ER space: working to avoid 'boarding' patients

[Guest]

October 18, 2006

 

By LAURA LANDRO 

Hospitals Open Up Space in the ER

Facilities Work to Avoid

'Boarding' Patients in Halls

By Making Beds Available

October 18, 2006; Page D16

The Wall Street Journal

A family forced to make end-of-life decisions for a patient dying on a gurney in a hospital hallway in California. An Ohio man with chest pain who dies of a heart attack waiting for a hospital bed to open. Critically ill patients forced to disrobe and use bedpans in hospital corridors in New York City.

Such horror stories are becoming increasingly common as more overcrowded emergency rooms are forced into the practice known as "boarding" -- admitting ER patients to the hospital when no beds are available, and then parking them in hallways for up to 48 hours at a time.

Stacked up like planes on a runway, boarded patients are a leading cause of emergency department gridlock, long waits for treatment, and ambulance diversion to other hospitals, according to the American College of Emergency Physicians, which says that half of medical directors surveyed this year reported boarding one to five patients for four or more hours each day.

Now, a growing number of hospitals are taking steps to fix the logjam in their hallways, sharing strategies at the annual emergency physicians' conference in New Orleans this week.

They are borrowing industrial production models to move patients through the ER more efficiently, and enforcing more-rigorous discharge policies to free up inpatient beds more rapidly.

They are forcing other hospital departments to shoulder some of the burden with "Adopt-A-Boarder" programs, shifting boarded patients to inpatient hallways, and asking nurses in intensive care and other units to take on a higher number of patients to relieve their colleagues in the ER.

Emergency departments are also looking for ways to avoid admitting patients to the hospital in the first place, opening special observation units for some patients and sending others home to be followed by home health aides.

Some states are cracking down on boarding in emergency rooms, and Congress is also weighing legislation that could provide financial incentives to hospitals to stop or reduce the practice of boarding and increase Medicare payments to doctors who provide care in emergency departments.

Right now, emergency-care experts say, the boarding problem is being exacerbated by cuts in payments for emergency care and a shortage of both emergency-room doctors and on-call specialists.

Emergency doctors say hospitals also have little incentive to stop boarding because they can bill patients as if they are in the hospital even though they are in a hallway, and they often leave beds open for more profitable elective-surgery patients.

Both humiliating and dangerous for patients, boarding is also a growing liability risk for hospitals, since many boarded patients are critically ill and waiting for intensive-care rooms.

With limited access to the doctors, nurses and equipment needed to treat their conditions, boarded patients are less likely to be carefully monitored by busy emergency-room staff dealing with new patients coming in the door, and their conditions can deteriorate quickly.

"Our focus is the immediate stabilization of patients," says Nancy Bonalumi, president of the Emergency Nurses Association. "We are geared towards the first two hours of lifesaving care and we are being challenged to learn additional skills and competencies we are not familiar with."

While some hospitals are moving to make hallways more comfortable by adding curtains and televisions, most rarely offer such basic comforts as privacy, a bathroom or a call light to summon help.

One solution gaining adherents is the Full Capacity Protocol, a standard developed by Peter Viccellio, clinical director of the emergency department at Stony Brook University Medical Center.

When his hospital emergency room is full and patients are being boarded in hallways, the emergency department can begin transferring patients to halls in other units, spreading the burden of care around the hospital -- and ratcheting up the pressure on those units to free up beds by discharging patients who are fine to go home.

Data he presented at the New Orleans meeting showed that one-third of patients being boarded in the Stony Brook emergency department last year were transferred to other units, and 20% waited less than an hour to get into a room once in those units.

"If the emergency department has to hold patients, no one has any incentive to open beds," says Dr. Viccellio. "But put patients in other hallways, and rooms magically appear." To appease patients who have been boarded, the hospital adopted a formal policy to send flowers once they are in a room.

At Shore Health System's two hospitals 15 minutes apart in Cambridge and Easton, Md., staffers from the emergency department and other hospital units began "bed huddles" in November 2004 -- meetings that lasted 10 to 15 minutes three times a day to update each other on admissions that are coming from the ER and predicted discharges from inpatient beds; it is now able to predict 70% of its discharges compared with 25% to 30% two years ago.

Shore spent $400,000 to add several more admissions nurses who spend most of their time in the emergency room to expedite the transfer to inpatient units, and it sometimes shifts staffers from one hospital to another if one emergency room begins to get overcrowded.

The hospital is also putting more nurses through critical-care training and asking intensive-care nurses, who usually care for no more than two or three patients, to take on additional patients when the ER gets two crowded with boarders.

"Sometimes it's not a crowd pleaser with the staff nurses," says Christopher Mitchell, manager of emergency services for the Memorial Hospital at Easton. "But if it is in the patients' best interests, that's what we will do."

[JBE 328]

I can attest to this. My wife waited over 24 hours in the ER before she got admitted. Sat out in the hallway on a gurney. And the patients just kept on coming in. There's a point where you have to say enough is enough and go on diversion.

PS: She worked at this hospital and I was surprised they didn't do the right thing by one of their employees.

[CAM502 6]

Happened to my brother this weekend. Sat in the ER all night waiting for a bed.

[201/65 94]

When the new Orange Regional Medical Center opens it will have more than twice as many ER beds then the two hospitals that will be closing. The new ER will have 50 beds. However they are dropping the overall inpatient rooms than the two currently have. I think this is good to add more ER beds, however they both go on divert a few times a month as it is due to haveing no beds available to admit people to.

[Guest alsfirefighter]

Most hospitals will go on diversion. However there are many agencies whom have a "I don't care" mentality. One transporting agency I have to work with is notorious for this and act as if the its the hospital's problem instead of the patients. All this does is add to the problem and keep them on diversion longer. Add in the walk ins that still come and there you have it.

Deliver your patients where they can get difinitive care that they may need by by passing hospitals on diversion. Not by what is convient for you or what your mental picture of the situation is.

[Guest X963toOEM9]

I wonder what agency that is?????

We are suppose to be patient advocates... if we bring our patients to facilities that are already stretched beyond their capability what are we doing for our patient besides putting them in harms way!

Granted the hospitals need to work on better surge and overflow capacity but until then, instead of taking the " I don't care" approach why not be proactive and work with the hospital to create a solution. How hard is it to pick up a phone and call... Give a courtesy call and ask the charge nurse or Dr. if they can handle the patient, especially if the patient insists on going to that facility.

In times where we are trying to prepare for MCI's and other disasters, this should be a priority in the healthcare field...

Most hospitals will go on diversion.  However there are many agencies whom have a "I don't care" mentality.  One transporting agency I have to work with is notorious for this and act as if the its the hospital's problem instead of the patients.  All this does is add to the problem and keep them on diversion longer.  Add in the walk ins that still come and there you have it.

Deliver your patients where they can get difinitive care that they may need by by passing hospitals on diversion.  Not by what is convient for you or what your mental picture of the situation is.

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[Guest]

Would you go to a different hospital if the closest hospital was on diversion and you had a critical patient?

Edited October 20, 2006 by JaredHG

[Guest]

Would you go to a different hospital if the closest  hospital was on diversion and you had a critical patient?

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If it's a critical patient it's a different story, if a hospital is on diverstion I don't believe they can deny care to someone who is in critical need of care. But there are many patients who can wait a little bit longer than others and even though they may complain about a longer ride, or maybe its not their hospital of choice, but its only for their benefit. They'll recieve quicker, and definatly more thorough care when you drive an extra 5 min.

[ny10570 745]

and sometimes you just can't avoid a hospital on diversion when either the patient insists or there are just too many hospitals on diversion.

[Guest X963toOEM9]

Critical Patients are a totally different ball game.... If you would divert from a closer hospital with a critical patient... someone is in need of a refresher... I worked with a medic who diverted to a different hosp. with a cardiac arrest and did they get chewed out!!! EMS is always based on best clinical judgement... Diversion is only a courtesy!!! A hospital cannot deny a patient... that is against the law, and don't let them tell you otherwise...

Would you bypass 2 or more hospitals with a traumatic arrest just to bring them to a trauma center... Of course not!

[Guest alsfirefighter]

X963...I'm sure you can agree with me, especially being we've worked together that it depends on the critical patient and the quality of the medic. The whole chewing out about the arrest was the receiving hospital's BS added in also. Which is another problem of what we deal with. Other hospitals take it personally like its our problem the normal is on diversion.

Why for the life of me agencies do not talk to each other and come up with effective plans to assist in coverage of areas when hospitals are on diversion. If they don't cover you have to go anyway at anytime so why not resource share during diversion times.

[Jybehofd 85]

Would you go to a different hospital if the closest  hospital was on diversion and you had a critical patient?

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NO!! Diversion is a curtesy not to go there. Its really gray. But if you have a hospital that is 5 minutes out on diversion and the next hospital is 30 minutes out with a life threating or critical patient. They can't turn you away. Granted if it was a cpr job and i had a medic i think we would try to go somewhere else or get the pronouce on the scene if possible.