Creating a Rapid Admit Unit

1. Creating a Rapid Admit Unit to Prevent Overcrowding and Provide Safe Passage for Patients Marie Hankinson, PhDc , RN

2. O bjectives I. Define Emergency Department Overcrowding II. When to Create a Rapid Admit Unit III. Describe the Benefits of Creating a Rapid Admit Unit IV. Describe Metrics to Measure Your Program Success

3. Definition of ED Overcrowding “ A situation in which the identified need for emergency services outstrips available resources in the ED” ACEP Crowding Resources Task Force, 2002. Retrieved from http://www.acep.org/workarea/downloadasset.aspx?id =8872

4. Common Strategies to Decompress the Emergency Department Code Purple Fast Track Hallway Beds Pull till Full Advanced Nursing Interventions Rapid Medical Evaluation (RME) Bedside Registration

5. Front End Flow Tactics RME- Clinician in Triage Midlevel Provider in Triage MD in Triage Intake Team Fast Track Low Acuity Super- Track ( ESI 5’s + Simple 4’s) Fast- Track ( ESI 5’s, 4’s & simple 3’s)

6. Boarding Patients ED patients who need to be admitted are “boarded” until inpatient beds become available. The practice of “boarding” patients creates safety and negative consequences such as increasing LWBS, patient walkouts, adverse events, errors, mortality rates and diversion of ambulances.

7. Causes of ED Overcrowding In 2006, the Institute Of Medicine (IOM) described emergency care in America at the “breaking point”. The most common documented factor for ED Overcrowding is scarcity of beds for patients admitted through the ED. Studies consistently tell us that inpatient occupancy is positively associated with patient waiting in the ED.

8. 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 p hysicians willing to take ED call Inability to cover specific specialties and having to transfer patients to other facilities.

9. Behavorial Health Patients 5-8% of ED volume Shortages of Mental Health Care Bad news is that we have a lack of studies that can explain the impact on ED Overcrowding!

10. ED Overcrowding Reduces H ealth C are Quality Patient Safety Patient Mortality Failure to receive antibiotics and analgesic medications Adverse events such as hospital acquired pneumonia and pulmonary embolisms. Research Use existing capacity more efficiently. Improve internal processes. Resources Joint Commission IHI RWJF Urgent Matters ACEP

11. When is a Rapid Admit Unit Needed? ED is overcrowded Boarding patients Long waits for inpatient beds Patient satisfaction decreases LWBS numbers increase Staff satisfaction decreases

12. How to Sell The Idea Holdover hours Capacity/Code Purple status LWBS Satisfaction Identify and optimize/ profitize an area with low utilization

13. What is and isn’t a Rapid Admit Unit? Not an Observation Unit. Clearly delineates responsibility for patient care between the emergency department physicians and admitting physician.

14. What is Needed to Create a Rapid Admit Unit? Support from administrative team Support from Medical Staff Physical space outside the ED Determine number of beds Staffing Skill mix Orientation

15. Involve Other Departments Finance How will you charge these patients? Dietary Pharmacy Environmental Security Volunteers Hospital operators Admitting #1 department to involve: IT

16. Supplies & Equipment Patient care supplies Copier Fax Pyxis ® automated medication dispensing system Patient monitors Thermometers Crash cart Computers Phones

17. Inclusion/Exclusion Criteria Types of patients Medical/ telemetry Direct admits ICU patients Isolation Geriatric Patients Pediatric Patients Hours of service

18. Standards of Care Admission procedures Transfer / Discharge procedures Documentation guidelines Customer Service Guidelines

19. Quality Monitors Types of patients Levels of service Satisfaction ( both inpatient and emergency) Incident reports Staff feedback LWBS Door to Doc Time

20. Cost Staff Reimbursement

21. Measuring Success Decrease ED wait times Decrease LWBS Improve Patient Satisfaction Improve Staff Satisfaction Reduce Medical Errors Improve Quality and Safety

22. 2011 ED Patients Triaged, Not Seen

23. 2011 Total ED VISITS

24. 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

25. Elements of Performance (EP) Publication of the Joint Commission in December 2012. Standards LD.04.03.11 and PC.01.01.01 are revised standards that address an increased focus on the importance of patient flow in hospitals. Go into effect January 1, 2013, with two exceptions: LD.04.03.11, EP’s 6 and 9 will be effective January 1, 2014 .

26. LD.04.03.11 The hospital manages the flow of patients throughout the hospital. EP 1. The hospital has the processes to support the flow of patients throughout the hospital. EP 2. The hospital plans for the care of admitted patients who are in temporary bed locations, such as the post anesthesia care unit or emergency department. EP 3. The hospital plans for the care of patients placed in overflow locations. EP 4. Criteria guide decisions to initiate ambulance diversion.

27. LD.04.03.11 continued EP 5. The hospital measures and sets goals for the components of the patient flow process including: The available supply of beds The throughput of areas where patients receive care, treatment and services ( such as inpatient units, laboratory, operating rooms, telemetry, radiology and PACU). The safety of areas where patients receive care, treatment and services. The effeciency of the nonclinical services that support patient care and treatment ( such as housekeeping and transportation). Access to support services ( such as case management and social work).

28. LD.04.03.11 continued. Effective January 1, 2014 EP 6. The hospital measures and sets goals for mitigating and managing the boarding of patients who come through the emergency department. – it is recommended that boarding timeframes not exceed 4 hours in the interest of patient safety and quality of care.

29. 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 feedback from staff members. Implement and Evaluate the plan . Sustain and Continue to Improve!

30. Next Steps Evaluate other processes. Involve other departments Such as Admitting, Customer Service, Inpatient Nursing Units. Sustain the Gains! Share data immediately and regularly. Continue to assess the process. Measure different aspects of this process to eliminate boarding times.

31. Thank you

32. References Amarasingham , R., Swanson, T. S., Treichler , D. B., Amarasingham , S. N., & Reed, W. G. (2010). A rapid admission protocol to reduce emergency department boarding times. Quality and Safety in Health Care, 19, 200-204. doi:10.1136 / qshc.2008.031641 Burley, G., Bendyk , H., & Whelchel , C. (2007). Managing the storm: an emergency department capacity strategy. 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 (Research Synthesis Report. No. 17). Princeton, NJ: Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/pr/product.jsp?id=45929 Liew , D., Liew , D., & Kennedy, M . P . (2003). Emergency department length of stay independently predicts excess inpatient length of stay. Medical Journal of Australia, 179, 524- 526. Retrieved from http://www.mja.com.au Liu , S . W ., Thomas, S . H ., Gordon, J . A ., & Weissman , J. (2005). Frequency of adverse events and errors among 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 department overcrowding. 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 January 22, 2013, from http://www.hospitalovercrowding.com Weiss, S. J., Ernst, A. A., Derlet , R., King, R., Bair, A., & Nick, T. G. (2005). Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic emergency department. American Journal of Emergency Medicine, 23, 288-294. doi:10.1016 / j.ajem.2005.02.034

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