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How to Get a Handle on ED Overcrowding

Joe Cantlupe, for HealthLeaders Media, May 30, 2013

With the bed request model, Mikos identifies another benefit: It reduces the need to build more bed space for the ED.

For many hospitals, "I think the instinct is you need more beds," she says, "but that's not the case to improve patient flow in the emergency departments."

To improve bed control, Kaczynski, the patient flow coordinator at UPMC, also keeps her eye on the numbers. The hospitalwide bed meeting is attended by the chief nursing officer, medical director of care management, nursing and clinical leaders, and directors of ancillary support departments. In a presentation before the Institute for Healthcare Improvement, Kaczynski said the "ED and inpatient must partner for success."

Using a real-time demand/capacity management program, the staff works to predict capacity each day. It begins with a "unit-based huddle" where nurses evaluate who will be discharged, what rooms are available, and who might be admitted. It is determined whether procedures such as MRIs are needed and if transportation must be arranged.

By 8:30 each morning, they evaluate capacity and whether demand could exceed that. If so, transfers may need to be arranged or special units may be contacted for extra bed capacity. Then evaluations are made during a "housewide bed meeting" attended by nurses representing each unit who review data on a large screen.

In addition, while many hospitals attempt to have discharges by noon, Kaczynski does not subscribe to that philosophy. "We want to make sure we have a bed when we need a bed, whether it's 10 a.m. or 5 p.m."

Started at its Shadyside campus, a 512-licensed-bed tertiary care hospital, the real-time demand/capacity management program has been replicated on other campuses.

Carrying out the patient flow philosophy ensured successful reductions in the hospital's ED length of stay, Kaczynski says.

Rick Wadas, MD, chief of community emergency medicine for UPMC, says six years ago, the Shadyside campus, which sees a high-acuity population, had ED lengths of stay that hovered "in the 400-minute" range. By 2013, the ED length of stay generally decreased "down to 230 or 240 minutes," he adds. Wadas says a key reason for the improvement was the real-time demand/capacity management program. "That's why there was a lot of success," Wadas says. "We also have gotten buy-in from the entire hospital knowing that this is not just an emergency department problem, but one involving the whole facility."

Success key No. 3: Physicians First
While having patients wait in the ED is aggravating to just about everyone involved, the 340-bed Roseville (Calif.) Kaiser Permanente Hospital decided to take a bold step to improve patient flow: It got rid of the waiting areas and began a Physicians First program.

Within the past year, the hospital increased the size of its ED, a 60-bed unit equipped for 70,000 patients annually. "Instead of having patients in a waiting room, we put them into the ED itself," says Pankaj Patel, MD, an emergency medicine specialist. "We didn't need a large waiting room."

If patients have to wait, they do so in an ED bed or sitting area within the department, where there are increased diagnostic tools and emergency cardiac catheterization equipment readily available, he says. The increased size has not only led to improved and swift care, but has given a psychological lift to patients who usually wait long periods for ED beds.

"With this new system, the physician is right there and will determine if you should be taken care of," Patel says. "When a patient comes in, instead of being in a waiting area, a nurse or physician will see him in the ED itself, as the Physicians First name implies," he adds. "We've eliminated our triage area in the front where most of the patients would be and instead added rooms," Patel says. "It makes it a much more efficient process."

The overall door-to-doc waiting time has been reduced to 5–15 minutes as opposed to the 45 minutes it was previously, he says. The hospital ensures that three physicians are "up front in the ED and try to assess the patient within 5 minutes of arrival," he adds. At that point, the ED uses a triage system, depending on the care that a patient needs. "If you stubbed your toe, we give you a treatment and discharge you from the front [of the ED]," he says. "If you have chest pain, we can get an EKG or lab workup, so we can get that process started up front right away, as well."

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