1. Surge capacity: What can we do now?

2. Surge capacity? Do we need a disaster to make it happen? The morning report vs. ED holds

3. Answer • Simple • Costs nothing • Makes money • Increases safety • Improves nurse/patient staffing ratios

4. Not …

5. Why did this happen? Why did this happen to the ED?

7. Properly categorize the problem • EMTALA • the poor • the safety net • The unnecessary visit – who else complains? • Subtext – the poor • SHOOT THE MESSENGER • What’s the SCIENCE?? • Temporary problems … or ….. • Too many inpatients in the ED !!!!

8. Strategies for the fix and the blame • Ambulance diversion • Transfer • Triage out • EMTALA, the poor, the safety net • The unnecessary visit • Temporary problems • Data data data Send our business away Strategy of victimization, race, and tragic heroes Strategy of ignoring the problem Strategy of beating the problem to death

9. Rules of the road • It should help ALL of the patients, not the ED • Operating principle: ED is necessary • ED CANNOT bear brunt of the deficiencies of the entire health care industry • Inpatients don’t belong in the ED • ED provides LOUSY care of inpatients • The insecurity-driven scam • The problem and the solution should be moved out of the ED

10. Implementing the rules of the road • Fix the problems you can • No excuses from problems you can’t • The ED is currently PREVENTING the solution to the problem • Discharge planning • Bed availability • “Safety”≠ “Happy” • Leadership COUNTS

11. An ED designed with monitors by each bed because of the unpredictable needs of incoming patients does not mean it is automatically an ICU or telemetry inpatient unit. The willingness of emergency physicians to cope with just about anything is not a virtue if this situation is the result. Mark Henry

12. What your ED does for you • AD Little community survey • 5 vs. 40 • Keep the hospital full • Financial • 1 more • Trauma center With bad service, who leaves?

13. What your ED REALLY does for you

14. Defining the problem

15. x x x x x x x HUGE inpatient areas Itsy-bitsy ED x x x x x x x x x x x x x x x x Everything is filled to the brim

17. x x x x x x x x x Current model x x x x x x x x x x x x x x x x x x x x x x x x x

18. Current model • Core measure: Timely administration of antibiotics • Core measure: Door to balloon time • Timely treatment of strokes • Patient satisfaction Inadequate staff Inadequate space Lots of meetings

19. Current solution to HOSPITAL overcrowding Crowd the ED Space Staff Structure Expertise

22. x x x x x x x x +/- Radically new model – 1970’s x x x x x x x x x x x nasty nice

23. WHY can’t we make it happen? • “Against the rules” • “DOH won’t allow” • OB OB OB ED ED ED • “That’s the way things are done” • Generational indoctrination • Reinforcement via the fire extinguisher • Keep the chaos IN the ED

24. Defining the real problem Too Many Admitted Patients

26. A fateful day … in isolation

27. 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.viccellio.com/overcrowding.htm

28. What about ambulance diversion? • Simply Diverts to other overcrowded ED’s • Not good business • Can’t divert walk-ins

29. Solutions: • Move patients upstairs Can’t do that???

30. Hospital overcrowding • Implementation of full capacity protocol • First three months www.viccellio.com/overcrowding.htm

32. Initial reaction • DOH will not allow • Not in the patient’s best interest • ED needs to deal with this without impacting in-patient units

33. Our CQI Efforts • Meetings • Measures • Graphs • Memos • Repeat the above

34. Where leadership meets the road…. • Implementation of full capacity protocol • A hallway -> a hallway? • Leadership Concerns • Nobody does this • Not safe • Nurses will quit YOU are a leader EITHER WAY.

35. The Real Solution • Move the patient upstairs.

36. The Administrative Decision Focus on what is best for the patient How is being in the hallway better for the patient?

37. But do we have to???????

38. Yes, Because…….. • Inpatient Units are: less crowded, less noisy, less chaotic • Inpatient Units provide appropriate clinical expertise (MD’s, RN’s) • Staging in an inpatient hallway will result in closer, therefore faster access to a room

39. The Golden Rule of Health Care If it were your Mother…….

40. Operating assumptions • The ED MUST remain open • Critically ill patients MUST be cared for • We act in the best interest of the PATIENTS, not the ED

41. Process • Interdisciplinary Group • Develop clear guidelines • Communicate, communicate, communicate

42. Development of Policy : Key Points • Identify applicable units • Identify individual roles & responsibilities • Limit in-house hallway bed placement • Prioritize “real” bed admissions : hallway, ICU downgrade • List criteria for hallway placement

43. Keys to Success: “One Song, One Voice”* *Drum Line

44. Keys to Success: Identify a neutral party to make decisions And communicate process

45. Keys to Success: Support from The top

46. Keys to Success: Don’t make this into a Big thing

47. Full capacity Protocol: How it Works • Step 1 : ED attending in collaboration with ED charge nurse identify need for protocol to bed coordinator • Step 2: Bed coordinator gains approval from Medical Director or designee • Step 3: Bed coordinator notifies Clinical Associate Directors and the Inpatient Units that Full Capacity Protocol is being implemented • Step 4: Units assigned hallway patients. No unit will receive mote than 2 hallway patients.

48. Priority of Hallway placement • Non-telemetry patients with little or no co-morbidity • Non-telemetry patients with minimal or moderate co-morbidity • Telemetry patients as follows: • Little or no co-morbidity • Low index of suspicion for cardiac event • ED attending approval • Telemetry box availability and central monitoring slot

49. Exclusions to Hallway Placement • Patients requiring step-down or ICU • Rule-in MI or at high risk for cardiac event • Ventilator dependent patients • Patients requiring negative pressure or Isolation rooms • Patients requiring greater than 4 liters of O2 via nasal cannula

50. The Impact of Calling Full Capacity Protocol? • Expedited mobilization of resources to discharge patients • Nursing influence results in physician practice change • Improved communication between departments • Those areas not subject to FCP continue the same inability to improve