Are you aggressively addressing ED crowding? JCAHO says you must

Poor patient flow is dangerous, and no longer just an ED problem

Is your hospital’s emergency department (ED) reporting record diversion hours, with patient volume and acuity higher than ever? Is the practice of holding admitted patients for long periods in the ED becoming the rule rather than the exception?

If so, this can have a profoundly negative effect on quality of care in your organization. "Poorly managing patient flow can impact vulnerable areas, such as the emergency department, where overcrowding can occur and create an environment with patient safety issues," warns Robert Wise, MD, vice president for standards at the Joint Commission on Accreditation of Healthcare Organizations.

Now a new leadership standard from the Joint Commission calls for you to implement strategies to address ED overcrowding by managing patient flow throughout your organization. The new standard takes effect Jan. 1, 2005.

As a quality manager, you now must incorporate ED overcrowding into your performance improvement activities. That means using performance indicators to predict and monitor the capacity of areas that receive emergency patients and planning for the care of patients placed in temporary beds.

It’s not just the ED

Many quality managers still consider overcrowding, diversion, and boarding of admitted patients an "ED problem," says Kim Shields, RN, clinical systems safety specialist at Abington (PA) Memorial Hospital. "Often, there is a disconnect between the ED and hospital inpatient side," Shields adds. "We need to stop thinking of ourselves as silos, and recognize we are one entity, not two separate entities."

The Joint Commission standard initially was referred to as the "Emergency Department Overcrowding" standard, but as a result of comments after a June 2003 field review, the standard’s name was changed to "Managing Patient Flow" to more accurately characterize the problem.

"While the emergency department is a vulnerable area when patient flow issues occur, the improvements needed lie in organizationwide changes rather than changes solely in the emergency department," Wise underscores.

In addition, a 2003 report from the Washington, DC-based General Accounting Office found the inability to move patients out of the ED into hospital beds was a key factor contributing to overcrowding.1

To effectively address ED overcrowding, use these effective strategies:

• Look outside the ED.

At Scottsdale (AZ) Healthcare, a "Patient Throughput Project" has achieved dramatic results by addressing overall capacity in the hospital. "We could improve all we wanted to in the ED; but if you don’t have any place to move patients, they are going to sit in the ED," says Sylvia Bushell, consultant for organizational effectiveness. "We saw that we needed to improve overall capacity."

Project leaders identified three key areas to improve capacity: discharging inpatients earlier in the day; streamlining the process of getting a patient admitted from the ED; and improving management of bed control.

Here is a partial listing of some of the changes that were made:

— Mobile phones are used to give reports. While the process to admit patients to the hospital used to require as many as nine separate phone calls, now only a single call is made, Bushell reports. "Fewer calls are made because the ED and floor supervisors have mobile phones to communicate and give reports on," she says.

— Guidelines were developed for admission to each floor or unit.

— Discharge alerts were put on patient charts to give priority to patients about to be discharged.

— Carpets were removed to make room cleaning faster.

— Transporters now alert housekeeping that a room is ready for cleaning when they move a discharged patient out of the room.

During the organization’s 2003 survey, Joint Commission surveyors had good things to say about the changes being implemented. "They liked what we had done and thought we were headed in the right direction," Bushell adds.

• Look at the process from the patient’s point of view.

All process changes were made with patients’ viewpoints in mind. "We asked ourselves, How can we only ask for information one time instead of four or five times?’ We documented all the times patients were asked the same questions repeatedly and designed our processes so we ask as few times as possible," she says.

• Use trigger points to avoid diversion.

A tool was created to standardize the decision to go on ED diversion. "Before we created this tool, going on diversion depended on individual preferences and perceptions," Bushell explains.

Despite significant improvements in managing capacity, there still are times when patients can’t be moved into the hospital because of lack of beds, she says. To address this, an action plan was put into place for when bed availability does become scarce. "We set up a process for what specific people need to do when we get down to X number of intensive care, telemetry, or med/surg beds, and when we get down to Y number of beds," Bushell adds.

The action plan identifies trigger points, which call for specific actions to avoid ED diversion or holding of patients.

The Trigger Point Tool is as follows:

Green = All beds are open. No triggers are in place. Beds are assigned as usual.

Yellow = 10 to 20 beds remain in the hospital. The bed control manager implements discharge holding areas, assesses potential ED admits, stops accepting transfers from other facilities, and starts a standby list of direct admits. Nurse managers and supervisors, ancillary departments, and on-call staff are notified that this trigger point has been reached.

Red = 0-5 beds are available. Nursing directors implement the following as needed: Floors accept a boarder patient, lists are created of stand-by direct admits and elective surgeries, and a case manager is contacted to evaluate these cases.

The nurse directors also notify the administrator on call, chief of surgery, chief of medicine, community physicians, and ancillary departments so they will increase staffing and service levels.

The trigger points are guidelines and not hard-and-fast rules, Bushell adds.

"Everyone involved in their development agreed that lots of judgment is needed for when each of the trigger points will be implemented," she says. "By outlining the people responsible during each trigger, the actions to be taken, and who needs to be notified, a plan exists for the most frequent capacity situations."

• Use real-time communication to monitor capacity.

"Bed control huddles" are held four times a day during peak times and three times a day on a regular basis. All unit and floor supervisors, ED and surgery supervisors, and bed control staff attend the huddles, which last only five or 10 minutes, to share discharge status for each floor and the number of beds needed for the ED and surgery. "Establishing this communication process has been one of the essential success factors for managing capacity," Bushell says.

In addition, stoplights are posted at every interior doorway entrance in the hospital with red, yellow, and green color codes used to indicate the number of beds currently available. Each light consists of three bands of color about 4 x 6 inches in size situated high on the wall. "They are unobtrusive unless one knows to look for them," says Bushell. "But physicians and staff can look up and know immediately that if it’s red, we are very low or have no beds; if it’s yellow, we are getting close to red; and if it’s green, there are beds open and there is no problem."

If the light is red, floors are asked to board a patient while waiting for a patient to be discharged. "The goal is always to keep patients flowing from the ED into the hospital," says Bushell. "It is now an exception for us to hold patients for long periods in the ED, and our length of stay is pretty short compared to many EDs."

• Educate all staff about ED crowding.

Often, inpatient staff do not have a true understanding of what goes on down in the ED, adds Shields. "We are not working as a true team, and we have to break down those walls," she says.

To address this, Shields is developing a three-minute video for all staff to watch during orientation, depicting the entire process of a patient being admitted from the ED. "You’ll find that the inpatient side does have the ability to tighten up and get patients in a little faster, if they understand the impact this has on the backflow and overcrowding in the ED," she says.

• Ensure the same level of care is given to admitted patients in the ED.

When the decision is made to admit an ED patient, the Joint Commission requires that the patient receives the same level of care as he or she would as an inpatient. For example, an interdisciplinary admission assessment has to be done within a certain number of hours, and an interdisciplinary plan of care must be documented. In addition, the same staffing ratio should be provided as if the patient were upstairs, as you should not have two different standards of care.

At Scottsdale Healthcare’s EDs, if patients are going to be held for more than four hours, they are moved to a central area where an inpatient nurse provides the same level of care as if the patients were in a bed on the inpatient unit. If an inpatient nurse is not available, the ED may need to supply the nursing staff, but this would be in addition to the staff allocated for the ED, says Mary Kopp, ED service line manager. "We have been proactive to assure patient-to-nurse ratios and monitor staffing levels to assure quality care is delivered."

• Address ED delays.

Although patient flow is an organizationwide problem, delays in the ED do have to be addressed, Kopp says.

According to new statistics from the Centers for Disease Control and Prevention (CDC), EDs are experiencing record volumes, with more than 110 million ED visits in 2002 — an increase of nearly 3 million over the previous year. Patients also are sicker, with a greater percentage of patients being classified as emergent and urgent, and they are spending more time in the ED. The CDC report found that two-thirds of patients spent one to six hours in the ED, with the average duration of a visit lasting 3.2 hours.2

After overall capacity was addressed, Scottsdale’s project leaders turned their attention to the EDs in the two-hospital system, using a multidisciplinary approach.

"We involved all the stakeholders, including pharmacy, laboratory, radiology, transport, housekeeping, technicians, physicians, cardiovascular, nursing, and respiratory," says Bushell. "We had everyone involved, anytime we met."

Three main areas were addressed in the two EDs: Improving lab turnaround time, radiology turnaround time, and overall patient flow. The following changes were made:

— The laboratory initiative focused on the period of time from obtaining specimens until they are on an instrument. "The flow into and through the lab to the instruments was streamlined," Bushell says. "A new central processing area will enable the lab to know where specimens are in the lab at all times." In addition, several instruments will be moved for more efficient flow of specimens through the lab.

— The radiology initiative addressed communication, prioritization of orders, root causes of delays, and turnaround times. "The volumes require radiology techs dedicated to the ED. Ongoing problem-solving meetings are being held between radiology and the ED," she notes.

During the process for both lab and radiology improvement, work environments were organized using 5S quality principles — originally developed in Japan.

The ED has its own trigger points used to monitor bed availability and determine which actions are needed by other departments. "This process assures everyone is on the same page and working for the same goal — to assess bed capacity and decompress the ED," Kopp says.

There are three trigger points for the ED:

1. Green indicates that more than six beds are open in the treatment areas.

2. Yellow means that six beds are available.

3. Red signals that no beds are available.

"Each trigger has identified roles to assist movement of patients and staff allocation to an area to assist with admission, discharge, or treatments in flow of patients," she notes.

As a result of these and other changes, the average wait time for patients who were ready to leave the ED and be admitted decreased from 75 minutes to 23 minutes, and the ED’s average length of stay has gone from six to eight hours to two to four hours.

"This has improved patient satisfaction at both campuses," Kopp concludes. "Our diversion hours remain one of the best in the area and decreased 42% with implementation of the trigger points."

[For more information about improving patient flow in your organization, contact:

Sylvia Bushell, Consultant for Organizational Effectiveness, Scottsdale Healthcare, 3621 Wells Fargo Ave., Scottsdale, AZ 85251. Phone: (480) 675-4590. E-mail:

Mary Kopp, ED Service Line Manager, Scottsdale Healthcare Shea, 9003 E. Shea, Scottsdale, AZ 85260. Phone: (602) 227-0510. E-mail:

Kim Shields, RN, Clinical Systems Safety Specialist, Abington Memorial Hospital, 1200 Old York Rd., Abington, PA 19001-3788. Phone: (215) 481-4378. Fax: (215) 572-9087. E-mail:

The complete report Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities is available free at the United States General Accounting Office web site at Click on "GAO Reports," "Find GAO Reports," "GAO Reports," and type in "GAO 03-460" without the quotation marks. Single printed copies of the report are available at no charge. To order, contact U.S. General Accounting Office, 441 G St. N.W., Room LM, Washington, DC 20548. Phone: (202) 512-6000. Fax: (202) 512-6061.]


1. The Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary. Web site:

2. U.S. General Accounting Office. Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. GAO-03-460. Washington, DC: March 14, 2003.