Strategies to increase efficiency and involvement.
In 2011, nine out of 10 hospitals reported boarding patients in the emergency department while they awaited inpatient beds.
The Joint Commission has since made boarding part of its survey process because it’s a patient care and safety issue. But the negative effects don’t stop at safety and clinical outcomes. There are also the negative downstream effects of boarding, including the inability to treat newly arriving patients, longer cycle times for existing ED patients and poor perception of quality and confidentiality by boarded patients.
With the stakes so high, can you afford to not address this issue? Here are seven ways to solve the ED boarding challenge:
1.Make efficient throughput everybody’s job.
The best way to identify and address barriers to throughput is to form a hospital throughput committee that includes various stakeholders within the organization. This should be an interdisciplinary team of 12 to 15 individuals, including hospitalists, leaders from the ED and critical care, and telemetry and medical-surgical nursing, who can best drive process improvement and remove barriers for admitting patients quickly. An effective committee meets monthly and holds members accountable by aligning individual goals and tracking performance metrics in a dashboard.
The dashboard should be able to be drilled down by unit and/or support department. The nursing unit dashboard, for example, should include metrics such as the amount of time from discharge order to departure, average departure time and percentage of patients discharged and departed by noon. Environmental services should report on the average turnaround time for cleaning a room, break that down by time of day; and transport should include the average times from transport request to completion. This metric should also be broken down by time of day. Each department that contributes to the discharge process should have reported metrics on the dashboard. At monthly throughput meetings, the focus should be on action items to improve the metrics and not a discussion of the actual metrics. For instance, if a nursing unit is not meeting discharge order to departure goals, determine the reasons why and develop solutions to address those issues.
2.Involve physician leaders.
Engaging physician leaders in process improvement efforts is important as you work to minimize and/or eliminate the ED boarding burden. Connect the dots for physicians by explaining that delays in patient admissions is not in the best interest of patients and you need their help to change patient routing to expedite discharge. And ask hospitalists what metrics would be helpful for the group to monitor.
Physician involvement in the discharge process supports not only the throughput process, but also the physician communication and the care transition portion of the patient experience. Physicians involved in multidisciplinary rounds or rounding with the nurse provide better communication with the patient and family and the care team can begin the discharge planning earlier in the hospital stay.
3.Use a no-delay nurse report.
No-delay nurse reports ensure the ED and inpatient nurses have the same information, reducing time from admit orders to arrival on inpatient units, decreasing the potential for handoff errors and improving patients’ perception of care due to a timely transfer. A sample process might look like this: After the order is written and a request for a bed is made, the ED nurse opens a “transfer of care” report, which is accessible to the floor nurse. The ED nurse then awaits the patient bed assignment.
Fifteen minutes after the bed has been assigned, either the unit clerk calls down to the ED to accept the patient or the accepting inpatient primary nurse or charge nurse calls to ask questions. In either case, the ED patient is transferred within 15 minutes of a bed becoming available.
Standard work agreements must be created that address what the escalation process would be if this process is or can’t be followed. When implementing this process, begin with a single unit and have staff from both the unit and ED work together on defining the practice and rules that will be followed. The assignment of beds should be happening at central bed control area and not determined by the nursing unit. The cleanliness and readiness of room should be monitored by the central bed control area eliminating the concerns and delays over bed availability.
Many electronic medical records have electronic reports that can be utilized to expedite a report process and promote a no-delay report. To maintain consistency these times should be monitored and reported at monthly hospital throughput meetings. Units experiencing outlying report times should work together with the ED leadership team to develop an action plan to meet their goals.
In most cases, inpatients boarded in the ED are the last patients that hospitalists, intensivists and consultants round on. By rounding on them first in the morning instead, patients can be downgraded or discharged that same day. This can also prevent potential patient safety issues as the hospitalist may detect a change in condition requiring intervention or an upgrade.
In the same way, by rounding first on patients who were identified the prior day as potential discharges, you create more capacity early in the day. Adjusting workflow can have a huge positive impact on risk, safety, length of stay and patient satisfaction.
Because discharge and throughput involve so many departments it is important to review the work patterns in those departments to identify ways they can work together more effectively. Look for barriers that may be preventing efficient discharge.
For example, if housekeeping’s shift changes coincide too closely with usual discharge patterns, the unit will have inpatient rooms sitting empty while patients wait in the ED. In an academic medical center where patients are usually seen by students and interns before discharge, ensure they are rounding early in the day so patients aren’t left waiting after they’ve been given discharge orders. Consider the process for ordering patient transports, and the time from the initial call to actual transport, to see if there are slowdowns in that process.
5.Set a viable surge policy.
The goal of a surge policy is to create a proactive, early response system that decompresses busy times in the ED instead of operating in disaster mode. While most hospitals have such a policy, they don’t typically utilize it appropriately (or early enough) and operate most of the time in disaster mode instead.
A good surge policy is realistic and escalates gradually in a structured way that initiates a defined response from other departments and inpatient leaders. A color-coded system where green is good, yellow requires a heightened response and orange needs a greater response is useful. Then your ED doesn’t have to operate in “red” or “black” mode.
Driving the implementation of a new surge policy can be labor-intensive in the beginning, but it pays big dividends over time. As staff and providers become accustomed to how to respond, time drops dramatically.
Consider the following when creating a surge policy:
Ensure standards are realistic. Consider how the ED already functions—what is the norm? Then determine what the levels above would be and the response required to operate efficiently.
Some ED staff create saturation policies that set lofty expectations, meaning their department is always in the policy’s crisis mode because they’re always over capacity. As a result, staff who should be part of the surge response become accustomed to the saturation notifications, making the policy useless. One hospital sent out a surge notice nearly every morning and eventually there was no response. In such a situation, ED leaders may need to go up the organization’s leadership chain to get a response, as well as examine other ways the ED’s “normal” can be more manageable.
Here is an excerpt from an organization’s surge policy:
- Notify AL [administrative liaison] if holding three or more patients for admission.
- Consider calling Yellow(Patients are backing up in ED, need your help!) when three of the following criteria are met:
- Increase in ambulance traffic and offloading in hallway > 10 minutes
- Patient arrival to MSE (medical screening exam) time > 45 minutes
- Greater than five patients waiting for triage
- Three patients are ER-Admit Holds for > two hours
- Monitored beds in ED are all occupied
- Consider calling Red (we are very close to going on bypass or are on bypass) when three of the following criteria are met:
- Increase in ambulance traffic and offloading in hallway > 20 minutes
- Patient arrival to MSE time > 60 minutes
- Greater than eight patients waiting for triage
- Six patients are ER-Admit Holds for > four hours
- Monitored beds, hallway and routine beds are all occupied
- No inpatient beds are available.
- Consider calling Black (Nearly a disaster situation) when three of the following criteria are met:
- Multi-casualty incident victims arriving in ED via ambulance
- Patient arrival to MSE time > 90 minutes
- Greater than 12 patients waiting for triage
- Ten patients are ER-Holds for > six hours
- Greater than three ICU critical 1:1 ED patients
- No inpatient beds are available
- No available surgery add on time
6.Ask inpatient nurse managers to round on boarders.
When initiating nurse manager rounding on boarded patients, explain the “why.” This focuses on patient communication and quality of care for those patients awaiting an inpatient bed.
Then emphasize the “what” and “how.” The “what” is two-fold. First it is connecting the patient to an inpatient leader that is assuring them the highly skilled staff in the ED are providing excellent care to them as they await a bed and also to give time estimations to the patient and family as to how long they might expect to wait. The second reason why it is important is it helps connect the inpatient leaders to the urgency the ED is experiencing and also allows them to help support ED staff regarding any unfamiliar inpatient orders process.
The “how” is flexible. Different nurse leaders can be assigned to different days to round on inpatients or each unit leader may take a certain number of patients and round daily. This process of how is best determined by the nurse leadership team together. Inpatient leader rounding ensures both safety (e.g., a safe handoff and safe acceptance of inpatient) and quality (e.g., improved morbidity and mortality rates.)
By connecting inpatient leaders with boarders, you also establish ownership for the transition and build trust. Frequency of rounding is tied to your hospital’s surge plan with leader guidance and instruction for inpatient units and defined roles and expectations for staff and physicians at tiered surge levels.
It’s rare there are truly no beds available in a hospital. Unavailable beds are typically the result of delays in the inpatient discharge process. One such barrier to inpatient discharge is the time it takes to complete the electronic medical record. What can you do to minimize that barrier? Is it possible to chart ahead of time? Even if a nurse doesn’t know exactly when a patient will be discharged, he or she likely knows if a patient will be discharged soon. In such cases, it’s possible to begin working on discharges needs 24 hours ahead of time rather than at the moment of discharge.
For example, chronic patients that require significant education prior to discharge, begin this process earlier in the stay instead of day of discharge when it may be more challenging for patients and family to comprehend it all at one time. If it has been determined that the patient may need durable medical equipment or other services, start aligning those services and needs prior to day of discharge to expedite the discharge on day of discharge.
By bringing the care team together and involving the patient in their care plan, the discharge needs are identified early and expectations regarding the discharge process are set ahead of time. This requires a consistent commitment from the case management team to standardize this process and communicate the expectations of the teams involved.
Addressing boarding in the ED requires a company-wide response. It’s not just an emergency medicine problem. Executives play a critical role in goal setting, establishing accountability, and effective communication and building teamwork among stakeholders.