital and required the support of an inpatient nurse champion. Boarding patients in the ED could no longer be just an ED problem. Dr. Viccellio and Ms. Santora recognized the importance of continually focusing on what is best for the patient in order to gain staff acceptance of the new protocol. By moving the patient to the acute care hallway, the patient is closer to the right type of nursing and the right type of MD. Moving the patient to the acute care hallway also served as a visual reminder to staff that a patient was waiting for a room. The additional work load on the inpatient staff was small and, over time, not found to be an issue. In fact, the nurse: patient ratios were markedly improved by moving admitted patients out of the ED onto the floors. Of those patients transferred to the acute care hallways, more than 50 percent were either put in a room immediately or in a room in less than one hour. Elements of success include having adequate central telemetry monitoring, privacy screens, a call system, and identifying appropriate toilet facilities for these patients. Impact Coupled with other CQI efforts to reduce ED crowding, initiation of the Full Capacity Protocol has led to increased patient satisfaction at Stony Brook University Hospital and improved staff job satisfaction. Press Ganey ratings increased to the 80 th percentile for the emergency department, with inpatient scores unaffected. Patients expressed a strong preference for being moved out of the emergency department to a quieter, less chaotic environment. The average length of stay for patients boarded on the acute care floors was almost one day less than the average length of stay for patients with similar diagnoses boarded in the ED. This document is copyrighted to Urgent Matters or its original author. No copies or duplication outside the Urgent Matters project is authorized without express written permission.
ADMINISTRATIVE POLICIES & PROCEDURES MANUAL CODE: LD:0065 RE-REVIEW DATE: (Assigned by Policy Review Committee) SUBJECT Full Capacity Protocol RESPONSIBLE DEPARTMENT,DIVISION OR COMMITTEE: Medical Director's Office EFFECTIVE DATE ORIGINAL POLICY: EFFECTIVE DATE REVISED POLICY: 2/22/2001 SUPERSEDES POLICY NUMBER: LAST REVIEW DATE: 6/15/06 DATED: SUBJECT: SBUH staff facilitates the admission of patients held in the Emergency department awaiting Acute Unit Bed assignments through utilization of the Full Capacity Protocol. SCOPE: Hospital wide PURPOSE: To facilitate the admission of patients held in the Emergency Department awaiting Acute Unit Bed Assignment. POLICY: When a patient requires admission to an Acute Care Unit from the Emergency Department and that area cannot accommodate the patient because of lack of sufficient beds, the patient will be admitted to the next most appropriate bed. In the event appropriate hospital bed utilization has been maximized, and the number of admitted patients holding in the Emergency Department has prohibited the evaluation and treatment of incoming patients to the Emergency Department in a timely fashion, the admitted Emergency Department patients already awaiting in house acute care bed assignments will be admitted to acute care unit hall beds. The Bed Utilization Coordinator will facilitate this policy. When unavailable the house wide and will assume responsibility and assign hall beds in conjunction with the Bed Control Supervisor. On nights and weekends the ADN on duty serves this role. The placement of patients to hall beds will be implemented by the Bed Utilization Coordinator only after the Emergency Department Attending Physician, the Charge Nurse and the Bed Utilization Coordinator have declared the need to implement Full Capacity Protocol. The decision of patient placement by the Bed Utilization Coordinator after discussion with the Emergency Department Attending physician (if indicated) shall be binding. If hall bed placement has been maximized and the Emergency Department is still overcrowded the Chief Executive Officer, Chief Operating Officer and the Medical Director or their designees will be notified and make decisions on implementation regarding deferral of elective and urgent cases and Emergency Department Diversion.
FORMS: None POLICY CROSS REFERENCES: Commissioner of Health Memo on Emergency Department Overcrowding dated December 11, 2000. DEFINITIONS: Full Capacity Protocol identifies 'full capacity" when the main department of the ED is full and admitted (E.D.) patients are awaiting in-house placement.. All unoccupied acute floor beds should be utilized before Hall beds are used, where nurse competency permits such placement. A. Patient Priorities for Hall Bed Placement: 1 Patients with minimal to moderate risk factor co-morbidity will be first considered for hall bed placement. 2.. Adults can be considered for a Pediatric Unit if a bed is available. Telemetry patients will be assigned to hall beds only with approval of the Emergency Department Attending Physician and it has been confirmed that the receiving in - house unit has a telemetry box and a central monitoring slot. B. Exceptions: 1. Patients on Acute Units ordinarily will not be moved to hall beds in order to make room for patients admitted from the Emergency Department. 2. Patients being transferred out of Intermediate Care or the Intensive Care Unit beds will not be placed in hall beds. 3. If hall bed utilization has been maximized and the ICU is full, and there is one or more ICU patients waiting in the Emergency Department, the next available floor bed will go to an ICU patient transferring out of ICU (not to a hall bed patient). 4. Any "exception" to the above will be with the individual approval of the Medical Director or designee. PROCEDURE A. Hall Patient Placement 1. The Emergency Department Attending Physician, Charge Nurse and the Bed Utilization Coordinator will declare full capacity. If there is disagreement between the ED and the Bed Coordinator, the Medical Director or designee will be contacted for a decision. 2 The Bed Utilization Coordinator/house wide ADN will notify the Directors of Patient Care of the activation of the Full Capacity Protocol.
3. Nursing Staffing Office will notify the inpatient units that the E.D. Full Capacity Protocol is in effect and of the need to prepare for hall bed patients. Nurse Managers will be notified that Full Capacity Protocol has been implemented irrespective of that unit receiving a patient. 4. Patients admitted to hallways on in-patient units will be assigned, as possible according to service. Ordinarily no one unit will have more than two hall patients. B. Hall Bed Exclusions: Admitted Emergency Department patients that will not be placed in hall beds: 1. Patient requiring the Intermediate Care Unit or the Intensive Care Unit. 2. Vented patients 3. Patients requiring Negative pressure room. Patients with an isolation code, other than those requiring negative pressure, may be placed in hallways only with the approval of an Infection Control Practitioner. 4. Patients requiring 4 L or greater of oxygen. 5. Patients that require suctioning. 6. Patients that have diarrhea or are incontinent of stool are poor candidates for hall placement. C. Procedures for Discontinuation: 1. Full Capacity Protocol may be discontinued when (1) The Emergency Department no longer needs hall bed placements or (2) The Emergency Department Attending, Charge Nurse and Bed Utilization Coordinator agree to stand down from the Protocol. 2. The Bed Utilization Coordinator/designee will notify the Nursing Staffing Office. The Nursing Staffing Office will notify all units. D. Considerations for Patients Placed in Hallways 1. Patients will be placed in areas that least obstruct traffic flow. (e.g.: stretcher alcoves, treatment rooms). 2. Patients will be placed, whenever possible, in areas with access to a bathroom. 3. A nurse call device, such s a wireless call bell (preferable) or hotel bell will be provided.
4. Curtains or privacy screens must be provided. 5. A written Evacuation plan, and plan for transport of patient in case of fire/fire drill must be established by units receiving these patients. 6. All patients held in inpatient hallways will be sent flowers after they are placed in an actual room. Admitted patients held in the ED >12 hours will be sent flowers once admitted to an impatient bed. a) The Nurse Manager or designee will secure a supply of Greeting cards and Vouchers from the QOWL administrative representative (call 4-1956). b) The Nurse Manager or designee will assign a staff member to bring one voucher to the Gift Shop and exchange the voucher for a flower arrangement. c) The flowers and card will be brought to the patient after they have been moved out of the hallway to a designated inpatient bed. d) Nurse Managers will renew their par levels of cards/vouchers by completing a Flower Voucher sign-out sheet. When all cards/vouchers are used, the signout sheet will be exchanged for a new set of cards/vouchers.