As high-volume hospitals face continual overcrowding and ED boarding problems, leaders are recognizing that change is needed. To resolve logjams, some institutions are turning to a centralized command center model that relies on a nurse navigator to be the ED point person.

Yale New Haven Hospital (YNHH) in New Haven, CT, has adopted the model, centralizing operational decision-making in its Capacity Coordination Center (CCC). The CCC includes representation from key hospital capacity decision-makers and hinges on the use of real-time data about incoming and outgoing patients.

The 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. This point person anticipates clinical services incoming patients may need further down the line and streamlines communication among hospital departments.

YNHH administrators note the CCC has changed the culture, eliminating the previous silo mentality that hindered efficiency. Essential to the hospital’s model is a steady stream of real-time data flowing simultaneously to key decision-makers through the system’s electronic medical record.

The hospital has a large inpatient service and an active ED. As providers struggled to deal with increasing volumes of patients, leaders recognized that they needed to bring key resources and people together under one umbrella, explains Andrew Ulrich, MD, operations director for the department of emergency medicine at YNHH.

Stakeholders in the ED have been big supporters of the approach, Ulrich observes. When the hospital is overcrowded, he says, “it all filters back down to us because we essentially are the front door to the institution.”

YNHH encompasses two separate campuses and two adult EDs within one mile of each other, serving about 150,000 patients a year. Because the system has one major EMS provider bringing patients to the two ED ports of entry, “we were very interested in having improved communications,” Ulrich notes.

Previously, the larger ED served a heavier load of patients while the smaller ED often took in 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 nurse navigator worked alongside the prehospital provider agency to direct ambulance traffic to the facility best prepared to receive specific patients, based on capacity and services. The navigator worked next to the dispatchers, focusing on public safety and public health, explains Thomas Saxa, MSN, RN, patient services manager for the adult ED and supervisor of the nurse navigators at YNHH.

When the CCC opened in the Smilow Cancer Hospital, near YNHH’s primary ED, the nurse navigator role expanded. Now the navigator and the EMS point person are housed together in the CCC. “That relationship is critical, so we moved both over,” Ulrich says.

Besides EMS, the nurse navigator has direct access to staff handling bed management, admitting, environmental services, patient transport, and other operational services. “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,” Saxa explains.

The navigator also anticipates 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.

Essential to the CCC’s operations are rich operational data updated constantly. The hospital’s electronic medical record vendor created dashboards that display available beds at both campuses, the time it takes to clean a bed, transport time, and quality and patient safety indicators. The dashboards also show patients en route, admitted, and being discharged.

The communications aspect is important, as YNHH has complex patient movement challenges. The navigator confers instantly with other operational decision-makers in the CCC and notifies the ED about incoming patients with specific needs. Typically, the navigator corresponds with the charge nurse in the ED or the nurse expediter, who manages flow from the waiting room, Saxa explains.

The full potential of the CCC has not yet been realized, according to Ulrich, although the system has seen some operational metrics improve. “The culture itself is the first big change,” Ulrich observes. “We are light-years ahead of where we used to be because at least we have a shared resource and a shared approach.”

SOURCES

• Thomas Saxa, MSN, RN, Patient Services Manager, Adult Emergency Department, Yale New Haven Hospital, New Haven, CT. Email: thom.saxa@ynnh.org.

• Andrew Ulrich, MD, Operations Director, Department of Emergency Medicine, Yale New Haven Hospital, New Haven, CT. Email: andrew.ulrich@yale.edu.