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Ambulatory Care Quarterly
If nurses hoard patients, can you improve flow?
Question: How do we avoid patient "hoarding," in which nurses or physicians intentionally delay moving a patient out to delay the next patient and give themselves a breather? We’ve already warned that hoarding won’t be tolerated, but it still happens and thwarts our efforts to improve patient flow through and decrease waiting time.
Answer: Hoarding patients is an age-old technique for slowing down the workload, and chances are good that all emergency departments (EDs) have been the victims at one time or another, says Marilyn Margolis, RN, MN, director of nursing for emergency services with Emory Hospitals in Atlanta.
But ED managers must work proactively and aggressively to stamp out this practice, because it can undermine all your other hard work, she says.
Hoarding is very different from "boarding" patients until a bed is available elsewhere in the hospital. Hoarding is voluntary and done on the sly. It can be hard to detect because the nurse or physician doesn’t have to do anything overt; simply failing to discharge or transfer a patient as soon as possible can be enough to slow down the process.
"EDs are so overcrowded, and we’re working our nurses and physicians so hard, that it’s almost understandable when they want to take a little bit of a breather, because it’s just constant chaos," Margolis points out.
"But even if we understand why they’re doing it, we can’t let that be the solution because it creates bigger problems," she notes.
The solution is to create incentives for nurses to move their patients, she says. In her ED, the admission policy calls for rotating new patients through each nurse’s zone rather than simply going to the first available bed.
That helps avoid having nurses feel they are penalized for being efficient and clearing beds fast, adds Margolis.
"If you move four patients out quickly, we’re not going to necessarily send you four patients right away to fill those beds, " she explains. "They will go to the zone that is next in the rotation instead of dumping all of them on you."
That strategy has to be flexible so patients don’t back up and empty beds go unused because they’re in the wrong zone; but Margolis says the idea helps reassure nurses that they can move patients out without another appearing instantly.
Using techs in expanded roles
Emory also has increased the use of nurse technicians and expanded the typical tech’s role to include starting intravenous lines, transporting patients, and drawing blood samples. She points out that some EDs employ paramedics for these expanded tech roles.
The ideal arrangement would be a tech devoted to each nursing zone, but Emory doesn’t have quite that many. Nurses benefit from the assistance of the techs, which in turn decreases any temptation to hoard patients, she says.
Emory also is about to introduce a new tracking system for the ED, moving patient flow to the bedside. The triage nurse will handle placement of the patients, allowing the charge nurse to concentrate on patient flow and assist with patient care.
Another idea in the works at Emory is a "discharge expediter." This nurse would take care of discharging patients rather than having the zone nurse be responsible for discharging his or her own patients.
All of those strategies can help take the pressure off of nurses so they are not inclined to subvert patient flow through, but hoarding still can happen. When you detect hoarding, Margolis says you must act. But reprimanding the individual nurse or physician isn’t enough.
"When we see people trying to purposely slow down the flow, we address it in a system way," she continues. "If people are so overworked that they’re trying to slow down the system, we need to see why they want to do that and how your systems can improve. Staff appreciate that philosophy and see that we’re not being punitive, that we want to improve the whole system."
So even at Emory, with all its resources and proactive strategies, does hoarding still happen?
"Oh yeah, it happens," Margolis admits. "If we see it with an individual, we address that person directly, but we don’t make it punitive. We would be more likely to ask, What can we give you to help you expedite patients quicker?’ In our experience, that works better than just coming down hard on the person who was slowing things down."