For Peter Viccellio, MD, solving overcrowding in emergency departments is mostly just a matter of semantics.
When patients sit for hours in the waiting room and the seriously ill ones wait days in an observation area, it's not the emergency department's problem alone. The problem involves the whole hospital, and the solution is found in the cooperation of the entire hospital as well.
Dr. Viccellio, a clinical professor and the vice chairman of the department of emergency medicine at the State University of New York at Stony Brook, said contrary to popular wisdom, emergency department overcrowding is not caused by the medically indigent who have no other access to health care. It is not the fault of the Emergency Medical Treatment and Labor Act (EMTALA), annual influenza epidemics, or managed care.
“Our primary source of overcrowding was from inpatients. We needed to fix that. We needed a functioning emergency department,” he said. “We had to quit pretending that we could mimic inpatient care in the emergency department. It is a lousy place to try to do that. We had failed at it, and we could no longer pretend we could be all things to all people.”
Dr. Viccellio said a mindset change was in order, changing every mention of “emergency department overcrowding” to “hospital overcrowding.” By identifying the problem with unsolvable issues like the poor and the uninsured, he said, no one will ever solve the real issue.
Yet emergency departments across the state and in much of the nation board seriously ill patients because their leaders were told that placing patients into inpatient hallways violated health codes, Dr. Viccellio said. It turns out that just wasn't true. “I had done a lot of work with the health department,” he said. “I called a senior guy there, and asked why it was illegal to put people in a hallway upstairs, but it was OK to put them in a hall in the emergency department. It set off a time bomb.”
Armed with Proof
Armed with proof that it was legal to board patients in inpatient hallways, Dr. Viccellio marshaled together his colleagues in the New York chapter of the American College of Emergency Physicians to meet with the health department officials.
That meeting helped dispel long-held myths about overcrowding. “They went through a series of informational letters to hospitals, first informing them that it was allowed. In subsequent letters, they encouraged it, and then insisted on it,” he said.
The rationale for keeping patients in the emergency department had its roots in the early days of emergency practice. “The average emergency department was run by nursing with little physician direction. Moonlighters and a motley crew of doctors had no voice,” Dr. Viccellio said. “When there was a struggle or the staff upstairs was not ready to take a patient, they could just say no and there was nothing the emergency department could do about it.”
“It's a fundamental workflow phenomenon,” he said. “You can easily predict what would happen. In a situation where you can give me work, and I can choose whether I want it or not, I will choose not to take the work.”
Fixing the problem took the cooperation of the entire hospital, he said. “It's been received very well.”
Stony Brook University Hospital received a 2001 Press-Ganey Award for improving patient satisfaction in the emergency department by decreasing waiting time to see a doctor and to be admitted to a hospital bed. According to a portion of the award, “The team identified contributing causes for the delays in placing patients in hospital beds. Based upon retrospective baseline data, the team decided to focus on decreasing wait times for acute care and telemetry beds.
“We had to quit pretending that we could mimic inpatient care in the emergency department. It is a lousy place to try to do that.”
Dr. Peter Viccellio
“The team instituted a ‘full capacity protocol’ that identifies steps taken when the ED is full. This protocol decompresses the ED during periods of peak volume by reducing the number of patients held in the ED and admitting patients to acute units regardless of bed availability.”
The same team won the New York Governor's Workforce Champion award for improving patient satisfaction in the emergency department.
“First, I have to compliment strongly our nursing administration who has the stunning ability to ask the question: ‘What's best for the patient’ rather than ‘What's best for my turf?’” said Dr. Viccellio.
After several meetings and allowing nurses to rotate from the floor to the emergency department where they could see the problem, the hospital began to implement the protocol allowing patients to go upstairs rather than boarding them in the emergency department.
“When push came to shove and people started going upstairs, in the first three to four months, no one ever went to a hallway,” he said.
Of course, that did not last. “Some patients had to go to hallways and be distributed so no more than two patients were put on any units,” said Dr. Viccellio. “The nurses found that the incremental work was not that great. The whole threat that the place would fall apart and that nurses would quit did not happen.”
Even though the emergency department continues to hold some patients, the emergency department functions, he said.
The plan had some unexpected advantages. A study done in the emergency department showed that the average 50-year-old patient with atypical chest pain admitted to the hospital to rule out a heart attack showed that patients who were boarded in the emergency department stayed in the hospital an average of 6.2 days. Those in the inpatient hall stayed in the hospital an average of 5.4 days. That length of stay decrease was an added bonus.
“An ultimate objective is to do away with ambulance diversion. If this policy were implemented in a system-wide fashion, it would do away with ambulance diversion, which didn't always work anyway. If one hospital is overloaded, they are all overloaded. If you go on diversion, there is a sine wave effect,” Dr. Viccellio said. “We don't do diversion, as a matter of fact, anyway.”
The simplicity of the plan, however, sometimes works against it. A meeting with a panel that included the heads of the New York Hospital Association and the state nursing association elicited the reaction that “this can't be right because it's too simple.”
Andrew Wilson, MD, the corporate chief of emergency medicine at William Beaumont Hospital in Royal Oak, MI, said his institution has used the full capacity protocol for a few years.
“It's a help. Absolutely,” he said. “Our institution has been struggling to meet the demand for years now. When we first embarked on this — what we call virtual beds or hallway admits — the effect was to engage the inpatient nurses' imagination and creativity to help deal with a problem that appeared in the emergency. It's anathema to inpatient nurses to have patients in the hall.”
The nursing solutions were many. They cleaned beds faster and urged hospital administrators to convert offices back into inpatient care rooms. Patients were admitted to the hospital faster. “Ersatz beds were set up in lounges,” said Dr. Wilson. “Anything to keep patients out of the hall. It worked for a couple of years.”
During that period, the emergency department boarders dropped from 30 or 40 a day to five or 10 a day. “We have a 50-bed emergency department so that wasn't bad,” he said.
Eventually, all their compensatory mechanisms failed because of increasing demand for services. Patients have been in the hallways for the past eight to 10 months. “There were too many patients in the halls,” Dr. Wilson said.
Yet now it was apparent that the problem was institutional, not limited to the emergency department. Solving it had to involve hospital administration at an institutional level.
“It's of incredible importance that the hospital understand that the emergency department holds are in the emergency department, but that they are not the emergency department's problem. It only shares the problem. It is perfectly acceptable for the emergency department to have holds, but not so many that we can't function,” he said.
Virtual beds and hall patients also improve morale in the emergency department, Dr. Wilson said. “We don't feel we are the only ones being hit by this. The day the inpatient nursing director and I conveyed the first patient to a bed upstairs in the fall of 2000, it was dramatic. The fact that it was the inpatient nursing director and me impressed everyone. It meant the emergency department and the inpatient side agreed that this is a problem seen in the emergency department, but it is not just that department's problem to deal with.”
Dr. Wilson said once a hospital overcomes the notion that it's an emergency department problem, huge things happen. “It feels so much better to work on problems collaboratively rather than competitively,” he said.
Today, Dr. Wilson chairs the hospital's resource management committee, once called beds management. Now the chief of staff, the hospital director, the department chiefs, and the directors decide how to handle the problem of demand, this year focusing on backups in the operating room.
“The really heartwarming thing is that the whole institution focuses on these problems, and everyone accepts the idea that they have to do their part. Internal medicine does not expect to never have patients in the halls, just their share. The emergency department does likewise. We expect the number to be at a level we can tolerate.”
A number of initiatives are underway to solve the problem, Dr. Wilson said. His department sees 115,000 patients per year, with 27 percent admitted. Another seven to eight percent are observed. “We can take care of stuff that would tie up an inpatient bed for three days in one day, “ he said. “The hospital appreciates that.”
William Beaumont also uses about 12 emergency department beds after midnight when the census goes down for patients who were on hold, in halls upstairs, or tying up surgical beds in the postoperative unit. “It's an experiment in using emergency department territory,” he said. “We plan to go upstairs with 25 beds.”
The beds can be freed by admitting patients upstairs by 11 a.m. the next day, he said. Discharge lounges also may be used to accommodate patients who are waiting to go home.
“Hallway beds are an important resource,” he said. “You can put 60 patients in the hall, including step-down patients.”
Dr. Viccellio is buoyed by the notion that the problem has been accepted by the entire institution and not just dumped in the emergency department, although he and Dr. Wilson admit it is not a total solution.
“It's a choice among poor choices. There is a real crisis issue with hospital capacity generally and severely in particular areas,” he said.
State rules that limit the ability of hospitals to build new beds constrain their ability to respond to changes in demand, said Dr. Wilson. His hospital cannot add beds now because it cannot obtain a certificate of need.
The state says there are plenty of beds in southeast Michigan, which ignores that patients want to go to well-run hospitals near their homes, Dr. Wilson said.
“As public policy, it makes sense, but it doesn't take into account individual encounters between a doctor and a patient. Individual patients are not going to want care affected because the state feels there are enough beds in a given area,” he said.