Three strategies to reduce overcrowding and gridlock

Want to cut your diversion hours down to zero? That’s exactly what Hoag Memorial Hospital Presbyterian in Newport Beach, CA, has done by instituting its emergency saturation triage, or Code EST. When Code EST was implemented in July 2000, diversion hours were about 130 monthly.

There are multiple reasons to reduce diversion hours. Missed service and revenue opportunities are two, says Marty Karpiel, FACHE, FHFMA, president of Karpiel Consulting Group in Long Beach, CA.

And always keep in mind why you’re there, says Ray Ricci, MD, FACEP, an ED physician at Hoag Memorial. "To deny patients access to care is contrary to the hospital’s mission," Ricci says.

Here’s how the successful Code EST process works: "Once the ED approaches saturation, and while we are holding patients who need to be admitted, we want to let everyone in the hospital know how bad it’s getting in the ED," Ricci explains. "The idea is that all the people who have influence on moving patients out of the hospital will take extraordinary measures to prevent closure."

When Code EST is announced over the loudspeaker, a chain reaction is set in motion. "The charge nurse contacts the nursing supervisor, the nurse super comes down to assess needs as to who needs be put upstairs," says Ricci. "The lab is asked to send over a phlebotomist, if one is needed. Radiology is asked to have all ED patients expedited."

The process goes beyond medical staff. The head of housekeeping must prioritize bed cleaning for any beds not clean at the moment. She is given a list of the type of beds needed most urgently, and the housekeeping staff then scours the hospital for unclean beds. Transportation staff come to the ED and transport anyone who can go into the next open room. Pharmacy support also is available — i.e., an acute pneumonia patient may be given meds in the ED.

Hoag’s ED staff are hoping to add a new requirement to Code EST: that charge nurses from the floor actually come to the ED to share their information. Even more important than the 15-20 minute meeting in the ED to discuss the situation on their floor is that "they get to share the pain a little bit. They tour through the waiting room, see kids with fevers, vomiting in buckets," Ricci shares. "I hope this will give them some compassion for people waiting for that bed upstairs."

A very simple, but effective strategy involves pre-emptive bed requests, Karpiel says.

"The process of getting a bed in a hospital may take five or more phone calls and from one to four hours or more," he observes. "If we are able to identify the need for a bed sooner and start the admitting process sooner, we might be able to cut that time."

The basic premise is this: Any good emergency physician or nurse can walk in a room, look at the patient, and almost immediately determine with a high degree of reliability whether the patient needs to be admitted and what kind of bed the patient would need. "So, why not start the process then and there, rather than waiting to admit the patient and then begin waiting for a bed?" Karpiel poses.

Adventist Medical Center in Portland, OR, has been using pre-emptive bed requests for about two years and has cut turnaround time from 3.5 to four hours down to two to three hours, says Jan Paquette, MD, FACEP, ED director. However, pre-emptive bed requests must be part of a larger multidisciplinary program to decrease your turnaround, she adds.

The disciplines that need to be at the table are those affected by patient admission, she maintains. "The planning meeting should include representatives of the emergency physician, nursing and unit secretary staff, the admitting clerk, the nursing supervisor, and housekeeping," Paquette says.

All of these discipline must be at the table to be educated to respond to this change in process, she explains. It’s typical for admission clerks to submit the patient’s name, their diagnosis, and attending at time of bed assignment, she says. "But with pre-emptive beds, you have to change the process so they take the name, plus general diagnosis class — i.e., chest pain — without a doc assigned," Paquette says. "At that point, housekeeping can be notified, the bed can be made, and the nursing staff can be prepared to receive the patient. All of these processes can start earlier."

Another win-win strategy involves creative staffing. Ricci says the initial plan was to try to have space where admitted patients could go before they went on the floor. "But after vainly looking for unused space, we flipped our thinking," he says. "Instead of having a space where patients could go to see new nurses in preparation for going upstairs, why not add a nurse to the ED staff and have him or her be the emergency care admit nurse?"

This doesn’t gain you any space, he concedes, but it transfers the responsibility of the laborious process of admitting paperwork from the ED nurse to this new nurse. "The ED nurses are delighted, the nurse on the floor is much less resistant to that new admission, because he or she knows the 17 pages of paperwork already are done," says Ricci.

Speaking of win-win, all of these strategies result in a win for the ED and for the hospital. "If you can improve throughput time on access to beds, or reduce patient stay by half a day in a 300-bed hospital, it’s the equivalent of adding 30 more beds to that hospital," Karpiel asserts.

[Editor’s note: This article is the first in a series on reducing delays in the ED. If you’d like to share your success strategies, contact Steve Lewis, Editor, ED Management, 215 Tawneywood Way, Alpharetta, GA 30022. Phone: (770) 442-9805. Fax: (770) 664-8557. E-mail:]

Sources and Resource

For information on cutting admission times, contact:

  • Marty Karpiel, FACHE, FHFMA, Karpiel Consulting Group, 6475 Pacific Coast Highway, Suite 402, Long Beach, CA 90803. Phone: (562) 597-1108. Fax: (562) 597-7448. E-mail:
  • Jan Paquette, MD, FACEP, ED Director, Adventist Medical Center, Portland, OR. Phone: (503) 680-6933.
  • Ray Ricci, MD, Hoag Memorial Hospital Presbyterian, 11 Marisol, Newport Coast, CA 92657. Phone: (949) 376-4967. E-mail:

For more information on bed tracking, contact:

  • Tele-Tracking Technologies, The Times Building, 336 Fourth Ave., Pittsburgh, PA 15222. Phone: (800) 927-0294. Fax: (412) 391-5148. Web: