Creating a Rapid Admit Unitto Prevent Overcrowdingand Provide Safe Passagefor PatientsMarie Hankinson, PhDc, RN
ObjectivesI. Define Emergency Department OvercrowdingII. When to Create a Rapid Admit UnitIII. Describe the Benefits of Creating a RapidAdmit UnitIV. Describe Metrics to Measure YourProgram Success
Definition of ED Overcrowding“A situation in which theidentified need for emergencyservices outstrips availableresources in the ED”ACEP Crowding Resources Task Force, 2002. Retrievedfrom http://www.acep.org/workarea/downloadasset.aspx?id=8872
Common Strategies to Decompressthe Emergency Department• Code Purple• Fast Track• Hallway Beds• Pull till Full• AdvancedNursingInterventions• Rapid MedicalEvaluation(RME)• BedsideRegistration
Front End Flow TacticsRME- Clinician in Triage• Midlevel Provider inTriage• MD in Triage• Intake TeamFast Track Low Acuity• Super- Track ( ESI 5’s+ Simple 4’s)• Fast- Track ( ESI 5’s,4’s & simple 3’s)
Boarding PatientsED patients who need to be admitted are“boarded” until inpatient beds becomeavailable. The practice of “boarding” patientscreates safety and negative consequencessuch as increasing LWBS, patientwalkouts, adverse events, errors, mortalityrates and diversion of ambulances.
Causes of ED OvercrowdingIn 2006, the Institute Of Medicine (IOM)described emergency care in America at the“breaking point”.The most common documented factor forED Overcrowding is scarcity of beds forpatients admitted through the ED.Studies consistently tell us that inpatientoccupancy is positively associated withpatient waiting in the ED.
Key Drivers of ED Overcrowding• Lack of staffed inpatient beds• Lack of ICU and Critical Care beds• Shortage of hospital or ED Staff• Shortage of specialist physicians willing to takeED call• Inability to cover specific specialties andhaving to transfer patients to other facilities.
Behavorial Health Patients• 5-8% of ED volume• Shortages of Mental Health CareBad news is that we have a lack of studiesthat can explain the impact on EDOvercrowding!
ED OvercrowdingReduces• Health Care Quality• Patient Safety• Patient Mortality• Failure to receiveantibiotics andanalgesic medications• Adverse events such ashospital acquiredpneumonia andpulmonary embolisms.Research• Use existing capacitymore efficiently.• Improve internalprocesses.• ResourcesJoint CommissionIHIRWJF Urgent MattersACEP
When is a Rapid Admit UnitNeeded?• ED is overcrowded• Boarding patients• Long waits for inpatient beds• Patient satisfaction decreases• LWBS numbers increase• Staff satisfaction decreases
How to Sell The Idea• Holdover hours• Capacity/Code Purple status• LWBS• Satisfaction• Identify and optimize/profitize an area withlow utilization
What is and isn’t a RapidAdmit Unit?• Not an Observation Unit.• Clearly delineates responsibilityfor patient care between theemergency departmentphysicians and admittingphysician.
What is Needed to Create aRapid Admit Unit?• Support from administrative team• Support from Medical Staff• Physical space outside the ED• Determine number of beds• Staffing• Skill mix• Orientation
Involve Other Departments• Finance• How will you charge these patients?• Dietary• Pharmacy• Environmental• Security• Volunteers• Hospital operators• Admitting• #1 department to involve: IT
Measuring Success• Decrease ED wait times• Decrease LWBS• Improve Patient Satisfaction• Improve Staff Satisfaction• Reduce Medical Errors• Improve Quality and Safety
2011 ED Patients Triaged, Not Seen253521363927283538 38218012345678910111213141516171819202122232425262728293031323334353637383940Jan Feb Mar Apr May June July Aug Sept Oct Nov DecNumberofpatientsGOOD
2011 Total ED VISITS41403943449339163875 3787 3785 3723 36573776407142263693 362039213485 341531043259 3192 31123334 333235820500100015002000250030003500400045005000Jan Feb Mar Apr May June July Aug Sept Oct Nov DecNumberofpatientsGOODTOTAL TARGET
Metrics to Measure Success• Reduction of patient boarding in the ED• Decrease the Time to Admit Orders• Improve Patient Satisfaction• Improve Staff Satisfaction• Reduction of LWBS
Elements of Performance (EP)Publication of the Joint Commission inDecember 2012.• Standards LD.04.03.11 and PC.01.01.01are revised standards that address anincreased focus on the importance ofpatient flow in hospitals.• Go into effect January 1, 2013, with twoexceptions: LD.04.03.11, EP’s 6 and 9 willbe effective January 1, 2014.
LD.04.03.11The hospital manages the flow of patientsthroughout the hospital.• EP 1. The hospital has the processes to supportthe flow of patients throughout the hospital.• EP 2. The hospital plans for the care of admittedpatients who are in temporary bed locations, suchas the post anesthesia care unit or emergencydepartment.• EP 3. The hospital plans for the care of patientsplaced in overflow locations.• EP 4. Criteria guide decisions to initiateambulance diversion.
LD.04.03.11 continuedEP 5. The hospital measures and sets goals for the componentsof the patient flow process including:• The available supply of beds• The throughput of areas where patients receivecare, treatment and services ( such as inpatientunits, laboratory, operating rooms, telemetry, radiology andPACU).• The safety of areas where patients receive care, treatmentand services.• The effeciency of the nonclinical services that support patientcare and treatment ( such as housekeeping andtransportation).• Access to support services ( such as case management andsocial work).
LD.04.03.11 continued.Effective January 1, 2014• EP 6. The hospital measures and setsgoals for mitigating and managing theboarding of patients who come through theemergency department.– it is recommended that boarding timeframesnot exceed 4 hours in the interest of patient safetyand quality of care.
Conclusion – putting it all together!• Create your project team.• Assess and map your current process.• Define your guiding principles:“design a rapid admit unit.”• Develop initial draft and solicit feedbackfrom staff members.• Implement and Evaluate the plan.• Sustain and Continue to Improve!
Next Steps• Evaluate other processes. Involve otherdepartments Such as Admitting, CustomerService, Inpatient Nursing Units.• Sustain the Gains! Share data immediatelyand regularly.• Continue to assess the process. Measuredifferent aspects of this process toeliminate boarding times.
References• Amarasingham, R., Swanson, T. S., Treichler, D. B., Amarasingham, S. N., & Reed, W. G. (2010). A rapidadmission protocol to reduce emergency department boarding times. Quality and Safety in HealthCare, 19, 200-204. doi:10.1136/qshc.2008.031641• Burley, G., Bendyk, H., & Whelchel, C. (2007). Managing the storm: an emergency department capacitystrategy. Journal for Healthcare Quality, 29, 19-28. doi: 10.1111/j.1945-1474.2007.tb00171.x• DeLia, D., & Cantor, J. C. (2009, July 17). Emergency department utilization and capacity (ResearchSynthesis Report. No. 17). Princeton, NJ: Robert Wood Johnson Foundation. Retrieved fromhttp://www.rwjf.org/pr/product.jsp?id=45929• Liew, D., Liew, D., & Kennedy, M. P. (2003). Emergency department length of stay independently predictsexcess inpatient length of stay. Medical Journal of Australia, 179, 524- 526. Retrieved fromhttp://www.mja.com.au• Liu, S. W., Thomas, S. H., Gordon, J. A., & Weissman, J. (2005). Frequency of adverse events and errorsamong patients boarding in the emergency department. Academic Emergency Medicine, 12(Suppl. 1),49-50. doi:10.1111/j.1553-2712.2005.tb03828.x• Richardson, D. B. (2006). Increase in patient mortality at 10 days associated with emergency departmentovercrowding. Medical Journal of Australia, 184, 213-216. Retrieved from http://www.mja.com.au• Viccellio, P. (n.d.). Our environment: The silent issue (PowerPoint presentation). Retrieved January22, 2013, from http://www.hospitalovercrowding.com• Weiss, S. J., Ernst, A. A., Derlet, R., King, R., Bair, A., & Nick, T. G. (2005). Relationship between theNational ED Overcrowding Scale and the number of patients who leave without being seen in anacademic emergency department. American Journal of Emergency Medicine, 23, 288-294. doi:10.1016/j.ajem.2005.02.034