Create an express admissions unit

Some EDs have found that an express admission unit (EAU) can work in tandem with an observation unit to cut costs and streamline patient care. ED managers struggling to justify the additional resources and staffing necessary for an observation unit can use an EAU for leverage. The EAU can use cross-trained staff, cut costs, and streamline patient care, eliminating the need for an admitting department upstairs.

EAUs simplify admitting procedures by grouping them together in one central location. Patients are registered, have their paperwork done, and the physician’s first set of orders are carried out, finishing the process often started in the ED. This includes labwork, ECG, radiology, first doses of medication, and all initial treatments such as IVs, urinary catheterization, and respiratory treatments.

Staff are cross-trained

At Edward Hospital in Naperville, IL, a total of 26 full-time employees are cross-trained for the observation unit and the EAU. "If one area is a little slower than the other, the staff just rotate back and forth, helping out whichever area needs the most manpower at a given time," says Pat Levan, RN, MS, director of emergency and ambulatory services at Edward Hospital, where the EAU and observation unit are both placed adjacent to the ED.

Each shift, staff are assigned to specific areas, but they may cross over depending on the workload. "That’s given us a lot of efficiency with the staff," says Levan. "We can either send people home early or have them on standby or on call, knowing we can pull from the other area if need be." Staff also enjoy the diversity of working in two separate but complementary areas.

Muhlenberg Regional Medical Center in Plainfield, NJ, opened its first EAU in 1994, which is integrated with the hospital’s admitting department. Two years later, a second "annex" EAU was placed adjacent to the ED. Staff flex back and forth between the main EAU and the annex, which was formerly an ED holding room for patients waiting to be admitted. "It was really wasted space; now it’s a fully functional unit," says Janet Biedron, RN, BSN, MBA, the hospital’s director of admission services. The EAUs have reduced by 20 minutes the average time it takes to get patients upstairs.

If the ED is extremely busy with patients who aren’t appropriate for the EAU, the EAU staff can go work in the ED. "For instance, we don’t take isolation patients in the annex because we’re not set up for that," says Biedron.

The skills required in the EAU are similar to those of the ED. "The nursing staff in the EAU need to have a mindset that things move very quickly with a quick turnover of patients," says Levan. "So, when you are looking at what kind of staff you want to hire, look for somebody who’s worked in an ED."

Getting EAU up and running takes time

Although all three areas require similar skills, it’s a mistake to underestimate the length of time it will take staff to adjust to new areas. "Closing the admission department and having the EAU take over that function was foreign to the staff," says Levan. "There is a steep learning curve, and it’s taken a long time for them to feel comfortable."

To prepare for the EAU’s opening, staff worked in the admitting department doing patient registration. "We also had the patient care technicians work with the labs to learn phlebotomy skills," says Levan. Even with advance training, expect some initial glitches. "Once things are up and running, don’t expect things to be 100% the first day. It’s taken a couple of months to work out a smooth process."

It also takes time for staff to learn to work as a team. "We pulled people from different departments and hired new people, so you’ve got this brand new body of people working together, and it takes time for them to gel," says Levan. Planning activities and projects for the EAU staff to work on ahead of time can help build team skills, she adds.

Experts say having a single manager over both the EAU and observation unit is most effective. "That way, there isn’t any competing between two different managers over how these areas will work," says Levan.

A major benefit to Edward’s EAU was removing the incentive for physicians to send patients to the ED to be prepared for admission. "Before our EAU opened, we had some physicians sending patients to the ED who were really direct admits," explains Levan. The physicians knew their patients would have their labwork, X-rays, and medications started faster in the ED than if they were admitted directly to the floor.

Inappropriate ED visits eliminated

The EAU eliminated the problem, which was causing patient backup in the ED. "Those patients had no reason to be in the ED, so it was really an inappropriate ED visit," she notes. "By opening the EAU, we were able to move those kinds of patients out of the ED."

At Muhlenberg, a similar situation existed. "A lot of the gridlock in the ED was a result of doctors sending in patients they knew they wanted to admit, but they wanted to get testing done in a timely fashion. So we were taking up beds with those types of patients," says Biedron.

The result was a chaotic situation which at times slowed ED traffic to a standstill. "Because admissions on the floors were so time-consuming, they put off getting patients from the ED and seemed to always get them from the recovery room or transfers first," says Biedron. "All these problems compounded each other."

The EAUs have improved patient flow through the ED. Physicians now do a medical evaluation for patients in the annex EAU instead of the ED to determine whether the patient should be admitted. "That way, if the patient is admitted, they’re already in the system or they could be treated and discharged," says Biedron.

The volume of patients in the ED has been reduced. "Between the straight-through admissions the ED doesn’t have to see, and the doctors realizing they can get their testing done just as quickly in the annex as in the ED, they’ve actually seen a decrease in the amount of patients they see in the ED."

Patients generally spend two or three hours in the EAU before going to an inpatient bed. "The goal was to decrease the patient’s length of stay," says Levan. "If we could get done in a couple of hours what was historically taking eight to ten hours, we can have an impact on length of stay."

EAUs can result in significant cost savings. "There’s not a lot of rework, missed orders, or delays in getting medications, which may add to a patient’s length of stay," says Biedron. There is no significant financial investment for the hospital. "We didn’t incur any costs because all the resources we use are simply reallocated from areas which are no longer involved in the admitting process."

EAUs can improve relationships with other departments. "It’s common for us to have 10 or 15 admits at the same time as several discharges," says Cathy Mikos, director for ambulatory services at Swedish Covenant Hospital in Chicago, IL. "Nurses were getting frustrated trying to finish up admissions. Meanwhile, doctors were screaming, ‘Why did it take 10 hours for the patient’s antibiotic to get started?’"

The EAU smoothed over a lot of tension. "All the receiving units are so grateful to have this work done for them," says Biedron. "Their patients are coming in in a good mood now rather than sitting in the ED for hours tired and hungry. They’ve been cared for, and they feel that things are happening."

‘It isn’t rocket science’

The EAU has removed bottlenecks between the ED and the floors. "The ED wants to push the patients out, and the floors want to be able to filter them in when they can fit it into their routine, so they’re at opposing ends," says Biedron. "In fact, if we’re very busy and the patients have to go right from the ED to the floor, that’s when we get the problem because the floors expect this service."

EAUs have increased both patient and physician satisfaction tremendously. "We get letters daily from patients who are satisfied, and physicians rave about it and consider it to be the jewel of the hospital," says Biedron. "It isn’t rocket science; it’s just common sense and fits so easily with what we were doing before."

Edward’s ED physicians are pleased with the EAU’s streamlining of patient care. "We got immediate feedback on physician satisfaction with the turnaround time on getting results back," says Levan. At Muhlenberg, a survey showed that 97% of physicians were satisfied with express admission.

Patients were unhappy with the existing system. "Patients didn’t perceive we had a good team approach between nursing and physicians," says Mikos. A group was formed to consider the concept of an EAU and ultimately submitted a business plan to senior management. "As the word got out, everybody wanted to be involved in this, and we ended up with a task group of 18 people," she recalls. "We didn’t turn anyone away because we wanted to have a lot of buy-in."

When Edward’s EAU opened several months ago, patients who were going to be admitted from the ED were sent there before going upstairs. "After two weeks, we had so many patient complaints that we stopped doing that," says Levan. "The ED patients being admitted felt it was just prolonging their final destination to an inpatient bed." Family members tended to want to stay with patients until they finally got to the floor, which was often inconvenient.

A decision was made to stop sending ED admits through the EAU. "We figured, if they get the same things done in the ED, why have them go through this middleman?" says Levan. "We misjudged that patient population, which was the biggest negative result we’ve had with this. Now, we just send direct admits to the EAU, and it’s working very well."

ED patients who are admitted to the hospital are now prepared in the ED. "We’re trying to carry over the same concept of express admission in the ED with those admits. The nurses in the ED will do the first dose of antibiotics and most labs and X-rays, so most diagnostic testing is already done when the patient gets upstairs."

Flowcharts eliminate bottlenecks

Flowcharts were created that charted all the different ways patients were admitted to the hospital, including the ED, admitting, radiology, the cardiovascular institute, the cancer center, and same-day surgery. "We flowcharted all of those to find the bottlenecks and decide how the EAU would eliminate some of those," says Levan. "In some areas we were able to eliminate five to seven steps in the process."

Later in the process, a flowchart was created that showed the steps involved in an express admission. "First, we had to define the meaning of express admission — it was very different from what we thought of admission in the past," says Mikos. "With an EAU, you have multiskilled workers who do everything except take chest X-rays." Services are being brought to the patient, which simplifies the process.

When implementing an EAU, it’s important to take the individual needs of the ED and hospital into account. "There is no canned recipe for this in any shape or form," says Mikos. "You have to take the concept and mold it and be as creative as you can for your organization."