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Breaking News: A Hundred (and One) Ways to Clear an ED

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000433391.77280.79
Breaking News
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Christopher Celentano, MD, was working on the federally mandated surge plan for his 160,000-plus visit emergency department when the institution's CEO threw a wrench in his plans. “I need something to use on a daily basis, he said. “We are dealing with surge on a daily basis.”

That sent Dr. Celentano, the medical director of the Office of Emergency Management at Los Angeles County + University of Southern California Medical Center in Los Angeles, back to the drawing board to develop a plan that would not only deal with the immediacy of an unexpected disaster but also the daily demands of crowding and a census that placed serious demands on the department and its personnel.

Dr. Celentano admitted that the plan they were using then did not make a lot of sense, and the first thing they did was find a good measuring tool: the National Emergency Department Overcrowding Study Calculator to the rescue. (See FastLinks.) NEDOCS, as it's known, determines the level of crowding using constants — the number of ED and hospital beds — and variables — total patients in the ED, number of respirators in use in the department, longest admit time in hours, total admits in the ED, and wait time for the last patient called from triage.

The LAC+USC NEDOCS score was divided into five categories instead of the usual six: not busy (50 or less), busy (51 to 100), crowded (101-140), severely crowded (141 to 180), and dangerously crowded (greater than 180). The emergency department assesses its NEDOCS condition every hour, and a special emergency notification system goes into effect to alert designated personnel if the level changes.

Triage protocols are ramped up and the center's auditorium and a field hospital are activated for emergency use at the dangerously crowded level. Residents on elective, administrative, and other county facility rotations help with direct patient care in the ED, and inpatient wards will open beds for patients during the surge or catastrophe. The plan is complicated, but calls for maximum response in all areas. (See FastLinks.)

“It was a controversial plan, and most people outside of the emergency department did not like it,” Dr. Celentano said. “We took a huge chunk of what Peter Viccellio did.”

Dr. Viccellio, the vice chairman and clinical director of emergency medicine at Stony Brook University Medical Center and a professor of emergency medicine at the State University of New York at Stony Brook, was the first to call for an all-hospital response to ED crowding and the patient boarding issues that exacerbate it. He advocated moving patients out of the emergency department to inpatient floors, even if they had to put in hallways.

“The plan was that when we went up to severely overcrowded, bed control would pony up 20 beds,” Dr. Celentano said. “The nurses did go out of ratio. [California laws mandate nurse-to-patient ratios.] It was justified because for our institution, it was a health care emergency if it was crowded in the ED. The charge nurse ended up taking care of those patients. We could decompress those boarding patients.”

The surge protocol was first enacted in the old hospital, and a move to a new facility with fewer beds and a differently configured ED meant a new surge plan, which Dr. Celentano said is now working well, though crowding was so problematic initially that the Los Angeles Times called it “severe” and “intense.” (See FastLinks.)

Dr. Celentano and his colleagues presented the results of their work at the 2013 Society of Academic Emergency Medicine annual meeting, comparing NEDOCS scores for four months before and after implementing the hospital-wide surge plan. The proportion of time during which the emergency department was considered dangerously crowded decreased by 33.2 percent after implementation, and the time it was considered severely crowded decreased by 27.1 percent. Average length of stay in the emergency department went from 11.7 hours to 8.5 hours, and the number of patients who left without being seen declined by 580 patients.

“I think what we did was a novel concept,” Dr. Celentano said. “We said, ‘Here's a crowding meter. You have to respond to it.’ We held everyone accountable. For a glorious period of time, people responded. I think the great thing about the plan was that it showed inefficiencies in the system that have to be addressed. When you collectively as an institution have a goal, you can meet it.”

The study intrigued Ellen J. Weber, MD, the interim chair and a professor of clinical emergency medicine at the University of California San Francisco School of Medicine, who said some EPs see a connection between a disaster and what happens in the emergency department when it is crowded. “In both cases, we don't have enough capacity for the number of patients we have. There is a potential for harm if we don't get to our patients quickly,” she said. “Even we have become complacent about the fact that we have these patients who are boarding in our departments and even more so about the patients in the waiting room we cannot see. In many cases, there has been harm done. Yet we all know when there are disasters, somehow, magically, within a short time, the emergency department clears out. We know our hospitals are capable of this.”

Dr. Weber said that same level of urgency has to be applied to crowding, maybe not with the degree of angst and anxiety that is applied to disasters but still in a way that relieves the ED. “We are not asking them to do extraordinary measures all the time,” she said. “Maybe there is something about the way we respond to a disaster.”

Having a plan like the one at LAC+USC Medical Center means never having to sound the alarm for crowding, she said. “[T]he full-capacity protocol that some hospitals have put into place [means] the hospital knows that if the emergency department gets to a certain point, you move patients out of the ED onto the floor or into the hallways. People comment that this situation often results in a bed for patients at that time or shortly thereafter.”

It's a matter of culture in a way, Dr. Weber said. “If it is made a priority and leadership makes people feel it is priority, it happens. And the methodology is less important than the fact that people are focusing on it. The hospital was willing to do this. That's the biggest hurdle, saying to the hospital that this is a disaster, then it is treated as a disaster. Institutional buy-in is important,” she said. “Yes, you can do it if your management buys in. There may be a hundred ways to do it.”

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