ED gets patients upstairs in 60 minutes or less

Getting floor nurses to accept patients without delay is a major roadblock for almost every ED, but specific steps can be taken to avoid this problem, according to James Espinosa, MD, FACEP, medical director of the ED at Overlook Hospital in Summit, NJ. (For more on getting patients admitted faster, see ED Management, July 2000, p. 80.)

There is no chance of reducing delays in the ED unless the admission cycle time is decreased, argues Espinosa. "If you block the receptor sites to accept new patients in ED by holding patients excessively, then the functional capacity of the ED is essentially eaten up," he says.

At Overlook’s ED, the admission cycle time ranged from 3½ to four hours, according to Linda Kosnik, RN, MSN, CS, chief nursing officer for the ED. The ED set a goal of reducing the time from "decision to admit," to "transfer to unit bed" to less than 60 minutes, she says.

Here are the changes made to achieve that goal:

1. Delays were measured. First, baseline data were collected in "bite-size pieces," says Kosnik. The following times were measured: when the decision is made that the patient will require a bed; when the patient is assigned a bed; and when the patient actually leaves the ED. Each time period was broken into more components, so that specific obstacles could be identified.

Now that the goal of a 60-minute turnaround time has been reached, admission cycle times are routinely collected in real time as part of the ED tracking system, says Kosnik. "If it goes over 60 minutes, we immediately evaluate what the holdup is, whether it’s someone not sending report or the ED not sending the patient upstairs." (See "Admitting Process Flowsheet/Feedback Form" and "Admission Report," inserted in this issue, and ED admission flowchart, p. 106.)

2. Bed control was brought under the ED’s authority. Bed assignments were made part of the ED tracking system so ED staff are kept informed as beds become available, Kosnik reports. "The reason you need that is because 40% to 60% of admissions come from the ED," she says. "So the only way the ED can control the flow is by having a visual picture of what is going on through the whole hospital."

That makes the ED aware of admissions coming from other areas, says Kosnik. "There is a tendency to blame the inpatient side for everything," she adds. "Admissions discharges tend to appear in a lump- sum total, and this allows you to watch for that." It also keeps the floors from hiding beds, Kosnik adds. "This way, you know who is going in and who’s going out."

3. The role of "czarina of bed control" was created. Kosnik serves as the point person in the ED to resolve any problems that arise. "The goal is to find the beds to put patients in," she notes. A bed controller follows up on bed availability, she explains. The bed controller at Koznik’s ED is a secretary, she says.

The "czarina" ensures that things are moving along and supports the bed controller. "We still allow the nursing staff on the units to assign the beds," she says. "I only get involved if the bed controller is meeting resistance."

The ED tracking system measures cycle times (giving a continuous visual display in 15-minute data points with bar graphs) to make sure they fall within certain limits, says Kosnik. "If we are not meeting those parameters, then the czarina is called and asked to intervene. But we’ve only had to do that a couple of times. Eventually, the units realized we meant business."

Interventions usually are handled at a staff level, Kosnik stresses. "We don’t want this to be a hierarchical program," she says. "We want the core process to be at the staff level so they can converse with each other when problems arise."

4. Registration and housekeeping were decentralized. Registration for all direct admits is now handled on the floor, Kosnik says. "That’s a significant patient satisfaction component, because the patient goes directly to the floor and is given a bed assignment, as opposed to waiting in the ED."

A common excuse from the floors was that beds weren’t ready, so a housekeeping staff member is assigned to clean the beds on each unit as his or her primary responsibility, she says. "As a result of that, we can turn beds around much more quickly now."

Previously, a core group of housekeeping staff cleaned beds throughout the institution, not in any order of priority, explains Kosnik. "There might be four beds to clean on the 10th floor, but we need beds on the second floor." Now, the resource nurse on each unit prioritizes bed cleaning, she says. "They know where the assigned beds are located. This way, beds are cleaned on each unit as soon as they are empty."

5. Discharge holding was eliminated. Holding patients who are being discharged from units can slow the process, says Kosnik. "This tends to hap- pen in most facilities unless somebody is watching, because it’s a matter of convenience for the nursing staff."

Now the ED can access a list of patients who are being discharged in real time. "If we see there are 12 discharges from one unit at once, we know there is a problem, because they should be discharging patients in real time," says Kosnik. "The floors should not be waiting until a change of shift to put discharges into the system. That’s a way of hiding beds."

Executive Summary

The ED at Overlook Hospital in Summit, NJ, reduced admission cycle times from 3½ to four hours to less than 60 minutes.

• Although nursing staff members are encouraged to resolve problems on their own, the "czarina of bed control" serves as a point person in the ED to resolve significant problems.

• A housekeeping staff member is assigned to clean the beds on each unit in order of priority.

• ED staff have access to real-time information about patients being discharged from the floors.