Based on the considerable reader feedback I received in response to my column on the practice of shifting emergency department patients to inpatient hallways, the quality and patient safety community has some fervent—and often disparate—opinions about how hospitals should deal with ED overcrowding. Many of you offered some candid remarks about your experiences at your organizations, so I thought I would share some of the comments to give the rest of you a chance to see what your fellow readers think about this often contentious issue and the viability of a "third option" beyond ED boarding or hallway medicine. Some of the e-mails have been edited for length.
We can't choose ED boarding or hallway inpatients
Let me speak as a former ED nurse: I have worked in a large metro hospital ED, and we ran out of "room in the inn" often. We would have patients in the hallways on gurneys waiting to be seen by the ED doc. Med sheets would not print for patients; they all had to be hand-written. ED documentation records did not support the type of assessments and checks that are done by med/surg or ICU nurses. Calling the attending physicians for orders and then getting them transcribed or entered was often a challenge, as procedures and routines are different. Lots of opportunities for errors.
Now, let's couple that with some other issues. Most ED nurses are ED nurses for a reason: They don't like "bedside care." Patients do not get turned, bathed, mouth care for vents, or other kinds of "maintenance issues." Also, there is usually no "extra help" afforded with the increase in census—so the emergent patients are first priority. There is a mental "move on to the next patient" when the admission orders are written.
Housing patients in the hall on the floor has many of the same issues. Where is the bathroom? Where is any privacy? What does the family do—stand alongside your bed in the hall as well? How can medications/tests/labs be SAFELY administered without real estate with a room number attached? What of fire codes? What about surveyors? (I would be very interested to hear if any facility that does this has been under survey at the time.)
Nope. Neither of these is safe, in my estimation. I will choose Option No. 3 as well, for me and mine.
Charlene Boggs, RN, Director of Quality Resources, Johnson Memorial Hospital, Franklin, IN
Look beyond symptoms to the cause
All I'm reading and hearing is that patients are stacked up in the ED waiting for an inpatient bed, but I'm not reading or hearing the reasons why the patient can't get admitted to the inpatient floor. If it is the lack of staff or inpatient beds, then you're never going to solve that issue. Whether the patient is kept in the ED or in the inpatient hallway, the real solution is to get them admitted. So, what are the issues hospitals are struggling with on the inpatient setting that is preventing this from happening? That is where the focus should be.
Hospital quality services director, Name withheld by request
Idea is to pull patients up, not push them out
This is an issue we have been grappling with at my hospital for the past several years. The problem I have with your Option No. 3 and improving ED efficiency is that it only improves throughput on the front end and decreases waiting times to care. It doesn't decrease the number of patients awaiting admission and, depending on how well that process works during peak volume times, may actually increase the number of hallway patients in the ED during certain times of the day.
In answer to your question about whether patients in the ED hallway are any less safe than in a hallway two floors up, I would answer, "Absolutely!" The ED specializes in acute care, and their priority will always be the new patients, especially those with life-threatening presentations. By definition, the admitted patient is the sickest category of patients in the ED, but the staff taking care of them are now focused elsewhere. I believe that spreading the care of these patients with the areas that specialize in that care is the safest route.
The concept of hospital floor hallway patients, though not ideal, is that patients are "pulled" up to the floors (rather than being "pushed" from the ED). The floors are then stimulated to discharge patients earlier than routine to make space for the newly arrived, highly visible, hallway patients. It also decreases the ED crowding burden and allows the ED to concentrate on acute care. I think Option No. 3 regarding hallway patients lies not in improving ED efficiency, but with improving the discharge process, length of stay, and numbers of hospital beds within each hospital.
Stephen T. Holland, MD, Chief Medical Officer, Saint Mary's Health System, Waterbury, CT
Deal with elective surgery schedule
As a former VP for perioperative and emergency services at a large Midwest level 1 trauma center, I must admit I was tempted to advocate [placing patients in hallways] in my organization. However, I know now, as I did then, that the ED is at the mercy of the inpatient capacity of the hospital, and the inpatient capacity of the hospital is driven by the elective surgery schedule. The peaks and valleys we see in most hospitals can be traced directly to the variability of the elective schedule in the OR—those that are scheduled in advance, not the emergencies from the ED. Most ED directors can tell you very easily how many patients they will admit from the ED next Thursday, but very few OR directors can tell you how many patients will be electively admitted from the OR. The end result is large peaks and valleys that cause patients to be placed in inappropriate inpatient beds with nurses who may be unprepared, overworked, or simply not accustomed to caring for that type of patient. That leads to delays, cancellations, increased risk of morbidity and mortality—and ultimately huge increases in cost that we all have to bear. The answer to this is not placing patients in hallways anywhere but to fix the root of the problem, which is the elective surgery schedule. Hospitals are reluctant to do this because they are afraid their surgeons will leave and take their business with them. However, hospitals we've worked with and the surgeons who work in those hospitals have actually benefitted by addressing the root of the problem. We have seen hospitals increase their capacity both in the OR and the hospital without building costly infrastructure or hiring more people (or putting anybody in the hall).
Christy Dempsey, RN, Senior Vice President for Clinical Operations, PatientFlow Technology, Inc., Boston
Obvious solutions not always right solutions
Hospitals are taking a wide variety of steps to solve their ER overcrowding issue. No one solution works for all hospitals. We have tried to optimize our ER throughput in a variety of ways in the ER, and are now bottlenecked because we don't have enough beds at any given time. We are taking a very comprehensive approach, starting out by looking at "wasted beds," and trying to match demand to capacity. We got started by sending several teams to the IHI's course on hospital throughput, and now have an operations group working on this problem. The obvious solutions are not always the right solutions, as we are finding that throughput is affected by multiple factors, all of which must be understood and optimized before the right solutions can be implemented.
David McGreaham, MD, Vice President of Medical Affairs, Munson Medical Center, Traverse City, MI
As you can see, the problem of ED overcrowding may be a universal one, but opinions about what to do about it are all over the map. I still don't know what the answer is—in fact, I don't think there is a singular right answer—but I'll continue to keep watch for inventive solutions.