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Creating a Rapid Admit Unit to Prevent Overcrowding
and Provide Safe Passage for Patients
Marie Hankinson, PhDc, RN
ObjectivesI. Define Emergency Department OvercrowdingII. When to Create a Rapid Admit UnitIII. Describe the Benefits of Creating a Rapid
Admit UnitIV. Describe Metrics to Measure Your
Program Success
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
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
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)
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.
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.
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 take
ED call• Inability to cover specific specialties and
having to transfer patients to other facilities.
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!
ED Overcrowding
Reduces • Health Care 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
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
How to Sell The Idea
• Holdover hours• Capacity/Code Purple status• LWBS • Satisfaction• Identify and optimize/profitize an area with
low utilization
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.
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
Involve Other Departments• Finance
• How will you charge these patients?
• Dietary• Pharmacy• Environmental• Security• Volunteers• Hospital operators• Admitting• #1 department to involve: IT
Supplies & Equipment• Patient care supplies• Copier• Fax• Pyxis® automated medication dispensing
system• Patient monitors• Thermometers• Crash cart• Computers• Phones
Inclusion/Exclusion Criteria
Types of patients• Medical/ telemetry
• Direct admits
• ICU patients• Isolation• Geriatric Patients• Pediatric Patients• Hours of service
Standards of Care
• Admission procedures
• Transfer / Discharge procedures
• Documentation guidelines
• Customer Service Guidelines
Quality Monitors• Types of patients• Levels of service• Satisfaction ( both inpatient and
emergency)• Incident reports• Staff feedback• LWBS• Door to Doc Time
Cost
• Staff• Reimbursement
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 Seen
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
25
35
21
36
39
2728
35
38 38
21
8
GOOD
Nu
mb
er o
f p
atie
nts
2011 Total ED VISITS
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
41403943
4493
39163875 3787 3785 3723 3657
3776
40714226
3693 3620
3921
3485 3415
31043259 3192 3112
3334 33323582
TOTAL TARGET
GOOD
Nu
mb
er o
f p
atie
nts
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 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.
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.
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).
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.
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!
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.
Thank you
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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