Crowding and the full capacity protocol
I am a practicing emergency physician and clinical director of the emergency department at Stony Brook on Long Island. Our institution believes that the ED is a vital community resource, and must be able to deliver needed services at all times. We do not consider ambulance diversion a responsible option. We also believe that admitted patients are best cared for by health care providers whose specialty is inpatient care, in a quiet and calm place where that care can be best provided.
To responsibly shepherd limited and expensive resources, hospitals must do what they can to maximize the capacity they have, through scheduling, smoothing, addressing length of stay issues (see the 24/7 hospital), in addittion to a multitude of other issues that impact on overall throughput.
Process improvement has become an industry unto itself, and many institutions grapple with the problem of boarding of admitted patients in the ED. There are many things one can do to improve flow in the ED. However, it is crucial to understand that, of the many processes that can improve flow, most of these will not, in fact, reduce boarding, although success with small improvements can give participants a feeling of accomplishment. For instance, improving bed turnover by housekeeping from 40 minutes to 20 minutes is all well and good, but for the patient having to wait 8 hours for an inpatient bed, this improvement is unnoticeable. It’s not enough to “do something”. We need to do the RIGHT things to meet and conquer to problem of boarding of admitted patients. Use the “sniff test”: will your current improvement effort, if wildly successful, actually impact on boarding?
So what does work to improve capacity? If the measure is “we had boarding and now we don’t”, there appear to be three major strategies. Not 100. Three. All three relate to smoothing: smoothing of electives across the week, smoothing within the day (via early discharge of patients), and smoothing of discharges across the week (by increasing weekend discharges). Contrary to many other processes, these three result in less boarding, shorter overall hospital length of stay, improved hospital capacity, smoother work load of the staff, and dramatic cost reductions. These strategies do not require that anyone work harder. It does not require significantly more staff. But they do require that we work differently.
The impact of the weekend is profound. The rate of discharge on weekends is half what it is on weekdays. In NY state, a discharge on a Saturday averaged a length of stay of 4 days; if discharged on a Monday, it was closer to 7. It should be no surprise to anyone capable of simple mathematics that increasing the number of discharges on a weekend can dramatically improve capacity.
This is not to belittle the importance of smaller improvements. If you DO have capacity, then the time it takes to give report, clean a room, and move the patient are all important processes. Also, maximizing efficiency in the flow of patients through the ED is of critical importance. Even the best run ED, however, can be crippled by boarding of admitted patients.
In spite of processes that maximize the availability of resources, the reality of modern day health care requires that hospitals operate at close to capacity. This necessarily means that being overcensus should be an expected and routine occurance. In short, this is a problem by design. As such, there should also be a responsible plan for how best to care for admitted patients during times of full/over capacity.
When faced with a full census, we use the "Full capacity protocol" (FCP) at Stony Brook, which moves patients upstairs when we're full, allowing us to address high hospital census in a distributive and safe fashion. This protocol, in existence since 2001, has been broadly applied in many hospitals in the United States and Canada, although many institutions unfortunately continue to choose to leave the problem of boarding of admitted patients in the emergency department. As noted below, this is not the wiser choice.
Although unstudied at this point, optimal use of the FCP might well be to place patients awaiting discharge in the hallway, allowing ED patients to move up to rooms. Based on our own institutional findings that FCP decreased overall LOS, and NYU’s finding that patients arriving on the wards before noon experienced a shorter LOS, I would propose that concerted efforts to move boarded patient to the unit before noon would maximize the benefits of the FCP.
Included here are some articles on overcrowding, our FCP, and some rulings by the DOH on this matter. The articles may be helpful in changing the culture which surrounds the issues related to hospital overcrowding. Use them as you see fit. You are welcome to contact me if you have questions about our initiative to assure our patients' safety and provide care in a humane fashion.
Overcrowding Powerpoint Presentation - contains information on length of stay, nurse-patient ratios, patient satisfaction scores, etc.
Key Points Powerpoint Presentation - contains data related to the grave harm caused by overcrowding, and the impact of the full capacity protocol on waiting times.
Stony Brook "full capacity protocol" policy
Grant Innes published data on flow and length of stay related to a "before and after" implementation of the FCP: The St. Paul study by Innes et. al.
Dr. Innes followed this study by evaluating the effectiveness of the FCP implemented in the entire province of Alberta, Canada. His results are here.
Our experience with some 2000 patients at Stony Brook is available here. This paper provides support for the safety of inpatient overcensus placement (in our case, hallways) rather than remaining in the ED.
A wealth of studies have documented the dangers of boarding of admitted patients in the ED. Our study demonstrates quite clearly the grave consequences of boarding in the ED.
Finally, in a study where patients experienced both ED and inpatient boarding, our 2013 study showed a clear preference by the patients for being out of the ED and upstairs.
The official ACEP 2008 Boarding Task Force report on the causes, consequences, and high-inpact, low-cost solutions to hospital crowding is now available. This provides what I believe is an important literature-based review of safety issues, demonstrating the grave consequences of crowding and emergency care.
If your hospital is committed to patient safely, note particularly the information on nurse-staffing ratios near the end of the PPT presentation. Also show your CEO the data on length of stay. Previous studies documented that boarding was associated with an increased length of stay of approximately one day. In our experience, moving a patient upstairs rather than boarding in the ED was associated with a 0.8 day decreased length of stay. Other studies have shown similar results.
For a collection of other articles, go here.