ED Accreditation Update: EDs must offer inpatient level of care to admitted patients, new Joint Commission standard says

Patients in the hallways must be treated the same

As of Jan. 1, hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations must meet a new standard that has a higher requirement for care given to admitted patients in the ED, and CEOs will depend on ED managers to lead the effort in complying with this standard.

"Those patients who are held in hallways are actually entitled to the same level of care as any other patient," says Deana Bowlds-Williams, former associate project director in the Joint Commission’s Division of Standards and Survey Methods.

If patients in hallways don’t have access to beds or restrooms, meet with administrators to determine another way to handle these patients, she advises. "You need to look out for patient confidentiality, for patient rights and dignity," Bowlds-Williams says.

Some metropolitan hospitals have set up overflow areas, she says. Care protocols include targets for how long patients can be kept, notes Bowlds-Williams.

At University of Texas Health Science Center in San Antonio, an eight-bed transitional care unit boards medical and surgical patients, says David Hnatow, MD, FACEP, chief of emergency medicine and medical director of University Hospital Emergency Center. Patients typically stay four to eight hours, which compares to an eight to 12-hour stay nationally for observation units, which are similar to transitional care units, he says.

"We were having a problem in that the average wait for all patients to get a hospital bed was about nine hours," Hnatow says. "We’re below three hours now with all the innovations we’ve made," which include having nurses on the floor call the ED to get report and an electronic bed tracking system that pages housekeeping when an open bed is identified.

Keep careful documentation, says Marcia Wilson, MBA, deputy director of Urgent Matters, a Washington, DC-based organization initiative of the Robert Wood Johnson Foundation to help hospitals eliminate ED crowding. "Once a patient has been identified as needing to be admitted, [surveyors] are going to be looking at what’s in place in writing in terms of how the patient is handled," Wilson says.

It will be very difficult to ensure the same level of nursing care for admitted patients in the ED, admits Kathy Hendershot, RN, MSN, BC, director of clinical operations at the emergency medicine and trauma center at Methodist Hospital in Indianapolis.

"Realistically, the EDs have not been staffed for patient care hours as much as the inpatient units," Hendershot says. "And even though we have new [Emergency Nurses Association staffing] guidelines, we remain one of the few areas where we cannot always predict what comes through our doors."

From the draft standard, it appears that the Joint Commission will be looking for a standing committee that addresses patient flow, Wilson says. Include an ED physician, an ED administrator, an ED nurse, and representatives from inpatient administration, senior hospital management, the inpatient medical staff, ancillary services, and housekeeping, she suggests. Document when the committee meets, what decisions were made, and who followed through, Wilson adds.

At Methodist Hospital, a multidisciplinary team addresses throughput during its monthly meeting. "This group has been instrumental in making decision about bed capacity, opening more beds, changing patient populations, making decompression guidelines, and even changing surgery schedules," Hendershot says.

In addition, an administrator broadcasts the 5 a.m. census, bed availability, patients waiting for admissions, possible discharges or moves from the critical care areas, staffing needs, bed closings, and estimate surgical volumes and catheter laboratory volumes, she says. "The administrator and the charges nurses from the units will meet at 10 a.m. and again at 1 p.m. to discuss problems, traffic, and staffing needs," Hendershot explains.

Resources often can be redirected, she says. "Communicating involves all the ancillary and support areas such as housekeeping, transportation, and pharmacy," she adds.

Other critical areas of meeting the patient flow standard include having ED policies and procedures in these areas:

Monitoring patient flow. Determine where congestion is located, Bowlds-Williams suggests. For example, you may be able to demonstrate bottlenecks in the way beds are handled by housekeeping, or you may identify a lack of intensive care beds, she says.

Map out patient flow, Wilson advises. "This is a critical first step in understanding how patients move through the system," she says.

Measure changes in patient flow, Wilson suggests. Hospitals that received grants from www.urgentmatters.org tracked 17 indicators including time from patient arrival to bed placement and time of day of discharge.

"If you can’t get patients out of beds, you can’t move admitted patients into beds," she adds.

Addressing problems with patient flow. EDs need to address patient flow and diversion, Wilson advises. "I think what the Joint Commission will be looking for is, what are your criteria for judging when something needs to be changed?" Wilson says.

"Are you having to go on diversion because you have a crisis with patient flow, or is this an ongoing patient flow problem with bottlenecks in the process?" she asks.

Hospitals are examining what can be done before they go on diversion, she says. For example, what’s the trigger threshold to take action, and who makes that decision?

• Following up with changes to patient flow. Data collection is essential, Wilson notes. The Joint Commission will want to see a tracking system that evaluates changes that you make, she advises. "It will want to know what was your process before, what is the new process, and how did it make a difference," Wilson adds.


The standard for emergency department overcrowding can be accessed free at www.jcaho.org. Click on "Accredited Organizations," "Hospitals," "Standards," JCAHO Requirements" and "Go to JCAHO Requirements Page." Click on "Hospitals," "Leadership (LD)," and "New Standard LD.3.11."