Ambulatory Quarterly: Use protocol to send inpatient holds upstairs

It was a typical scenario: The emergency department (ED) at Stonybrook (NY) University Medical Center was holding 15 or 20 admitted patients waiting for an inpatient bed to become available. This was a common occurrence, but Peter Viccellio, MD, FACEP, vice chairman of the department of emergency medicine for the school of medicine at State University of New York at Stony Brook, was fed up. "We had a longstanding history with the New York state health department, so I called a senior person," Viccellio says. "I asked in frustration why it’s against health codes to hold patients upstairs in hallways, but it’s OK for us to hold them in the ED," he says.

Viccellio was surprised to learn that no such distinction is made. "It’s a myth that has been perpetuated in hospitals for many years, but there is no specific code against holding patients upstairs," he says. Viccellio asked the official to put this in writing. "They wrote a series of letters saying that holding patients upstairs is encouraged and that boarding of inpatients in the ED is unacceptable," he says. (The letters can be viewed at Click on "Page 1," and "Page 2.")

As a result, Viccellio began lobbying to have admitted patients being held in the ED instead sent upstairs. "It became clear that this was obviously in the patient’s best interest," he says.

"Patients deserve the expertise of the inpatient physician and inpatient nurse." A "full-capacity protocol" was developed that requires patients to be held upstairs, often in the hallway, when the ED is at full capacity. "When we have to see newly arriving patients in our hallway, it is time for patients to be moved upstairs," says Viccellio.

The practice of holding inpatients in the ED came about as a result of lack of clout for EDs in general, he says.

"This practice went on for so long that a new generation of physicians, nurses, and administrators believe that this is the way things are supposed to happen. It makes absolutely no sense whatsoever. It never did and never will." Building a unit adjacent to the ED for overflow admissions is not a real solution, says Viccellio. "You still have the same problem, because there is no inpatient physician and nurse," he explains.

Here are benefits of the full-capacity protocol:

Patients are given better care. ED patients are seen more quickly as a result of the protocol, Viccellio says. "Our driving concern was giving people appropriate medical care," he says. "To force critically ill people to stay in the waiting room for hours so that the hospital can store all the admitted patients in the ED doesn’t make sense." However, the ED still holds inpatients for specialty units such as critical care and respiratory patients, he notes. "The problem that continues to plague us is that the protocol only applies to people we would put in our own hallways. Other patients still remain in the ED because there is no bed for them upstairs. But even given that limitation, the ability to move patients upstairs has a profound affect on diminishing the time patients wait for a doctor."

The full capacity protocol puts the focus on what is best for the patient, as opposed to the competing interests of individual departments, says Carolyn Santora, RN, MS, the facility’s associate director of critical care nursing.

Admitted patients are better served being held on the unit where inpatient nurses can provide appropriate care, says Cheryl A. Barraco, RN, MS, nurse manager of the ED. "For example, if cardiac patients are being held in the hallway on the floor instead of the ED, even though they are not in a room, they are still being cared for by inpatient nurses," she says.

Beds may become available immediately. There are times that departments are overloaded, and there aren’t any beds, Viccellio adds. "But oftentimes, when patients are moved upstairs to the hallway, a bed magically becomes available." This behavior is rampant throughout the hospital industry, he says.

"The bed may become available at 1 o’clock, but it doesn’t get reported until the change of shift," he says. Trying to get patients discharged early and nurses to report an available bed is fighting a losing battle, says Viccellio. "There is no incentive for them to rush or get patients upstairs. Once the problem is put in their lap, then they act to solve that problem."

Length of stay is reduced. The facility did a study which found that the average length of stay for admitted patients held in the ED was 6.2 days, as compared with 5.4 days for the patients moved upstairs, Viccellio reports. "Most hospital administrators would love to get that much of a reduction in length of stay," he says.

Morale of ED nursing staff improves. The full capacity protocol improved morale because ED nurses are freed to care for their own patients, says Barraco. "We aren’t dividing our time between taking care of admitted and ED patients, so we can concentrate on our specialty, which is the care of ED patients," she says.

[For more information, contact:

  • Cheryl A. Barraco, RN, MS, Nurse Manager, Emergency Department, Stony Brook University Hospital, Stony Brook, NY 11794-7400. Telephone: (631) 444-8028. Fax: (631) 444-6271. E-mail:
  • Carolyn Santora, RN, MS, Associate Director, Critical Care Nursing, Stony Brook University Hospital, Stony Brook, NY 11794-7715. Telephone: (631) 444-2922. Fax: (631) 444-6298. E-mail:
  • Peter Viccellio, MD, FACEP, Vice Chairman, Department of Emergency Medicine, School of Medicine, State University of New York at Stony Brook, UH L4-515, SUNY 7400, Stony Brook, NY 11794-7400. Telephone: (631) 444-3880. Fax: (631) 444-3919. E-mail:]