Task Force Confirms What EPs Knew: Boarding Causes Crowding
Anne Scheck · Emergency Medicine News · 2008
It can be whittled down, carried around, and handed out to any emergency physician who wonders what to do about an overflowing waiting room. And it received a warm reception, too, with USA Today noting that it calls on “hospitals to make common-sense changes to fix the ER mess.” But the best thing about the American College of Emergency Physicians' task force report, “Emergency Department Crowding: High-Impact Solutions,” is not the response it has gotten, but the information it can continue to provide, said Sandra Schneider, MD, a professor of emergency medicine at the University of Rochester in Rochester, NY. Drawing from research in emergency medicine over the past several years — from data showing that beds are freed more quickly once patients are sent to a hospital floor to an investigation demonstrating that slower times-to-EKG have substantial financial impact — the task force findings combine approaches to crowding in a single, straightforward report. “I am already finding it very useful,” Dr. Schneider said, alluding to the list of highlights. “On Grand Rounds, I use it as a handout.” By identifying boarding as the primary cause of crowding and suggesting some low- or no-cost solutions, the task force provided the means to make a good case for change, according to Dr. Schneider. “This document is something that can be given to hospital administrators to show there are alternatives to boarding,” she explained.Figure: “This document is something that can be given to hospital administrators to show there are alternatives to boarding.”Dr. Sandra SchneiderPeter Viccellio, MD, the chairman of the task force and a professor and the vice chairman of emergency medicine at the SUNY-Stony Brook, said the terminology and explanations in the document make it accessible and easy to grasp. “I think the main value of the report is that it provides a language to understand, properly, the real causes, real consequences, and real solutions to crowding that are do-able and realistic,” he commented. “Of particular importance is that the report makes absolutely clear that the problems and solutions are necessarily institutional, and cannot be addressed by focusing on the ED in isolation.” Research used by the task force suggests that moving patients out of the ED and into other units as quickly as possible is an idea whose time has come. The task force also recommends better distribution of the predictable influx of patients, calling for discharge of hospital patients by noon and for scheduling elective patients throughout the week, rather than at the beginning of it. In a prepared statement, ACEP President Linda Lawrence, MD, said some of the data show there are ways to lessen the likelihood of crowding by instituting changes in “routine administrative procedures” that involve hospital-wide modifications. At many hospitals, adoption of some of the task force recommendations could mean quite a cultural shift, conceded Dr. Schneider. “But this is a patient safety issue,” she said. “This needs to be seen as an institutional problem, not just [the domain of] the emergency department.” Among the suggested system-wide changes is that services such as radiology and physical therapy be made available seven days a week at busy EDs. “What needs to change is the idea that patients who come through the ED are not profitable, and that view doesn't take [into account] downstream costs for these patients,” Dr. Schneider said. Conversely, it's widely assumed there is a financial advantage for keeping ED patients in the ED. The task force findings come from literature searches that complemented a database of research that had been collected over the past several years, noted Dr. Viccellio. “Surprisingly, the literature is remarkably congruent in its findings on the impact of crowding,” he said. And, in terms of the solutions, “although the number of studies is smaller, the findings again are remarkably congruent.” And there may be a lot more of the same down the road. ACEP currently is running a contest aimed at getting more research on the issue out of residents. The competition, called the ACEP Residency Program on Teaching Innovations for Coping with Crowding, will select 10 entries for poster presentations at the college's scientific assembly this month in Chicago. Meanwhile, emergency physicians also are being encouraged to familiarize themselves with the task force report and to become part of the ACEP spokesperson network to get the message out when a newspaper or network calls. The effort appears to be needed, even with the favorable press coverage the task force has received.Figure: “[T]he report makes absolutely clear that the problems and solutions are necessarily institutional, and cannot be addressed by focusing on the ED in isolation.”Dr. Peter ViccellioOn the heels of its release to the public, federal statistics on ED waiting times were issued by the Centers for Disease Control and Prevention showing that people now wait nearly an hour on average. The story, when it appeared online, prompted scores of responses almost immediately. “An hour? Where? In Georgia, the wait is a near-death experience,” wrote one blogger. Another chimed in: “Duh, I thought a possible stroke was high priority. It was four hours before we were seen by the doctor.” The Rest of the Story on EM-News.com The contents of the ACEP crowding report contain no surprises for emergency physicians, but it should help them convince hospital administrators that boarding in the ED is a practice long overdue for the tar pit. The report, “Emergency Department Crowding: High-Impact Solutions,” notes, “Only when all stake holders agree that the problem is systemic and hospital-wide can solutions be implemented that will improve patient flow from triage to discharge and protect everyone's access to emergency care.” The task force included an illustrious panel of emergency physicians, none more so than Peter Viccellio, MD, who was the first to point to boarding as the primary cause of ED crowding in an editorial in Emergency Medicine News in August 2000. To read Dr. Viccellio's editorial or the ACEP Task Force report, visit the Exclusive Online Content at EM-News.com. Solutions to Crowding Proposed by the ACEP Task Force ▪ Move admitted emergency patients out of the ED to inpatient areas, such as hallways, conference rooms, and solaria. ▪ Coordinate the discharge of hospital patients before noon. ▪ Schedule elective and surgical patients at times other than early in the week. ▪ Register patients at the bedside, fast-track patients with nonurgent medical conditions, and consider adding an observation area. ▪ Establish turnaround-time goals for admitted and discharged patients, and decrease turnaround times for ancillary services, such as lab and radiology tests. ▪ Carefully evaluate staffing needs, and provide additional staff during increased volume. ▪ Use scribes for documentation. The average EP spends 90 to 120 minutes every eight hours on documentation. Consider use of an electronic medical record. ▪ Use protocols and order sets for uniformity and to ensure all tests occur early in the patient's stay, and define and measure response times for initiation and completion of consultations. ▪ Assign a physician to triage in departments with overwhelming capacity issues. ▪ Monitor individual practitioners in the emergency department for turnaround time, numbers and types of tests ordered, and percentage of patients admitted. Note: The first three approaches were designated “high-impact” by the task force. The full report contains many solutions in addition to those listed here, and can be accessed at www.acep.org/practres.aspx?id=32050. Comments about this article? Write to EMN at[email protected].