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

Contact Information

Marie.Hankinson@yahoo.com