Monday, February 14, 2011

“Full Capacity Protocol”—the fancy name for when an emergency department (ED) sends patients “upstairs” whether a bed is available or not—sounds like the clinical version of chutzpah. But it turns out that there is more thought and less bravado (albeit still a dash of chutzpah) in the approach than one might first think.

It’s also safe for patients. And the idea is catching on at a significant number of hospitals across the country. Some of the leading lights in emergency medicine, like Dr. Art Kellermann, now at Rand, think it’s a good idea—not as good as having hospitals and EDs work together to address overcrowding systematically and sustainably, but at least better than leaving patients in ED hallways for hours on end.

The story began about a decade ago in the overcrowded emergency department at Stony Brook University Medical Center in Long Island. Dr. Asa “Peter” Viccellio, who is now the vice chairman of the department of emergency medicine at the SUNY Stony Brook med school and a practicing emergency physician there, and his colleagues were disturbed by the ED crowding and the numbers of patients lying on gurneys in the hallways.

Sometimes patients pile up because the ED itself is overcrowded and not functioning with optimal efficiency. But often the patients become ED “boarders”—patients awaiting admission to one of the regular inpatient units in the hospital when there is no bed immediately available upstairs. The boarders—at Stony Brook it can sometimes be 30 or so at a time—then make the rest of the ED even more crowded and less efficient, which can mean even more boarders. It drove Viccellio nuts.

At Stony Brook, the hospital and ED administrators went through the same studies and contortions about emergency efficiency everyone else was going through at the time. Viccellio does not seem to have blissful memories of that phase of attempted troubleshooting. In a PowerPoint on his website (www.hospitalovercrowding.com), he has a slide summing up Continuous Quality Improvement sessions as:

• Meetings
• Measures
• Graphs
• Memos
• Repeat the above

Viccellio became frustrated by what he came to think of as “magical thinking” in his hospital. “Let’s hope that next week [overcrowding and undercapacity] is no longer a problem. We’ve had it for 20 years but let’s hope it goes away.” Of course, it never did.

He (and other physicians, administrators, and policy analysts working on ER needs during the last decade) became increasingly convinced that the ED problem wasn’t an ED problem. It was a hospital problem—having to do in part with overall workflows, incentives for who can slough off administrative work on who, weekend staffing that perversely affect admission and discharge patterns, and elective surgery schedules that bunch up too many procedures on too few days. Overall, he (like Kellermann) saw the hospital as functioning—at best—very 12/5 in a medical universe that increasingly needed to be 24/7.

He started thinking outside the box of the emergency department. What approach to ED crowding and boarding would work for the hospital as a whole? And, above all, for the patients?

Lingering unnecessarily in the ED was not in the patient’s interest. Studies have found that crowding really is not good medicine. As Kellermann wrote in an editorial in the Annals of Emergency Medicine last year, boarding “is associated with an increased incidence of complications, such as ventilator-associated pneumonia, longer lengths of hospital stay, and a greater risk of dying in the hospital.”

The patients, Vicellio recognized, would clearly be better off on a medical or surgical floor. But how to get them there? What would happen, he wondered, if the ED sent the patients upstairs, even if it meant waiting in those hallways. (They do not use the Full Capacity protocol for ICU or step down unit patients). Wouldn’t it be better for everyone if the “extra” patients were evenly distributed throughout the hospital, if each floor or unit had one or two extra patients for a short period of time, instead of bunching up 30 of them for hour after hour in an overstretched ER without any additional nursing staff. Vicellio suspected that once the patient was in a hallway of an inpatient unit, with the nurses and doctors and staff having to look at the patient in the hallway, a bed would be found quickly.

He was right.

Rooms got cleaned faster. Patients were discharged more efficiently. Available beds were registered in the system as being available more quickly.

“We found the nursing staff didn’t like patients in the hallway. It was not very nice to the patient, “ he said. Of course, it isn’t nice to have them in the hallway of the ED, either, but they weren’t so visible to the rest of the hospital when they were down there. “It’s not just room versus hallway—but which hallway,” he said.

For a long time, Viccellio thought his fantasy of sending them on up was illegal or at least against New York state health department regs to have patients in the hallways of the regular floors, even though they were often kept on gurneys in the ED hallways. Everyone else thought so, too. Nobody was quite clear whose rules it was against—the Joint Commission, or HHS, or the state health department, or maybe the local fire and rescue squad. But it had to definitely be against the rules.

When Viccellio checked, it turned out it wasn’t true.

“The New York Health Department told us there was no such rule. They put it in writing—and put in writing too, that they weren’t all that crazy about dozens of patients boarding in ER hallways either.”

That discovery changed how Viccellio and many others at his hospital thought. “It was like an explosion had gone off, conceptually, about what our options were, our approaches in dealing with overcapacity.”

So, after a lot of thinking and consultation, Stony Brook created the Full Capacity Protocol. “It made a lot more sense to do it this way, so we started doing it this way. And it wasn’t confrontational or dramatic.” When the ED was bursting to the seams, patients would go upstairs. They were cared for until a bed was found. And the beds were found.

Safety concerns were allayed. Yes, sometimes patients in the hallways “go sour” as Vicciello put it. That’s inevitable—patients are in the hospital because they are sick, and some get sicker or have some kind of crisis no matter where they are. But the hallway didn’t turn out to be dangerous—the patients tended to be in the hallway right near the nursing station. If there was a problem, someone noticed fast—possibly even faster than if they patient was in a private room, or behind a curtain in a semi-private room, down the hall. (The safety observation wasn’t just anecdotal. See this Annals of Emergency Medicine article as well as materials on his overcrowding website.)

The protocol hasn’t wiped out all the crowding or all the boarding, but it’s reduced it considerably—Viccellio estimates by about half. (Those ICU and step-down patients often still remain in the ED until a bed can be found). And about 20 percent of hospitals around the country have introduced a similar protocol or variant, at least up to a point, he estimates.

The system changed the whole hospital, for the better, he believes. People throughout the hospital came to see the ED problems as part of larger institutional problems, and worked more creatively on larger institutional solutions.

“You can imagine what happens when we do send patients up and they go to the hallway. It’s like a fire alarm that goes on in the institution. Everyone knows there’s a capacity problem.”

“You rattle the cage,” he said. And things start moving.


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