CLINICAL NURSE LEADER: A ROLE IN DECREASING EMERGENCY DEPARTMENT

CROWDING

Joanne Senn

The University of Alabama

Clinical Nurse Leader Candidate

Introduction

An organizational assessment of a southeastern hospital’s Emergency Department (ED), revealed waiting time as a chief problem. The hospital will be called hospital “X”.

Increased waiting times have a direct effect on quality of care and stakeholder satisfaction.

Stakeholders Patients and families ED and hospital staff Community- includes the Emergency Medical System

Goal statement

A Multidisciplinary Emergency Department (ED) Flow Team will be developed, and strategies will be implemented to reduce ED crowding.

Why?

Problem overview

According to the American Hospital Association, there are 40% fewer inpatient beds in the US due recent regulations (Richardson, Asplin & Lowe, 2002).

ED crowding is complex. Patients are older and sicker Less Primary Care Providers More uninsured persons

ED crowding is a public health concern and a threat to patient safety (Trzeciak & Rivers, 2003).

Problem overview continued

• EDs have been healthcare’s “safety net” for vulnerable populations for decades.• poor people• uninsured • Medicaid recipients and Medicare recipients• 40% fewer ED beds in the US, due to rising

costs of healthcare (Richardson, et al., 2002).

Problem overview continued

• EDs in the US had a 20% increase in visits in 5-year span (Richardson et al., 2003).

• The ED at hospital “X” experienced an 18% increase in volume this year (William Farohna, ED Director).

• All contribute to wait times and ambulance diversions.

• Ambulance diversion is a safety concern .

• patients needing emergency care

• disaster preparedness, according to Joint Commission for Hospital Accreditation (Trzeciak, 2002)• Examples: 911 World Trade

Center Disaster , Hurricane Katrina, Hurricane Sandy

A conceptual model A conceptual model partitions ED crowding into 3

interdependent components, within the acute acute care system (Asplin, Magid, Rhodes, Solberg, Lurie & Camargo, 2003)

1) Input

2) Throughput

3) Output A patient’s ED journey

has many variables can be tracked

Input-Throughput-OutputInput * Emergency care- ambulances, walk-ins• Transfers with emergency conditions• Unscheduled urgent care-due to lack of capacity in other ambulatory

care areas• Desire for immediate care- convenience, conflicts with work and

family• Safety net care- Medicaid, uninsured has increased. ED crowding

higher in poor communities (Asplin et al., 2003).

Access barriers- Finances Transportation Decreased availability of usual care, i.e.. Primary Care

Throughput• Patient arrives in ED

• Registered by clerk• Triage by trained RN• Patient placed in ED room• Evaluation by provider and diagnostic

tests, treatment, consults• ED boarding of inpatients

Output=disposition

• Admission

• Discharge

• Transferred to higher level of care, i.e.., trauma unit, or skilled nursing facility

• Patient leaves before seen (PLBM)

• Patient leaves after medical screening (PLAM)

• Patient leaves against medical advice (LAMA)

• Boarder= Patient boarded in ED as an inpatient after 2 hours of admission decision

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Target throughput for improvement

• Targeting entire ED length of stay (LOS) is important in ED crowding (Asplin et al., 2003).

• The Emergency Nurses Association (ENA), recommends evaluating throughput in regard to operations, staffing and care (ENA, 2012).

• Increased LOS decreases quality of care and poses safety risks for patients.

• Process improvements can target throughput to decrease ED crowding= decreased waiting times.

Target throughput and output to decrease waiting times

Asplin (2003) identifies throughput and length of stay (LOS) as a main contributor to ED crowding, hence increased waiting times.

The Emergency Nurses Association (ENA, 2006), stated increased LOS decreases quality of care and poses safety risks.

ENA recommends evaluating throughput processes: operations, staffing and care.

Out put also targeted for process improvement. Time of disposition

Transfer, admission, discharge Transportation delays- ambulance

Data collectionComputerized real-time data can be used to develop solutions

to ED crowding (Exadakytylos, Evanelopoulos, Wullschleger, Burki & Zimmerman, 2008)

The Computer tracking system at hospital X can track real time data Time of arrival Time of triage by RN Time of room placement Time seen by provider Time labs and radiology studies complete Time consults completed Time of disposition- admit/discharged Total LOS in ED

Plan Develop a Multidisciplinary ED Flow Team

Members- Clinical Nurse Leader (CNL), MD, RN, LPN (Fast-track), clerk, data specialist, bed coordinator, administrator, lab and radiology personnel, & housekeeping supervisor

Purpose- identify problems with throughput and output Success depends on-

top-down support staff acceptance hospital wide plan

Effect- facilitates positive change decreased wait times Identify Performance measures set by the ED community, i.e.

LOS, decreased patients leaving without seen. Performance Measures are being developed as CMS will reward

hospitals that perform better (Welch, Augustine, Camargo & Reese, 2006).

Timeline

• 0-3 months• Multi-disciplinary ED Flow

team meets weekly x 3 months• Develop strategies to target

throughput and output of ED processes

• Train staff and communicate changes through staff meetings and memos

• Recruit a CNL to spearhead the ED Flow Strategy

• Develop policies for process changes

• Set rollout date with communication to all departments

• Approve budget needs- CNL ($70,000+ meeting hours $10,000=$80,000)

• 3-6 months• Implement strategies and policies

as follows:• Process changes for throughput-

labs and radiologic studies turnaround time= 30 minutes

• Consults completed within 1 hour (unless emergent, i.e., MI )

• Nurse calls lab and radiology after 30 mins for results

• Physician calls consulting Md after 30mins pass, then calls Chief of specialty after 45 minutes.

Timeline continued

3-6 months (continued)

Output processes Bed Coordinator communicates with ED charge

RN, daily at 2p to discuss transfer needs with maximum census

Expectation for ready bed- 15 mins, and discharge bed- 45 min. Call ED nurse manager with bed delay Call Nursing supervisor after 4p-7am with bed

delay Charge RN calls housekeeping supervisor for

discharge bed delay Notify bed control as soon as admission decision

made

Enter time admission on tracking system (real-time) -Transportation-clerk completes paperwork

for transfers -Call ambulance company after 15 min delay -Call ambulance supervisor after 30 min delay

6-9 months

Evaluate effectiveness of process changes via EDIS

ED staff input via in staff meetings

LOS stay goal = < 2 hours Track ambulance diversions Evaluate with patient

satisfaction tool –Goal 85% satisfied with overall care

Clinical Nurse Leader reviews results in ED Patient Flow Summary meeting

Revise plan as needed

Conclusion

• Strategic Planning for Emergency Department crowding is complex, and EDs should not be alone in the solution.

• A Clinical Nurse Leader can play a key role in planning and implementing patient flow strategies.

• Decreased ED LOS and increasing efficiency decrease in ED crowding reduced waiting times and increased quality of patient care.

• ED improvement =

saved lives , decreased litigation, less ambulance diversions and increased financial rewards for hospitals.

Asplin, B., Magid, D., Rhodes, K., Solberg, L., Lurie, N., & Camargo, C. (2003). A conceptual model of Emergency Department crowding. Annals of Emergency Medicine, 42, (2), pp. 173-180.

Emergency Nurses Association. (2006). Holding patients in the Emergency Department (White paper).http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Holding_Patients__in_the_Emergency_Department__ENAQ_White_Papers.

pdf

Exadakytylos, A., Evangelopoulos, D., Wullschleger, M., Burki, L. & Zimmerman, H. (2008). Strategic emergency management department design: An approach to capacity planning in healthcare provision in overcrowded emergency rooms. Journal of Trauma Management and Outcomes, Retrieved from doi: 10.1186/1752-2897-2-11

Richardson, L., Asplin, B. & Lowe, R. (2002). Emergency Department crowding as a health policy issue: Past development, future directions, Annals of Emergency Medicine, 40, (4), pp. 388-391.

Trzeciak, S. & Rivers, E. (2003). Emergency department overcrowding in the United States: An emerging threat to patient safety and public health. Emergency Medicine Journal, 20, pp. 402-405

Welsch, S., Augustine, ., Camargo, C, & Reese, C . (2006). Emergency Department Performance Measures and Benchmarking Summit. Academic Emergency Medicine, 13: 1074-1080. doi 101197/j.aem2006.05.026

References