And they keep rolling in...

Most of our hallways have numbers that are associated to the closest room. When we fill those we go to HWxx. Assignment is by who's next to get a patient, this does take acuity into account (usually). It can get a little confusing when we're overflowing. Anyone in the waiting room is managed by the triage nurse.

Hallway? What's that? You should see when our 6 bed ER gets hammered.

We don't keep patients in our hallways since a state inspection stopped us years ago. Our department has worked extensively on finding ways to address the needs of patients for which we do not have rooms. When we do not have beds most patients are seen by a dedicated provider in the front at the same time they are triaged. A workup is started and potentially critically ill patients are directed in any way possible to the back. For other pts, orders are started and sometimes a patient is ready for a final evaluation by the time they see a provider in the back. Some patients can be evaluated and discharged from triage after seeing the provider and some require a test or two and waiting room time and then are discharged by the provider in triage. It has been a multidisciplinary, multi-department strategy with a learning curve over a number of years. It has also decreased our patient waiting times, total department times and LWBS patients so I think it has been a success.

But I think there is also another issue for many EDs. It is the issue of overcrowding secondary to boarding admitted pts. Joint Commission is requiring new standards for boarded patients at the beginning of 2014. Look up Dr. Peter Viccellio on overcrowding issues (including "Overcrowding for Dummies") and check out the Joint Commission document.

overcrowding

Overcrowding for Dummies

http://www.jointcommission.org/assets/1/18/R3_Report_Issue_4.pdf

We have a hospital-wide strategy for working on ED boarding and overcrowding which has improved things for our ED quite a bit. I noticed immediate results after our managers put their heads together and came up with a plan to which there was buy-in all the way around. The ED charge nurse and the house supervisor work pretty closely on coordinating efforts to keep patients moving out of the ED. We still have some work to do in this area but we are making good progress. The Joint Commission is setting the standard pretty high for boarded patients so perhaps more progress will be coming soon.