Take the lead in helping to remedy ED crowding, diversion, boarding

Efficient patient throughput is the key

Hospital case managers are in a unique position to help their hospitals find solutions to the ever-increasing problem of overcrowded emergency departments (EDs), emergency department diversions, and boarding admitted patients in the emergency department because there are no available beds, says Toni Cesta, PhD, RN, FAAN, vice president of patient flow optimization for the North Shore-Long Island Jewish Health System. Cesta is responsible for patient flow at 15 hospitals in the Great Neck, NY-based system.

The recent Institute of Medicine report on the crisis in emergency care points out what many people in the hospital field have known for some time — that patient flow is a tremendous issue that affects patient care, patient satisfaction, quality, and safety, she adds.

The report, Hospital-Based Emergency Care: At the Breaking Point, one of three reports issued in June by the Institute of Medicine of the National Academies (IOM), calls for action to bolster the country's emergency care system.

The demand for emergency care grew by 26% between 1993 and 2003 according to the report. Over that same period, the number of EDs in the nation's hospitals declined by 425. In 2003, nationwide, ambulances were diverted 501,000 times — an average of once every minute — because of overcrowded EDs.

"Emergency department overcrowding in a typical situation isn't due to what is going on in the ED; it's caused by patient flow deficiencies on the hospital side," Cesta says. "Patient throughput is a complicated problem affected by many factors, and it's an issue where case managers can show their value to the hospital."

The IOM calls for hospitals to reduce ED crowding by improving hospital efficiency and patient flow. It recommends that the Joint Commission on Accreditation of Healthcare Organization reinstate strong standards for ED boarding and diversion and that the Centers for Medicare & Medicaid Services develop payment and other incentives to discourage ED boarding and diversion.

Patient flow standards from the Joint Commission, which went into effect Jan. 1, 2005, call for hospitals to develop plans to overcome any roadblocks to efficient patient flow throughout the hospital.

"The standard requires hospital leaders to identify all of the processes critical to patient flow through the hospital system from the time the patient arrives, through admitting, patient assessment and treatment, and discharge and includes such issues as diagnostic, communication, and patient transportation procedures," says Dennis S. O'Leary, MD, president of the Joint Commission.

The IOM report expressed concern about "emergency room boarding," in which patients who have been admitted are held in the emergency department, sometimes for more than 48 hours, because there is not an available bed.

"It's a huge patient safety issue. We know from a quality of care and patient safety perspective that these patients don't get the same level of care in a holding pattern as they do in a regular inpatient bed. The emergency department isn't ramped up to deal with inpatients, and they don't focus on them," Cesta says.

Patient flow roadblocks occur on the front end with delays in getting patients worked up, diagnosed, and treated and on the back end when discharge is delayed, she says.

Hospital case managers have numerous opportunities to expedite patient flow in the emergency department, on the floor by assuring that procedures and other patient care take place in a timely manner, and by starting discharge planning early in the stay so the patient and family are prepared when the discharge orders are written.

"Case managers are in the best position to assume the role of seeing that patient flow is efficient. The nurses are busy providing daily care. The physicians aren't on the floor all the time. It's one of the value-added functions that case managers can bring to the table," Cesta says.

Hospitals need to have a good understanding of what is delaying patients getting through the emergency department portion of the stay, and consequently should be aware of the roadblocks throughout the hospital stay, she notes.

Cesta advises case management directors to look at all of the inpatient care processes and determine the inefficiencies. Develop metrics for assessing inpatient throughput and the roadblocks to a timely discharge, and then come up with ways to alleviate the problems and track the outcomes, she says.

Case management software programs that can help you track delays and other throughput issues are essential in today's hospitals, Cesta adds.

Cesta suggests that the case management leadership approach hospital administration to invest in software to help identify where the process gaps are.

"Collecting data helps us see where process improvement needs to take place. We have to identify where the gaps occur so we can fix them. We need data to help us understand where the inefficiencies are so we can take steps to correct them," she says.

Hospitals need ED case managers who are dedicated only to the emergency department, Cesta says.

ED case managers can identify patients who are inappropriate for admission and arrange post-discharge community services, such as home health care and nursing home admissions. They can facilitate the care of the appropriately admitted patients and their transfer to the floor.

"People are starting to realize that hospitals need case managers in the roots of entry to the hospital, especially the emergency department," Cesta says.

A case manager in the admitting office can be helpful if the majority of the hospital's patients come through there, she adds.

Cesta recommends that hospitals determine periods of high occupancy in the emergency department and assign a dedicated case manager to the ED during those hours. Typically, the high-volume times occur between 11 a.m. and 11 p.m. or noon and midnight.

If social workers are assigned to the emergency department, a social worker could come in earlier to fill the morning gap, she suggests.

"Patients who are potential social admissions or who have other psycho-social problems may wind up sitting in the emergency department overnight. The social worker could come in the next morning and deal with those issues," Cesta says.

Bed management and bed tracking are important as hospitals tackle patient flow solutions.

Bed-tracking nurses are dedicated to making sure that beds are turning over in a timely fashion and that housekeeping is alerted when a bed is available for cleaning.

Backlogs in admissions occur when housekeeping doesn't know when to clean and nobody lets admitting know when a bed is available, Cesta adds.

"The case manager's role has always been to optimize each day that patients are in the hospital and to see that things get done in a timely fashion," she says.

But in many hospitals, case managers are spending their time doing insurance reviews, instead of concentrating on moving patients through the continuum, she adds.

"Most case management departments are understaffed because the administration doesn't understand the value of case management, and we in the field haven't quantified what the case manager does," she says.

In addition to discharge planning so patients can go home in a timely manner, hospital case managers should work to make sure patients get the tests and other procedures they need to begin treatment.

High occupancy rates

Cesta cautions that timeliness of services is likely to slow down and lengths of stay increase when a hospital's occupancy rate exceeds 90%.

"High occupancy rates put the hospital at a significant disadvantage in terms of patient flow. There are the same number of MRI machines, stress machines, laboratory workers, and more patients lining up for the services. Patients end up waiting longer for tests and staying in the hospital longer," she says.

The reasons for the emergency department crisis are numerous, with roots in the health care crisis affecting the country, Cesta points out.

Many times patients can't access their physician in a timely manner. If they have a sick child and it's after hours, they're likely to be directed by their physician to seek care in the emergency department.

Many patients, particularly Medicaid recipients, use the emergency department as their first source of health care, automatically going there instead of to a clinic or a primary care physician. Then there's the problem of the uninsured who don't make enough money to afford health care insurance and come to the emergency department for care. Federal guidelines say that hospitals can't turn them away.

As the number of emergency diversions has gone up, length of stay has started to creep back up incrementally, Cesta says.

"Hospitals are being hit with a double whammy. More people are going to the emergency department, and the hospitals are experiencing longer inpatient stays. The problem is compounded by a shortage of community resources. There is a lack of nursing home and subacute beds, and many patients may not have home care benefits," she says.