Managers at recently surveyed EDs warn: Surveyors target overcrowding standard
Managers at recently surveyed EDs warn: Surveyors target overcrowding standard
ED patients must receive same level of care as inpatients, no matter how crowded ED gets
It’s an ED manager’s worst nightmare: You have one of the most overcrowded and underfunded EDs in the country. Of the 40 patient care spaces for adults, five to 15 are filled at all times with admitted patients waiting for a bed. And here comes your accreditation surveyor wanting to know how you’re complying with the new 2005 standard to ensure those patients are receiving the same level of care as inpatients (LD.3.11).
Proactive approach saves survey
Despite the potential for a disastrous survey, Harbor-University of California Los Angeles (UCLA) Medical Center in Torrance received continued full accreditation by the Joint Commission on Accreditation of Healthcare Organizations with only a supplemental recommendation for an inadequate physical plant. Robert S. Hockberger, MD, FACEP, chief of the department of emergency medicine, credits this achievement to the hospital administration being proactive in making changes and plans to address ED overcrowding.
"We knew you couldn’t walk into our waiting room or ED and not know we weren’t extremely overcrowded," Hockberger says. "We say up front, we know we have a problem. This is what we’ve done in the ED to address it.’"
Hockberger presented his surveyor with a written list of changes that had been made, were currently being made, and would be made in the future. He said to the surveyor, "This is evidence of the true commitment of the hospital leadership to address the problem." The reviewer responded that he couldn’t ignore the fact that they had overcrowded conditions, but "he was impressed with things we already had done and were doing to address it," Hockberger says.
Patient flow facilitator tracks admissions
When presenting his surveyor with the list of changes, Hockberger pointed out that when the ED is full, physicians go to the triage area to see patients. Also, "we’ve implemented a nursing patient flow facilitator that takes care of tracking admissions to all monitored beds from the ED and transfers from other places," he says.
Hockberger was able to tell his surveyor that his county leadership recently voted to build a new ED that had been proposed 10 years earlier. Also, he pointed to a committee and subcommittee that had been established to address patient flow.
He also told the surveyor that the hospital plans to open an additional 40 monitored beds within three months. Also, an urgent care center will expand its hours from 9 a.m.-5 p.m. to 8 a.m.-midnight six days a week, he said.
In addition to being asked what you’ve done to address ED overcrowding, expect these questions from your Joint Commission surveyors:
- Is your documentation for admitted patients in the ED the same as that of inpatients?
When St. John Hospital and Medical Center in Detroit recently went through its accreditation survey, surveyors traced a couple of ED patients who were admitted after lengthy stays in the ED, says Patricia Mayne, RN, BSN, MHA, CEN, administrative director of emergency services.
"They came in and talked to nursing staff, trying to validate that the patient received the same level of care that they would have on floor," Mayne says. The surveyors looked at documentation to see that if a patient was on a pathway, they would follow the same pathway once the decision to admit occurred, she says.
The surveyors also checked to ensure that the documentation was appropriate for patients in restraints, Mayne says. "They were checking to make sure you follow the same policy for restraining as throughout the hospital," she says.
- Is staffing the same for those patients?
At St. John, surveyors asked nurses if they thought they had adequate staff to care for patients, a question sure to send shivers through any ED manager.
The nurses responded favorably, Mayne says. "That’s one of the things we’ve worked on closely with the inpatient and float pool for nursing support, to make sure we have the same level of care for the ED as on the floors," she says.
For example, if the standard of care is 1:2 for critical care, the operations manager for the ED works with the staffing office to make sure the ED has staff to care for the ED volume of those patients, Mayne says. Additionally, managers meet twice a day to discuss staffing and the number of patients being held, she says. "We try to match those admitted patients to the same level of care that they would have on the floor," Mayne says.
- How do you maintain confidentiality for those patients?
At Harbor-UCLA Medical Center, the surveyor asked how the ED provides for patient confidentiality in overcrowded areas. The department has an alcove where eight patients with minor head, neck, and orthopedic problems sit in chairs. Patients are taken one at a time into a room for evaluation and care, Hockberger says. Separate rooms are used for pelvic exams and rape assessments, and a family room provides space for confidential discussions with patients or their families.
"It seems that we answered his questions adequately," Hockberger says.
Curtain keeps ED’s white board private
The surveyor asked about the department’s white board for manually tracking patients. The ED has done two things to shield the board from patients’ view, Hockberger says. A curtain across the board shields it from almost all patients, he says. Additionally, the department now uses abbreviations for diagnoses, such as "AP" for abdominal pain.
"It’s pretty generic abbreviations so we could have a rough idea from a nursing and doctor standpoint, but patients couldn’t identify the problem of the patient in the bed next to them, or if they saw their own names, it’s clear no one else could tell what the problem was," says Hockberger.
- How do you handle medications for those patients?
At St. John, a quality improvement team looked at providing the appropriate level of care, including pharmacy support, for medical/ surgical patients in the ED, Mayne says. The result is that the ED nurses can send admitted orders to the pharmacy. The pharmacy sends the medications, which are put in a locked storage unit in the ED with the patient’s name and information, just as they are on inpatient units, Mayne says.
At Harbor-UCLA, the surveyor asked to see a chart of an admitted patient who had spent more than 24 hours in the ED, Hockberger says. The surveyor questioned the managers about whether patients admitted received the same level of care as inpatients with respect to medications. The hospital had recently implemented a holding orders program to address this concern, says Hockberger. When a patient is admitted, the admitting physician writes medication orders.
"Those orders are treated the same way as inpatient orders," Hockberger says.
All routine orders are scanned by nurses and sent to the pharmacy, he says. The pharmacist looks at the medications; checks for allergies, interactions, and appropriateness; and approves the medications before they’re administered by nurses, Hockberger says.
"Also, if the nurse or pharmacist has a question, they can page the doctor and talk to them directly, rather than going to the ED doctor as an intermediary, as we had done in the past," he says.
Sources
For more information on ED accreditation surveys, contact:
- Patricia Mayne, RN, BSN, MHA, CEN, Administrative Director, Emergency Services, St. John Hospital and Medical Center, 22101 Moross, Detroit, MI 48236. Phone: (313) 343-3408. Fax: (313) 343-6373. E-mail: [email protected].
- Robert S. Hockberger, MD, FACEP, Chief, Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance. E-mail: [email protected].
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