Boarding patients in the ER is a problem, a big problem. Anyone in the ER knows it. You cannot stop the flow of patients into the ER but all the roads out of it are blocked for one reason or another. It is going to have to come down to some sort of legislation that admitted patients MAY NOT stay in the ER, ever. It is not safe for the patients, it is not safe for the ER staff and it is definitely detrimental to the sick and dying patients that need urgent treatment waiting for an open bed. Hospitals must be held accountable to get the admitted patients out of the ER. They must quit performing elective surgeries when the hospital is over capacity even though they are big money makers. It has to stop being about the pocketbook and start being about what is best for the patients. They must either bring in contract labor for times of high census or the administrators need to put on their nursing shoes and get out on the floors. The ER needs to become as much of a priority as the cath lab or surgery even though the reimbursement for ER patients is less. Administrators need to spend less time in useless meetings and come up with some real solutions NOW!
11 comments:
A big problem in my area is the floors do not staff with the ability to admit to all available rooms. The want to run at full productivity at all times. A few hours prior to a shift they staff for the census at that time and known admits giving everyone a nearlly full load. Any extra staff are called off. So suprise, half way through the shift they cant admit anyone else because each nurse is at their max. So the ER patient sits in the ED hallway until the next shift comes in.
And that is a practice that has to stop. Unless the hospitals are forced to put all admitted patients in a room then they will continue to use the ER as their dumping ground while they sit in the ivory tower counting profits.
Our hospital was able to pretty much solve the boarding problem with some computer software, in-house protocols and staffing attitudes, shall we say (without building any more beds). If your facility is using handwritten grease boards and phone calls to find out if beds are clean/ready, you're being inefficient. Navicare software has been proven to be quite effective alone in facilitating good patient flow, for example.
Having on-call floor nurses who are paid $7 or whatever to sit at home and their usual salary to come in if there is a crisis is always a good idea.
We have in-house protocols as well that cause people to come out of nowhere to converge upon the ER to help move patients. Management, transport, float aides, etc. Doctors will forgo unnecessary waits to admit (eg. if a patient is going to be admitted no matter what, a bed is ordered immediately before results are back).
They have been working on this issue at my hospital. What they decided was to introduce "triggers" in the form of time-limits. So, for example, if a patient in the ER has been waiting for four hours, they are transferred to a unit automatically--no exceptions.
This is great for the ER! Patients spend less time there, new patients wait less time, and nurses are much less stressed out as they have smaller patient loads. And since the ER seems to be the most visible department to the public/media, they come across as looking wonderful. And here in Canada where public health care rules, that means votes for the government!
But the problem has been completely transferred to the inpatient units. Instead of those patients being lined up along the halls of the ER in an unsafe environment, they are lining the halls of the somewhere else.
This has resulted in night shifts where even though we are four nurses short and all of us have eight patients (five to six is the norm on our acute unit), we'll get a call to tell us that we're getting three new patients. Then an hour later we'll get a call informing us we're getting a few more patients. When we beg them to hold back, we're simply told, (rudely) "too bad--deal with it!"
We line them up along the hallway and desperately try to care for them. Not only do we have an unsafe load of patients, these "trigger" patients are typically inappropriate for us to care for. We're a general surgery unit, but we'll get stroke patients, orthopedic patients, cardiac patients etc. etc. All of which we only have vague abilities to care for.
Sorry, this turned into more of a rant than a response. My point was: yes, it's unsafe for patients to be crowding the ER in an unsafe way, but we need to be very careful how we solve that problem. Hiding the patients away from the media on a medical/surgical unit doesn't make it better!
Sean
As one of those dastardly administrators referred to above, I can say that this situation isn't usually caused by too many elective surgeries or greed or any other variety of adminstrative skulduggery. In my experience, it is caused by turf wars between clinical departments (note the conflcting perspectives of ERnursey and Sean).
At my hospital, we solved this issue with a combination of the kind of technology mentioned by Nurse K and by assigning a "bed control nazi" whose goal is patient safety and satisfaction rather than the convenience of the med/surg floor or the ER.
Why is every admit from the ER a complete surprise???
Noting that the referenced article refers to the crisis at Grady in Atlanta...Grady's also been on the verge of closing for some time. If it closes, the rest of the hospitals in Atlanta (none of which are trauma centers) will be overrun as well.
I also note the mention in the article of the full unit beds, and that brought to mind a seasonal problem around here - finding open beds to transfer people to when they need critical care. Generally the smaller rural hospitals are not set up for ICU care (only to stabilize and ship) so these folks have to go somewhere. When every bed in every referral hospital in the region is full, critically ill patients are stuck. Keep in mind the smaller hospitals often staff the ERs with only one or two nurses, and there have been many times at night and on weekends when I was the only RN in the building. There have been times that I've had to remain at the bedside one-on-one and just let the folks signing in at triage sit untriaged until I could get the critical patient transferred out - and if another critical patient came in, well...you can see the problem there. When there's nowhere to send them, everything just stops. I've also worked on floors where even though the beds are full, they've cleared out the sleep study room to make room for another. Moved out offices and moved in beds to make room for yet another, still not staffed to handle more patients than they had beds. So the issue is system-wide, and our current healthcare system simply cannot meet the demand on any level.
Things are really tough all over.
I'm going to add my two cents in too.
I totally agree that boarding patients in the ER is dangerous for them, the staff and everyone. I've seen the problems firsthand, in a terrible way (one death at least).
Lately it seems to be getting better, judging from the quick turnover I've been having lately. (I still never have empty stretchers--I'm just not doubled and tripled up as often anymore.) I know we've opened some floors that were previously closed and have designated them "overflow" floors--and they get staffed (during the day) by the nurses from our in-house education department, and--once---by the VP of nursing herself. We also have a "bed nazi" who is fantastic--but we're still using grease boards and magnets and what looks like an ancient computer with a hamster on a wheel running it in our admit department.
I really like the implementations of Nurse K's hospital; I need to find out more about what we're doing to solve the problem--because people lined up on stretchers in ANY hallway is bad news.
ER is just a dangerous place to hold any admitted patient. The floors complain that the ER unloads on them but don't they know that the ER generally goes 12 hours without a lunch, sometimes without a break only to be told the floor can't take report because they are at lunch or break?
How about the the fact that we can't tell the ambulances to circle the hospital until we get a bed for their patient, but we can be told to hold our patient's "just a few more hours," because the floor is busy.
I am only one nurse, I can not take care of 10 patients ALL of which have STAT orders and family demands. We see patient's when they are the most anxious, yet we have to alleviate their fears, take care of their immediate problem and make excuses for the floors and administration as to why they can't get to their own room.
Please, don't get me wrong, floor nursing is becoming a very strenuous and stressful job; but can you imagine getting two trauma alerts, a STEMI, and and arrest all within 15 minutes of each other and have the floor tell the ER nurse they are "too busy" to deal with the patient?
Don't look at me when a fist comes through the phone right at you.
You are so right. I remember that in the last trauma center/ER I worked in, they'd cheerfully announce ridiculous stuff like: "You'll be glad to know that tonight we're closing the ER's back rooms due to being understaffed."
But my sassy answer was always: "Big deal---the SAME amount of patients are going to come through our doors, dodo bird."
I do feel that every nurse should spend some time, well work in the ER. It is a different atmosphere and it is critical to understand the department before critisizing it.
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