To ease overcrowding, delay elective surgeries

Crazy idea or valuable strategy?

No one is claiming it’s a cure-all for ED overcrowding, but a number of facilities have turned to postponing elective surgeries that required admissions as an important part of a multifaceted plan to ease the burden on their harried ED staff. And when they do, many give the ED manager a key role in the decision-making process.

It’s important for ED managers to be in the decision loop, because they often will be the ones that give the most accurate information about the need for a hospital response, experts say.

Just this winter, two hospitals in Utica, NY — Faxton-St. Lukes Healthcare and St. Elizabeth Medical Center — announced that they had reduced the number of elective surgeries that were scheduled, and would evaluate, on a day-to-day basis, what further elective surgeries might need to be postponed to help move patients who need to be hospitalized more efficiently through their EDs.

But this is a strategy that has been used on an as-needed basis for several years at other facilities, such as Southeastern Ohio Regional Medical Center in Cambridge, and Latter Day Saints (LDS) Hospital, the flagship facility for Intermountain Health Care, in Salt Lake City. In both cases, the ED manager has been instrumental in the new processes.

"A couple of winters ago, we were full to the gills," recalls Mark Slabinski, MD, FACEP, FAAEM, director of emergency services at Southeastern Ohio. "Our ED works very well and almost never holds patients, but in that winter, out of our 15 beds, six were holding; and it was then up to us to figure out what to do." In response, Slabinski sat down with a hospital vice president, and together they crafted a policy for postponing elective surgeries that required admission. Their recommendations have been formally incorporated into the hospital’s diversion policy. (See an excerpt from the policy.)

"In 2002, our hospital hired a new CEO at the same time that our inpatient census was growing beyond our capacity, and we were frequently on diversion status," says Mike Gibbons, RN, BSN, the nurse manager of the LDS Hospital ED. The CEO implemented a daily administrative huddle. "When beds were tight, decisions were made as to how to limit admissions or increase discharges," he says. "As the ED manager, I provided input as to how long we could reasonably hold’ patients without placing the hospital on divert," Gibbons adds.

While the plan at LDS was devised by upper management, at Southeastern Ohio, it had to be sold.

"We had to get administration’s attention," Slabinski notes. "After crafting the basic policy, we got together with the medical and surgical chairs and figured out what made the most sense."

Selling administration was not really a problem, he says. "The harder sell sometimes is the primary care docs, who are used to doing something a certain way. But if you have administration’s backing, then that’s how it is, and they understand," Slabinski observes.

At LDS, it’s simply a matter of the plan playing out. "It’s totally based on the census on the surgical floors," Gibbons explains. "If all the surgical floors are full, we look at which floors will be the next to go. Then, if we run out of room, it’s time to cancel surgeries [that require admission]."

At that point, the OR manager and catheterization lab manager consult with the house supervisor prior to beginning elective cases that required admission.

"When it reaches that point, they call me, see how many patients we have in the department, and of those, how many we think will end up upstairs," Gibbons points out.

The managers attempt to review that information every couple of hours, he says. "If OR cases need to be admitted, they won’t let anesthesia start until they are sure there’s a bed for that person," he explains.

While LDS has not postponed or cancelled a large number of surgeries, the strategy has been used several times over the past few years, Gibbons says. "We’ve used it maybe five days in all," he adds.

It’s a great tool to analyze resources, Gibbons says. "When the hospital is that full, this process helps," he says. "Plastics cases, gastric bypasses, and such can certainly be delayed or postponed."

Of one thing, Slabinski is certain: "The ED absolutely should be involved [in decision making]," he asserts. "We admit 60% to 65% of the patients who come through our doors, so it’s silly not to include us at the table."

Gibbons agrees, and he notes that ED statistics are vital to the decision-making process. "Part of the huddle is knowing, for example, that you will typically get 30 patients from the ED [every day] based on averages, and a certain percentage of those will typically go up to elective surgeries," he says.

Sources

For more on postponing elective surgeries, contact:

  • Mike Gibbons, RN, BSN, ED Nurse Manager, Latter Day Saints Hospital, Eighth Avenue and C Street, Salt Lake City, UT 84143-0001. Phone: (801) 408-1100. E-mail: Gibbons@ihc.com.
  • Mark Slabinski, MD, FACEP, FAAEM, Director, Emergency Services, Southeastern Ohio Regional Medical Center, 1341 Clark St., Cambridge, OH 43725. Phone: (740) 439-8900. E-mail: mslabinski@emp.com.