Patient Flow Matters: Why Is My Sick Patient Waiting in the ED?

ABSTRACT: Overcrowded emergency departments (EDs) reflect a system-wide patient flow problem. Although there are multiple reasons for bottlenecks in flow, the inability to transfer patients to inpatient beds is a major factor. The Institute for Healthcare Improvement (IHI) has developed a process to assist hospitals in tracking and measuring patient flow. The IHI recommends setting up a process improvement committee to measure flow throughout the institution. The hospital administration must identify peaks and valleys in flow and try to reduce the severity in the swings in census. One effective strategy is "code purple," which can help relieve overcrowding in the ED.

Key words: emergency department, patient flow, hospital administration

Here is an increasingly common scenario: Your emergency department (ED) is full, the hospital census is at capacity, and there are not enough nurses to care for all of the patients. Hospital overcrowding and long ED wait times are difficult problems facing nurse executives today.

According to the Joint Commission's 2009 accreditation standards, leaders must identify and address any impediments to patient flow throughout the hospital.¹ The rationale is that the problem is system-wide and not just caused by ED overcrowding. Specific indicators address patient flow and should be measured to evaluate and manage the process improvement. The Joint Commission¹ states these indicators are:

In this article, I examine the reasons for overcrowding and discuss the steps that can be taken to improve patient flow.

WHY OUR EMERGENCY DEPARTMENTS ARE OVERCROWDED

In the United States, EDs have had a 20% increase in patient flow over the past 10 years.² At the same time, the number of EDs has decreased by 425 and the number of hospital beds by 198,000.³ The increase in the number of patients who come to the ED for treatment has increased wait times for admitted as well as nonacute patients. This problem is system-wide. EDs are part of the hospital organization, yet often other members of the hospital organization are not aware of the backups and bottlenecks in the ED.

EDs in the United States are historically very busy places. At 4 PM on a Monday afternoon, it would not be uncommon for an ED to have 50 persons in the waiting room and 20 persons waiting for admission orders.⁴ At the same time, the hospital may be at capacity because physicians typically discharge patients after they have finished their office hours. A bottleneck in flow occurs because the ED and inpatient services are now at capacity.⁵

Although there are multiple reasons for this backup, the US General Accounting Office found that the inability to transfer patients to inpatient beds is a major factor.⁶ This leads to safety concerns as well as poor customer satisfaction. Patients do not want to wait in the ED for extended periods, especially when they are just waiting for a room assignment.

Patients who are in the ED for extended periods essentially become boarders and may not receive quality care. The ability of an ED nurse to care for multiple critically ill patients is limited. The ED nurse cannot say no to admissions, and diversion is not always an option; therefore, the ambulances keep coming.⁷ The standard of care is not the same as, say, that of an ICU registered nurse (RN), who has 2 critically ill patients as an assignment. The critical care RN is in charge of 2 beds and can admit patients only to those beds. The patient to nurse ratio is thus 2:1, a standard of care the ED nurse cannot provide.

POSSIBLE SOLUTIONS

So, what are the solutions? The Institute for Healthcare Improvement (IHI) has developed a process to assist hospitals in tracking and measuring patient flow.⁸ The recommendation is to set up a process improvement committee to measure flow throughout the institution. This can assist with identification of problem areas and ways to improve flow. The IHI Web site has step-by-step instructions on how to create a committee and collect pertinent data: http://www.ihi.org/IHI/Topics/OfficePractices/Access/HowToImprove/formingtheteam.htm.

There are many strategies to handle flow problems once the committee has identified these areas and gathered data. Research done by Eugene Litvak, PhD,⁹ focuses on peaks and valleys of flow. According to Litvak, the hospital administration must identify these peaks and valleys and try to reduce the severity in the swings in census. Hospital census has some predictability, and Litvak has successfully instituted a flow model that staggers operating room times to later in the day to prevent backup of critically ill patients in the recovery room.

Patient safety is also an issue. When nurses are overworked because of patient flow problems, the percentage of errors rises.¹⁰ Medical errors are commonly the result of a systems failure, not individual errors.¹¹ The nurse executive is obliged to address areas of problematic flow to provide a safe environment for patients and staff.

As a bed flow coordinator for a 716-bed hospital in South Florida, I deal with the problem of patient flow every day. The hospital developed a patient flow committee about 18 months ago to address these difficulties. The support of upper-level administration has been a major factor in its success. A new chief nursing officer (CNO) has supported the cultural change needed to make progress.

The patient flow committee gathers data to identify bottleneck trends in our institution. Recently discovered bottlenecks include resistance to change by some hospital employees, lack of awareness of their own difficulties, and difficulty in seeing their department as part of a system. For the past 6 months, we have focused on separating specific areas of data collection and requiring accountability for change. The committee has been meeting bimonthly, and changes are starting to happen.

The committee is chaired by the CNO. The bed coordinator and the ED nurse manager are the team leaders. The team is currently working to increase the number of patients discharged earlier in the day and to hire more staff. To meet the demand for more acute care beds, a telemetry option was added to some medicalsurgical beds so that they can be used as both, depending on demand. These changes have reduced the patient waiting time in the ED.

The team is developing a strategy to handle patients when the ED is full and the hospital is also at capacity. Code purple is one such method being considered.⁴ The ED in Royal Oak, Mich, has implemented such a plan.

When the ED is at capacity, a code purple is called. Then nursing administration and all of upper-level management go into a mini disaster mode. The result is patients are sent to short-term hall spots on the inpatient floors. All patients scheduled for discharge are moved to the lounge areas to await their rides home. This temporarily relieves backup in the ED.⁴ The method seems drastic; however, it can alleviate an overcrowded and unsafe environment in the ED.

The implementation of a process improvement team is an effective way for nurses to influence decisions that will affect their practice. Supported by leadership, nurses can have an impact on the quality of patient care and patient safety.¹²

References:

REFERENCES:1. Joint Commission. Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission Resources; 2009.
2. Institute for Healthcare Improvement. Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. Cambridge, MA: Robert Wood Johnson Foundation; 2003.
3. Institute of Medicine. The Future of Emergency Care: Key Findings and Recommendations. Washington, DC: National Academies Press; 2006.
4. Gokenbach V, Wilson A. Code purple mode relieves ED bottlenecks. ED Management. 2000: 139-142.
5. Bullard MJ, Villa-Roel C, Bond K, et al. Tracking emergency department overcrowding in a tertiary care academic institution. Healthc Q. 2009;12:99-106.
6. United States General Accounting Office. Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. Washington, DC: United States Government Printing Office; 2003.
7. Espinosa J, Kosnik L, Nathanson L. Reports say diversion is on the rise: use technology to overhaul patient flow. American Health Consultants. 2002: 25-27.
8. Institute for Healthcare Improvement. Forming the Team. 2009. http://www.ihi.org/IHI/Topics/OfficePractices/Access/HowToImprove/formingtheteam.htm. Accessed June 7, 2010.
9. Litvak E. Do's and don'ts of patient flow. In: Litvak E, ed. Managing Patient Flow: Strategies and Solutions for Addressing Hospital Overcrowding. 2nd ed. Oakbrook, IL: Joint Commission Resources; 2009.
10. Penney B, Fuda K. Patient safety: does variability in admissions matter? HealthLeaders Media. December 20, 2007.
11. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
12. Needleman J, Hassmiller S. The role of nurses in improving hospital quality and efficiency: realworld results. Health Affairs. 2009;28:w625-w633.

FOR MORE INFORMATION:
• McIntyre SR. Is your ED overcrowded? Focusing too narrowly can distract from a larger patient flow problem. Healthc Exec. 2008;23:60-61.
• Miró O, Sánchez M, Espinosa G, et al. Analysis of patient flow in the emergency department and the effect of an extensive reorganisation. Emerg Med J. 2003;20:143-148.