crowded ER, solution?

Can't do much about increasing space but over the years we have increased staffing in response to increased census. Since we are in the same amount of space it means we are sometimes bumping into each other, but we'll put up with it to keep the bodies!!

We have added a second float nurse for most of 11am-11pm shifts, (a 20 bed ER) and we have a back hallway with five monitored and three unmonitored rooms, we also have added a few stretchers in the halls. We have not added any doctors though, so things do get backed up. We just doubled the size of the ER 2.5 years ago and it is already too small.

After a recent turn of events in our hospitals here (overcrowding of ER, pt dying in waiting room, miscarriage in waiting room etc) the health region has enacted "Emergency Capacity" program. This program comes into effect in each hospital if: ER reaches full capacity, ambulances are on Red Alert with no place to drop their pts off b.c there are no beds.

This directly affects the WHOLE hospital. Each unit has a designated "Full Capacity Stretcher" with a room equipped to hold the stretcher. For example, our unit had a two person room formed into a three person room to hold the stretcher in between the two beds. New curtains were installed, extra oxygen hole in the wall etc. This means that when full capacity of the ER is reached, the ER can start sending pts up to these "stretchers". We are not extra staffed for these extra "stretchers" to be used. Often times the room is so small that the most stable pt could be sitting in the hall for the rest of their stay. Each unit in the hospital has at least ONE "full capacity ready" stretcher, with some units now having two of them.

A lot of staff are outraged with the implementation. It was communicated THE DAY BEFORE implementation through an emergency meeting. Many staff are angry stating that we are not staffed adequately to handle the current pts, what more with another. This Emergency Capacity program has been in effect many times on the unit I work on & at other hospital sites. But for now, this is the bandaid that the upper echelon has in place to handle an overcrowded ER.

....This means that when full capacity of the ER is reached, the ER can start sending pts up to these "stretchers". We are not extra staffed for these extra "stretchers" to be used....

Am I understanding this correctly? When your ER gets full, they start sending ER patients right to the floors? So you have your own pt load, plus emergency patients???

Am I understanding this correctly? When your ER gets full, they start sending ER patients right to the floors? So you have your own pt load, plus emergency patients???

Yes! that is correct! Each unit has one emergency stretcher, recently a few units have another extra stretcher making it a total of 2 stretchers.

Of course the ER sends up pts that are "stable" & already waiting for a bed. We have no choice to say "NO we are too busy" anymore. Unfortunately it makes for an unsafe situation - as none of the units are adequately staffed to handle another pt ---- never mind the shifts when we are working SHORT.

I do realize this does make more room for the pts in the waiting rooms though.. It helps to improve the flow of pts in/out of the ER -- although from a floor nurses point of view.. It can be quite unsafe on the floor when that stretcher is in use....

We do something like this too, actually all hospitals in the area do the same thing; ED saturation score is calculated based on # of hall pts, filled rooms, # of EMS out of service, # of pts waiting in lobby, and # of hours pts have been in ER...when we hit a certain point, a code "purple" is initiated and admitted pts go up to hallway stretchers on the floors. Before we get to this point, a code "lavender" is called, alerting staff that they need to get their discharges out, rooms cleaned, etc. if at all possible to avoid a purple. (Sometimes we go into a purple first, depending how out of control the ER is) One day it was so bad that we had every available nurse (i.e., the higher ups who normally don't have a whole lot of pt contact) pushing stretchers to try to decompress the ER...moved out 25 pts in 45 minutes; usually don't see that kind of dramatic response, but having an actual hospital policy helps.

With the closing of some nearby hospitals (and the threat of closing some of the county clinics), we've seen an increase in patient load. Each day, we have patients parked in the hallway, and management has yet to increase staffing. It is a stressful situation for all. We are trying to work as we possibly can, and patients are still angry at everything. WOrking in the ER feels more and more like a lose-lose situation...

In the ED I work this is now getting to be a big problem with no solution except for stable patients to wait in the waiting room. We have the same protocol when we hit full capacity as mentioned previously of putting patients on the floor in hallway stretchers. I realize for the floor this can be daunting but when in the ER when all 35 rooms are full, along with 10 beds in Observation full, on top of 5 or more in the halls, in addition to the 25 or more in the waiting room we have no way to stop the in flux of EMS patients and patients that walk in. Our administration does not allow us to go on diversion for the most part. So you end up playing god, deciding who needs more care then the next person. Along with the people waiting who are very upset. Also I have noticed for the last 6 or so months the hospital as a whole is at full capacity with no beds to send these patients. The 5 ICU's are full. It seems that something has to give or the situation is only going to get worse. I don't know the answer but is seems that there needs to be some kind of resolution before we start losing patients. The only bright side to our situation is that we are more well staffed that we have been in the past.

attempted to restart fast track to get them in and out. ( seems good on paper but hasnt been too successful yet) Other than that- do they best we can or at least we are told to do that by management.. we start seeing patients in the hallways- in chairs if need be if we run out of stretchers. doenst help when we are holding patients for the floors or the mental health institute..

Our situation is very similar to Dakota0330's. We are not allowed to go on diversion plus the EMS units of several surrounding communities do not participate in the county diversion plan...so they bring pts. regardless of our diversion status. We struggle with the overcrowding issue. 26 "Hold" pts. in the ED, hall beds every where in the ED and 20 pts. in the waiting room waiting for a treatment room. How are we to reassess the pts. in the waiting room Q1hr per policy and care for the never ending new arrivals? We recently began using a "Doc in Triage" On days w/ enough staffing, a doctor sees pts. at triage. Some are d/c'd from triage without ever going to the treatment area. (Yes, we have a fastrack) We start IVs, do EKGs, draw labs, do X-rays, give contrast, do CT Scans, all at triage. We admitted a pt. from Triage to a Tele floor today. So far, the stats look promising. The ED nurses I work with HATE caring for admitted/"boarded" pts. Also, our ratio is not the same as the ICU/CCU but these pts. are expected to have the same level of care as they would if they were in the unit. This has been an ongoing problem for several years now. Not sure what the solution is.

I'll join the commisseration party. Our hospital is very small and it's not unusual to be holding patients in the ER waiting on a bed or tele pack. We fill up the hall beds (which officially we don't have of course) and fast track's only open until 10pm (last pt taken at 9pm). Why oh why can't people cut their fingers or sprain their ankles during day light hours?

Our waiting room is usually full up, and 9 times out of 10 we're down at least 1 nurse, sometimes 2. We can have several ICU holds (with nurses who have patients other than their ICU holds) and one triage nurse dancing as fast as he/she can to triage everyone, let alone re-vital and reassess them all. Our new nurses are oriented on the fast track and thrown in the deep end because staffing is so tough. Needless to say, many don't last long!

Diversion? Forget about it. We can't divert for the county (we ARE county) and the private amubulances show up anyway, saying "the patient requested to come here" - yeah right. So they line up in the hall waiting for a bed.

Add to all this management that continuously points out what we're NOT doing right (gotta love JACHO) when it's all we can do to make sure we keep the sick ones alive!

Last shift I worked, I was so beat up it was all I could do not to burst into tears and I'm not a crier by nature. I was sick, but came in anyway. Needness to say, I called in the night after cause I just felt TOO bad (mostly physically but I'm sure there was a tad of the mental anguish in there as well) - so now I feel guilty for that and am waiting to be yelled at for it.

Oh and on TOP of that - we're using some interim charge nurses, at least one of whom can drag a shift down in 15 seconds flat! That didn't help either. Oh and of course the doc that was on loves to play CYA and be condescending to the nurses to the point that we've complained about him several times.

I LOVE ER - but good grief, how much can we take. The two new nurses who're now off orientation are seriously considering bailing - already! Is 8 weeks for a new nurse and 3 weeks for an "experienced ER nurse" enough? Not if you've not worked in THIS heavy load before.

A nice out-patient endoscopy clinic is looking better and better.

Rant over...for now.

My last ED we added 2 MD's and a Mid level. We change using LEAN. We open 2 perform care rooms, an obs area. We increased RN's by 2 and PCT by 3. We went from an average lobby wait time >6 hrs down to 2 hrs. Our left without seeing Doc dropped to less than 2 percent. Our overall pt satisfaction increased. I went from running 8 hallway beds to only the occ EMS offload. Our visits increased from 24,000 in 2002 to 51,000 last year. This is only a 21 bed ED.