To handle increasing volumes better, Yale New Haven Hospital (YNHH) in New Haven, CT, has opted to centralize operational decision-making in a new Capacity Coordination Center (CCC). Here, a nurse navigator representing the health system’s two busy adult EDs works with representatives from EMS, admitting, bed management, and other key operations to manage incoming and outgoing traffic optimally and to anticipate clinical services that may be needed further upstream.
- YNHH is the latest hospital to adopt the command center concept, a new approach that is catching on with hospitals that offer a diverse, complex array of clinical services and serve a high volume of patients.
- Essential to the YNHH model is a steady stream of real-time data that are available simultaneously to all key decision-makers through the system’s electronic medical record.
- Hospital administrators note the CCC has changed the culture, eliminating a silo mentality that used to be prevalent in the different hospital departments, hindering efficiency.
It is a common and justifiable refrain of ED leaders faced with perpetual boarding problems: It is not an ED problem, it is a hospital problem. True enough, but how should one resolve such continuous logjams? A small but increasing number of institutions are buying into the concept of a centralized command center that includes representation of all hospital key capacity decision-makers and real-time data on incoming and outgoing patients.
The latest example of this approach is the Capacity Coordination Center (CCC) at Yale New Haven Hospital (YNHH) in New Haven, CT. “We have a very large inpatient service, a very busy, active ED ... and there has been increasingly more struggle as the volumes have increased and more patients are coming into the system,” explains Andrew Ulrich, MD, operations director for the department of emergency medicine at YNHH. “About a year and a half ago, there was some talk in a number of different areas about the need do just this, bring all these resources and all these people together in one area.”
Stakeholders in the ED have been big supporters of the approach and helped drive the move to establish the CCC, Ulrich observes. “We feel the greatest effects when the hospital is overcrowded and we are not working as efficiently as we can,” he says. “It all filters back down to us because we essentially are the front door to the institution.”
Address Unique Stresses, Demands
Officially launched in October 2017, the CCC was very much a work in progress early on, according to Ulrich. “We were trying to figure out how to do it, who needs to be part of it, and what systems and resources need to be in that room,” he explains. “Several of us visited places around the country that have done this in a successful manner.” One of the places that YNHH representatives visited multiple times was the sophisticated Capacity Command Center at Johns Hopkins Hospital in Baltimore. That center, developed in coordination with GE Healthcare Partners, opened in 2016. “One of the things they are very, very good at is the very timely use of data that is in front of the people in the room. That is one of the keys that our model is trying to bring forward,” Ulrich says. However, he stresses that each health system that has opted for this approach has customized a solution to fit its own unique stresses and demands.
For example, YNHH encompasses two separate campuses and two adult EDs that are within one mile of each other. Together, these two EDs serve about 150,000 patients per year. “We have one major EMS provider that brings patients to us, so we were very interested in having improved communications with [EMS] because YNHH has two ports of entry,” Ulrich notes.
Previously, the larger of the two EDs would serve a heavier load of patients while the smaller ED would tend to intake fewer patients than it could handle. “As the whole discussion about the CCC was starting to take seed and blossom, we were working with our own group to develop a nurse navigator role,” Ulrich says.
Originally, the job of the nurse navigator was to work alongside the prehospital provider agency to direct ambulance traffic to the facility best prepared to receive specific patients, based on capacity as well as specific services available.
“The [EMS agency] was kind enough to put [the nurse navigator] there. We were right next to the dispatchers,” explains Thomas Saxa, MSN, RN, patient services manager for the adult ED at YNHH and the person who supervises the nurse navigators. “We were able to balance our volume load by directing ambulances to one of our campuses or the other, whichever was best equipped to handle that patient with that particular complaint at the time.”
In that role, the nurse navigator primarily was focused on public safety and public health, Saxa adds. “Why take a patient to a crowded ED when there is an ED a half-mile away that has open rooms and is ready to go?” he asks. “The role was really designed with the public in mind.”
However, with the opening of the CCC, which is housed on the fifth floor of Smilow Cancer Hospital, not far from YNHH’s primary ED, the responsibilities of the nurse navigator have expanded. “We pushed real hard to bring that person up to the CCC, to sit [him or her] right next to the people assigning beds and to the people doing all the other types of activities that affect how we are able to handle patients in the ED,” Ulrich explains.
Along with the nurse navigator, the point person for EMS also is housed in the CCC. “That relationship is critical, so we moved both over,” Ulrich says. “The hospital did some necessary electronics and IT work to have the communications system that [the EMS provider] uses brought over as well so [EMS] can handle their responsibilities in our own hospital.” The EMS representative sits next to the nurse navigator in the CCC, but the navigator also has direct access to the person handling bed management, admitting, environmental services, patient transport, and other operational services. “Now, the navigator can not only direct ambulances, but we also have [him or her] working with bed management,” Saxa explains. “We understand what beds are coming open, what is being cleaned, and what is in the pipeline so that we know how to shift our patient volume.”
This enables the navigator to anticipate services needed further upstream when determining which campus can better accommodate incoming patients with specific clinical needs. “For example, if there is abdominal pain in a young male that sounds like it could be appendicitis, the navigator now knows what operating room is open and where they can send that patient. For orthopedics cases, they know where these services are better equipped at certain times of the day to handle the patients coming in,” Saxa observes. “If ICU beds are full and not expected to open for another 12 hours at one campus, but we have another campus with three ICU beds open, then a patient [requiring ICU care] is better served at the campus with the open ICU beds.”
Another key to the nurse navigator role is that it is shared among experienced nurses who come from both campuses, Ulrich says. “The two hospitals merged four or five years ago. It has been a continued work in progress to sort of change the culture from the two separate EDs to one big ED with two points of entry,” he says. “I think having the nurse navigator upstairs who is overseeing this for both sides has really been a big step in unifying our activities.” Currently, the navigator is on staff in the CCC for 16 hours a day, from 7 a.m. until 11 p.m., but administrators anticipate that these hours will be expanded. “Originally when we did this, we weren’t sure where [the role] would go and what the success would be, so we committed to 16 hours while the nurse navigator was still stationed [with EMS],” Saxa notes. “We didn’t realize the value in it until we pulled the role into the CCC. Now, we are really starting to see it.”
In the coming year, plans include a nurse navigator eventually working on site in the CCC around the clock. “We find that ambulance traffic is just better managed throughout rather than [ending the CCC presence] at 11 p.m., and then having more arbitrary destinations,” Saxa says.
Essential to the CCC’s operations is a rich source of operational data that are updated constantly in real time. The hospital worked with its electronic medical record (EMR) vendor to create electronic dashboards that display information pertaining to available beds at both campuses, the time it takes to clean a bed, transport time, and quality and patient safety indicators. Additionally, the dashboards reveal which patients are on their way to the hospital, which patients have been admitted, which patients are being discharged, and which ambulances are just heading out to respond to calls. “We are all on the same EMR. Everybody is accessing that same data and we are aware of things at the same time,” Ulrich notes.
While everyone can access the data, the navigator can confer instantly with other operational decision-makers in the CCC. Also, the navigator regularly engages in phone conversations with the ED to discuss alternative scenarios regarding patient placement or to notify decision-makers in the ED about incoming patients with specific needs. Typically, the navigator will correspond with either the charge nurse in one of the two EDs or the nurse expediter, a person who manages flow from the waiting room, Saxa explains.
“The nurse navigator upstairs is acting as a conduit and a communicator with the other parts of the hospital, [making] it easier for us to convey information about what is happening in the ED with the other services within the hospital,” Ulrich says. “There is a better sharing of information to make decisions about who can go upstairs, who is the next person to get a bed, and things like that.”
The communications aspect becomes increasingly important in health systems as large and multifaceted as YNHH.
“We are very complex, both in the ED as well as in the entire hospital with regard to patient movement because there are so many different clinical services upstairs and there are different beds assigned to different types of patients,” Ulrich says. “Within the ED, when we are in our very busy crowd-surge models, which is what we are in very frequently now, we are moving patients within the ED.”
For example, patients may be moved to one area for boarding to create care space in another area, Ulrich explains.
“Some of that involves handing off the care of patients to the hospitalist service, which then may take on the care of the patients while they are still down in the ED,” he says. “It is all very complex because there are so many moving parts.”
Change the Culture
The CCC already has been tested in some ways. For example, on Aug. 14, when a flood of overdoses racked New Haven, prompting a high volume of ambulance traffic to the two YNHH EDs until about noon on Aug. 16, the CCC was instrumental in effectively balancing the crush of patients between the two hospital sites.
“There was what could only be described as a mass overdose involving 60-plus patients in a short period of time,” Saxa recalls. “I am not sure what the drug was, but [the patients] thought it would be K2, [a potent synthetic compound that produces a marijuana-like effect], but it was probably something else, and it caused some very bizarre reactions and overdose symptoms.”
Since the navigator on duty that night was sitting next to the supervisor for EMS, who in turn was in direct communication with the ambulance crews, there was direct feedback from the scene of the overdoses as well as the two EDs.
“It really kept both [EDs] operating at maximum efficiency well into the night, whereas [under the old arrangement], that would have crippled one or both EDs for a good 12- to 24-hour period before we dug out,” Saxa explains.
In that incident, most patients were able to be treated and discharged home, although some patients overdosed a second time and returned to the ED.
“Had there been higher severity or some patients requiring more prolonged care that required hospitalization, then certainly the CCC would have been very involved with how to get [patients] upstairs and where to get them upstairs,” Ulrich notes. “Even so, the CCC was helpful because everybody knew right away together what was happening. We didn’t have go out and tell people.”
It will take some time for the full potential of the CCC to be realized, according to Ulrich.
“The early part of this is just getting people in the same room and learning how to share data together. We are really getting good at that,” he shares.
“Transparency was a big part of this because [in the past], when we all got busy and everybody really got stressed, not knowing exactly what someone else was seeing, doing, and acting on sometimes inhibited our ability to be effective. Now, by putting everyone in the same room and having all these services sharing the same data, we know that everyone is working off the same information.”
The CCC has produced a positive difference on some operational metrics, but the model is not yet mature enough to make definitive conclusions on effectiveness, Ulrich observes.
“We are now just starting to cross over from the data-sharing to the point where we can start to enact different activities and plans,” he says.
For example, the CCC has put YNHH in a position to develop a very structured, tiered surge plan for when the system gets busier to the point when patients begin to board in the ED.
“That is one of the real benefits of the CCC, which is [being able to] develop further plans and further structure for how to change our day-to-day operations when things are not going as well as they should,” Ulrich says. “As we start to do this more, I think we will be able to pull some very specific metrics around LOS, throughput, and boarding hours ... and to be able to say we are really making a difference. We are not there yet, but we are very close.”
While there is much work left to do in developing the CCC concept, the approach already has helped YNHH rid itself of a silo mentality whereby each department made its own decisions independently, Ulrich says.
“The culture itself is the first big change,” he says. “We are light-years ahead of where we used to be because at least we have a shared resource and a shared approach, which is much more than we had a short period of time ago.”