1 our environment – the silent issue hospitals 1960 vs. now ed 1960 vs. now
TRANSCRIPT
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Our environment – the silent issue
Hospitals 1960 vs. now
ED 1960 vs. now
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Crowding
The cause
The consequence
The cure
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1. What’s NOT the cause?
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Inappropriate or “unnecessary” visits to the ED
What are the results of the research?Sore throatsRetrospectivitis*****Franacek*****
What could be done about it?Education: 5% decrease vs. 20% increase
Does it matter?Excellent studies show that patients with minor
problems to NOT impact on the waiting times for the seriously ill
Therefore, any actions focused on this “issue”, if it is one, will NOT improve issues related to the boarding of admitted patients in the ED
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Money, not crowding, is the issue for these:
EMTALASafety net
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The big gorilla
Admitted patients, boarding in the ED, are THE major contributor to overcrowding and delays in care in the ED actual data!
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9Finito!
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What causes ED overcrowding?
Hospital overcrowding
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Boarding:What are the consequences?
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Sick people have to wait too long to receive care
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Boarding increases TOTAL length of stay in the hospital, further worsening access.
5 + studies – 1 day
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Boarding increases walkouts, some needing admission
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Overcrowding increases medical errors
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JCAHO
50% of sentinel events occur in the ED
1/3 of these are related to overcrowding
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Overcrowding causes deaths
….. beyond anecdote
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How big is the effect?
Pneumonia 1.07Crowding 1.2 – 1.4Weekend admit 1.01 – 1.05
Group sizes
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Comparison
100 pneumonias: save 7100 “crowding” admits: save 17
– 25(RR 1.2 – 1.34)
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The BIG question
Does this problem kill more people than problems identified
in other initiatives to improve outcomes of patients?
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Physicians are harmed
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25,000 patients
Frequency of suits based on whether the patient waited less or more than 30 minutes to be seen:< 30 = 0.9> 30 = 4.9
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Key points
Crowding is caused by boarding
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Boarding increases harm to patients in the following ways:
Waiting timesDiversionsLength of stayMedical errorsSentinel eventsMORTALITY
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Boarding increases harm to hospitals and doctors in the following ways:
Financial losses to hospital and MD
Malpractice claims
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How do we fix it?
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How do we currently deal with this problem?
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Everything is filled to the brim
Itsy-bitsy ED
HUGE inpatient areas
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Current model
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Current solution to HOSPITAL overcrowding
Crowd one areaSpaceStaffStructureExpertise
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Which block in this diagram is LEAST capable of surge?Which block in this diagram needs to be MOST capable of surge?
The question …..
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Xxxxxxxxxxxxxxxxxxxxxxxxxxx
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“Radically” new model – redistribute the load
nice
nasty
Move SOME boarders to the floors, even if it means putting them in the hallway. The ED CONTINUES to bear brunt of boarders
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The current status quo
Too many admitted patientsin the wrong space, in the wrong
place, with the wrong staffis dangerous to our patients.
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The cure
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Why not divert ambulances?
In most circumstances, it simply doesn’t work
If allowed:other solutions are not sought
Dangerous to the patient
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Summary: ambulance diversion is:
Unsafe IneffectiveMoney loser
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Other lousy solutions
Deferred careSafety?Effectiveness?
MD at triage; RN -> MD
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The ONLY current solution known to work:
Move the admitted patients out!
(The Full Capacity Protocol)
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Ask Four questions
Space, load, expertise, and necessity
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Question 1 - Space
Good space Bad space
If given both, where would you place the patient? Obviously, in the “good” space. But, what if there WAS no good space???? (see next question)
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Question 2 – Load – all units full
Ten patient units: A, B, C, D, E, F, G, H, I, J
No “good” space on ANY unit
Action plan??
20 additional patients beyond “good” space capacity. How would you distribute them?
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Question 3 – Expertise – all units full
Unit A Understaffed
4 nursesNeeds 6
Wrong expertise Wrong
environment
Units B, C, D, E, F, G, H, I, J
6 nurses Needs 6 Right expertise Right
environment
20 additional patients beyond “good” space capacity. How would you distribute them?
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Question 4 - Necessity
Is your emergency department necessary?
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CURRENT answers
#2: load up Unit A#3: load up Unit A#4: no, the ED is not necessary
This is NUTS! Worse than that, this is “the way we do things.”
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Answer to questions 1-4
Move the patient upstairs.
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The bold move by the NY State DOH:
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DOH April 2002
“continuing issue of hospital overcrowding” “Emergency Departments must remain open” “Maintaining admitted patients within the ED is not
acceptable” “the use of beds in solariums and hallways near
nursing stations should be considered” “Regardless of location within the facility, staffing,
services, privacy, infection control and confidentiality protections must be consistently in place”
www.hospitalovercrowding.com
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Inpatient Units are: less crowded, less noisy, less chaotic
Inpatient Units provide appropriate clinical expertise (MD’s, RN’s)Emergency physicians are great at what they do.
However, they are not cardiologists, pulmonologists, intensivists, etc. Once the patient is admitted, they deserve the appropriate specialty care
Staging in an inpatient hallway will result in closer, therefore faster access to a room
The ED can continue to fulfill its mission
Why? ….
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Full capacity Protocol: How it Works
Step 1 : ED attending and ED charge nurse determine that the ED is close to full capacity, and thus, the care of the next patient is threatened
Step 2: Bed coordinator evaluates the situation – NEUTRAL party
Step 2a: Medical Director approves any decision. NEUTRAL party
Step 3: Bed coordinator notifies Clinical Associate Directors
Step 4: Units assigned hallway patients. No unit will receive more than 2 hallway patients.
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How many?
PICU
Burn
SICUCV ICU
Floor9543
66.6% FCPeligible
Peds
MICUCCUNeuro
ED
12733 total3190
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Impact per boarded admission on ED wait-to-be-seen times:
Typical impact under “business as usual”: 15 minutes per boarded patient8 boarders: each patient waits an extra 2 hours to be
seen FCP at Stony Brook:
1 minute per boarded patient8 boarders: each patient waits an extra 8 MINUTES to be
seen (because of the “decompression” effect of the FCP)2/3 of floor admissions qualifyExperience with 2500+ patients placed on floors to
relieve crowding
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Impact
Better care for all patientsMore timely treatmentFewer errors
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Why? Safety
Decreased diversion, walkouts, delay, sentinel events, errors, deaths
EasyLarge work load redistributed across wide area, each area with
very small increase in work load Costs
Call bell, central telemetry, privacy screenNO extra staff, etc.
SavingsLOS Improve processes, ED AND inpatientMORE BUSINESSFewer suits
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Why not?
Can’t vs. won’tRefuse to considerRefusal to acknowledge safety issuesSilo mentality (only MY area matters)
Perfect and good are enemiesFailure of leadership
Fear of change
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Why Stony Brook?
A true commitment to patient safety for EVERYONE, not just as viewed from the individual silo
Willingness to succeed, and willingness to go the extra mile on behalf of the patient
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Who does it?
Stony Brook Duke Wm. Beaumont
EMTALA Yale St. Barnabus system NYU LOTS of places now “Inside the Joint Commission” JCAHO white paper and “Best Practices”
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Crowding is bad for hospital finances as well
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Move ‘em out ….
SimpleThe helping hand is tiny
Costs insignificant Makes money Increases safety Improves nurse/patient staffing ratios Improves processes No ambulance diversion
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Key points
The ED continues to function Patients receive expert care in the area
and by the people best suited to provide that care
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What is being asked?
LOTS of people are being asked to do a LITTLE extra so that a small number of people can accomplish the difficult, rather than the impossible.
It is being asked because this is the safest thing to do for the most patients.
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What is being asked? – the practical version
If the problem is more admissions than there are beds:
250 people take care of the easy ½ of a problem while 15 people take care of the hard ½ of a problem.