New admissions unit targets ED overcrowding

Clinical decision making to be enhanced

Surrounded by hospitals that either are being sold or closed or are merging with other health care organizations, Swedish Covenant Hospital has become — as was stated in a recent Chicago Tribune article — "the largest stand-alone inpatient facility in north Chicago," says Gillian Cappiello, CHAM, director of access services.

"What’s happened with all the closures and mergers is we’re growing in leaps and bounds," she adds. "When one of the closest competitors closed, our emergency department (ED) visits really increased."

An ED that often is on diversion status combined with a shortage of nurses and some technical support personnel has prompted a move toward more centralization of services, Cappiello says.

In an effort to streamline admissions and turn around rooms more quickly, she says, the hospital plans to begin construction around September 2002 on a new observation/express admission unit adjacent to the ED.

The unit will serve a dual purpose, she notes. "Patients who are now just admitted to the nursing unit from the ED can go through this unit first. It will act in some regard as a clinical decision unit." For cases in which the physician needs to rule out a myocardial infarction, for example, the unit will have a treadmill, she adds.

"At present, some of the patients admitted to the hospital don’t really need to be fully admitted," Cappiello says. "They could just stay [in the observation unit] for eight hours or so and go home. It will be close by, and will help reduce length of stay and keep beds open for patients who really need them."

The hospital already has a short-stay unit, but it is used for anyone with a stay of fewer than three days, she explains. "The model we use there is that everything needs to be done a little more quickly than in the regular medical-surgical unit. This [new unit] will take the true observation case out of the short-stay unit."

Express unit most exciting’

The express admission unit is "the most exciting piece" of the project, Cappiello says, from the perspective of both nursing and admissions.

On the traditional patient unit, she points out, doing an admission takes nurses away from their other duties. "It can take an hour and a half to do the admission assessment, process orders, and begin treatment."

The express admission unit will allow patients that ultimately end up on the nursing floors to be processed as transfers, Cappiello explains. "The nurse accepting there won’t have to spend a big chunk of time away from regular patients, so we hope it will be easier for the units to take patients more quickly. They may call sooner to say they can accept a patient."

And, she adds, "it’s certainly an admitting pleaser" in that rooms can be turned around more quickly and bottlenecks avoided. "If a room is not ready, this way the patient won’t be in the lobby, but will be getting care," Cappiello says. "We won’t have to tell the physician he can’t send someone right away."

The only ED admissions that won’t go through the express unit will be psychiatric patients and patients admitted to the intensive care unit (ICU) or the intermediate-care unit (IMCU), she notes.

There will be an effort to recruit nurses to work in the express unit who actually enjoy the process of admitting patients, she notes. "All [those nurses] will do is complete the admission assessment and do the first set of orders. There won’t be several other patients all needing care."

Enhancing the process will be the institution of bedside registration, Cappiello says. "We will have devices on mobile carts in the ED and the express admissions unit."

On a typical day, she adds, there might be 25-30 patients admitted from the ED in a 24-hour period. Taking away psychiatric and ICU/ICMU patients would reduce that number by 10 or 12, she adds.

"We’re anticipating there will be about 12 or 13 beds in the new unit, so if you figure we only need a couple of hours [per patient], we should be able to keep things moving," Cappiello says. "If necessary, we can keep patients in the ED a little longer, but this should help the ED overcrowding."

In the past, she says, patients occasionally have had to be boarded overnight in the ED and the recovery room because there were no beds available.

Being able to move patients through the system more quickly will please the hospital’s physicians, Cappiello notes, as should the good care outcomes that are likely. In addition to such features as the on-site treadmill, every room in the unit will have telemetry, she points out.

"We will also [provide telemetry] hospitalwide and have a remote room for monitoring," she adds. "That should cut down on our transfers."

A nursing executive who is no longer with Swedish Covenant proposed the idea for the new unit, she says, and the current vice president of nursing "has taken the charge on and developed it more."

"It made a big difference at other organizations who have a clinical decision unit, such as the Cleveland Clinic, for example, to be able to make clinical decisions right there and cut down dramatically on admissions from the ED," Cappiello adds.

The idea, she explains, was that taking the patient away — albeit just a few steps away — from the busy ED environment could provide a less-hectic setting in which to consider care options.

[Editor’s note: Gillian Cappiello can be reached at (773) 878-8200, ext. 5051 or at]