ED Accreditation Update: Standards governing ED patient flow, patient boarding are strengthened
Standards governing ED patient flow, patient boarding are strengthened
Ultimate responsibility for action is pushed up the chain of command
As demand for emergency care continues its upward climb, The Joint Commission is taking steps to strengthen its accreditation standards pertaining to patient throughput, and it is putting hospital leaders on notice that they will be held accountable for patient flow challenges that occur in the ED.
Under revisions to Standard LD.04.03.11, it will soon no longer suffice for hospitals to simply measure elements of patient flow. Hospital leaders will also have to use this data to set goals for improvement, explains Jeannie Kelly, RN, MHA, LHRM, an expert on risk management and quality assurance at Soyring Consulting in St. Petersburg, FL.
"This involves setting goals and reporting them up to leadership so that the CEO, COO, and CNO all know what is going on, and they are charged with making sure that [problems] get fixed," observes Kelly. "In the past, [the requirements] never went up that high. Managers had to be aware of what was going on, but now The Joint Commission has really pushed it up the chain of command to hospital leadership, and I think that is very important because they are the ones with the power to make things happen."
Further, The Joint Commission has expanded the standard to include all areas where patients receive care, treatment, and services, including inpatient units, laboratory, operating rooms, telemetry, radiology and PACU, as well as support services such as housekeeping and patient transport, observes Kelly. "This allows department managers and leadership to identify issues that impact patient throughput," she stresses. "Hospital leadership must take action to ensure that barriers, whether real or imagined, are removed so that patients are either admitted or transferred as appropriate."
Kelly suggests that data associated with the patient flow process could be part of the hospital's Quality Assurance and Performance Improvement (QAPI) plan. "This provides a ready-made platform for performance measurement and evaluation," she says.
Boarding: Safety needs to be the priority
The Joint Commission has also revised Standard PC.01.01.01, which covers the issue of behavioral health patients who present for care to the ED, and the common practice of boarding these patients in the department while other care arrangements are made.
The revisions state that hospitals that do not primarily provide psychiatric care or substance abuse services must have a written plan of care that "defines the care, treatment, and services or the referral process for patients who are emotionally ill or who suffer the effects of alcoholism or substance abuse." And the agency recommends that patients should not be boarded for longer than four hours.
Further, the revisions spell out specific standards that need to be met when behavioral health patients are boarded while awaiting care. "Patients with behavioral issues should be monitored in a safe area that is clear of items that the patient could use to harm himself or others," explains Kelly. "Also, patients need to be medically stabilized before transfer. Psychiatric issues can be caused or exacerbated by medical conditions. Failure to properly medically assess patients can lead to negative outcomes, including EMTALA violations."
Kelly acknowledges that meeting these standards will be challenging, as most EDs are not physically set up to monitor patients with behavioral health or substance abuse issues for an extended amount of time. "[Hospital administrators] are going to have to start looking at where these behavioral health patients are going to be held while they are awaiting transfer," she says. "And they are going to have to look at it from the point of view of safety."
Revisions will assist over-burdened EDs
Sue Dill Calloway, RN, CPHRM, AD, BSN, MSN, JD, president, Patient Safety and Health Care Consulting, Dublin, OH, and chief learning officer, Emergency Medicine Patient Safety Foundation, based in Folsom, CA, believes the revised standards will help to provide ED administrators with the kind of support they need to resolve patient throughput problems. "It is not an ED problem, it is a hospital problem," says Calloway. "So hospital leaders need to be doing studies and coming up with ways to mitigate problems with patient flow."
Calloway notes that the leaders of all the major emergency medicine organizations recognize hospital overcrowding and the practice of boarding patients in the ED as among their top challenges. However, she stresses that many of these problems require system-level solutions.
"I was visiting a hospital that had a six-bed ED hold that was staffed not by ED staff, but behavioral health staff," she says. "Leadership needs to do that. The ED can't do that alone."
In another instance, hospital leaders stepped in with a creative solution for an ED that had 20 boarded patients. "They decided that they would put one of these patients on every unit," she says. "It was a lot more manageable to have one additional patient on each unit than it was to have 20 sitting around the ED, so again, that was a leadership solution."
- Sue Dill Calloway, RN, CPHRM, AD, BSN, MSN, JD, President, Patient Safety and Health Care Consulting, Dublin, OH, and Chief Learning Officer, Emergency Medicine Patient Safety Foundation, Folsom, CA. E-mail: [email protected].
- Jeannie Kelly, RN, MHA, LHRM, Health Care Consultant, Soyring Consulting, St. Petersburg, FL. Phone: 866-345-3887.
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