Comply with accreditation standards for inpatients

As if caring for critical-care patients for extended periods in the ED wasn’t enough of a challenge, you also have requirements from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations to worry about, says Colleen Bock-Laudenslager, MS, RN, an ED nurse at Redlands (CA) Community Hospital and Redlands, CA-based consultant who specializes in staffing.

Once the decision is made to admit the patient, an interdisciplinary admission assessment has to be done within a certain number of hours, she says. The Joint Commission also requires that inpatients have an interdisciplinary plan of care documented, she says. ED nurses may not be familiar with those specific requirements, she says. "More and more, the Joint Commission has said that once the disposition has been made in the ED to admit the patient, that is when the clock starts for meeting inpatient standards," says Bock-Laudenslager.

This means that you not only have to learn the standard policy and procedures for inpatients, but also comply with all the regulations, she adds. You may receive training on how to implement the interdisciplinary plan of care, but if you don’t complete these every day, it takes longer to do, she explains. As holding critical care patients in the ED is becoming more common, surveyors are zeroing in on this area, warns Bock-Laudenslager. "They are pulling ED charts and making sure you are providing the same standards," she says.

Once the decision has been made to admit the patient, you’ll also need to provide the same staffing ratio as upstairs, as you should not have two standards of care, says Bock-Laudenslager. In other words, if a patient is going to be admitted to the ICU, and the requirement is one ICU nurse to two patients, you should configure the same staffing plan in the ED, she explains. "Often, this is next to impossible," says Bock-Laudenslager.

She recommends the following to standardize care across the continuum:

• Use pre-printed admission orders or clinical pathways for your high-volume diagnoses.

• Give ED and ICU nurses the same type of training. On competency days at Redlands, ED and ICU nurses go through stations together for managing pacers, defibrillators, central lines, and procedures related to sedation and pharmacology, Bock-Laudenslager reports.

• Put the ED and critical-care departments under one organizational structure. This allows for standardization of equipment, and provision of education and training along the same curriculum lines, she explains.

• Ask administrators to hire critical care nurses to create a "hybrid of ED and critical-care talent" in your department. Redlands Community Hospital has used this strategy in its ED, she reports. "We learn from each other every day," adds Bock-Laudenslager.