Just wanted to know how many hospitals are putting their inpatients in the hallways when the floors are full. This will be the new trend where I work. In MA there is a "no diversion" rule. Patients routinely line the hallway in the ER but now the hospital is planning to "admit" patients to hallway areas when rooms are full. Questions raised: What bathroom do they use, how are they billed, how will it affect the ever so wonderful "Press Gainey" scores, would you want to be in a hallway getting your care, does your family want to see you there, what about all the obstacles in the way, ie linen carts, dirty linen, patients trying to ambulate, walking past you with any host of different diseases???? Any thoughts out there? Management of course feels it will all work out fine, will the "VIPs" be put in the hallway?
it really isn't ok, but it is more ok in the er...
since we know that not all folks who utilize er services, are actually high acuity pts.
and i don't think you can fairly compare a temp stopover (er) to an admitted, inpt stay.leslie
I'm going to have to respectfully disagree with you here Leslie. It isn't okay anywhere. We all known that not everyone who is admitted is a high acuity patient and the likelihood of regularly having truly high acuity patients on a general med/surg floor is not very high. When I speak of high acuity I mean those with evolving MI's, impending intubations, etc. the type of things we get multiples of in any given shift in a busy ER. In addition when does a "temporary stopover" become not so temporary? Remember, we are holding admitted patients for days. In fact I have admitted a patient into a hold bed in the ER, had 2 days off only to return to discharge the patient who never actually made it to a floor. It clearly is not optimal in any situation for anyone but I think the floors are going to have to step up especially if the number of hold patients are crippling the ER's ability to take care of ER patients. In some cases it's a case of "out of sight out of mind". If you don't have to actually look at the problem then you are less inclined to do something to fix it (not you personally Leslie ;-) )Case in point. We had 8 hold patients in the ED because there were no available beds. Our administration demanded that an in-patient nurse come down to take care of them.We were even willing to give them one of our techs. The in-patient nurses did not want to do this because they were uncomfortable being out of their comfort zones and we didn't have the kind of supplies they needed. In less than an hour 8 beds magically became available and the patients were moved up. It was amazing how quickly things changed when it suddenly became their problem. Now I'm not saying that this would be the case everywhere, every time but it does make you think doesn't it? Maybe sometime in the future when ERs aren't being overcrowded it will be okay to board patients for extended periods of time but unfortunately that time isn't now.
Agreed. The patients should not have to pay for sub standard rooms and neither should the insurance companies. However, these are not overflow ER patients these are overflow admitted patents who are being overseen by their admitting doctor not the ER docs, utilizing in-patient charts and receiving in-patient care. I don't see it as pawning off anyone. I see it as survival.Now if I was sending you regular ER patients because all our beds were full then that would definitely be pawning things off but that will never happen because it wouldn't be appropriate to have in-patient nurses caring for ER patients on a floor. Although the good news for you guys would be that you could often get rid of the annoying ones instead of caring for them for days on end.
it really isn't ok, but it is more ok in the er...
since we know that not all folks who utilize er services, are actually high acuity pts.
and i don't think you can fairly compare a temp stopover (er) to an admitted, inpt stay.
again, and i reiterate, i think most of us do believe that overflow in er's is unacceptable.
but if your hospital has a 'no divert' policy in order to retain/add revenue, then the issues are w/admin.
The ER patients that Flying Scot & I are discussing here are "admitted." So these are patients who have been treated/diagnosed in the ER and their conditions are acute enough to require admission and yet there is a complete roadblock in moving them out of the ER and into whatever inpatient unit.
One of the hospitals where I work currently commonly holds admitted patients for up to 2 days due to lack of beds. I once worked a multi-day stretch in which I triaged, treated, and eventually discharged a patient "admitted" to one of the critical care units who never physically left the ER.
ACEP (the American College of Emergency Physicians) has studied the ED boarding issue extensively. Among their conclusions:
1. Boarding of admitted patients in the ER affects overcrowding to a far greater extent than the volume of patients seen.
2. Lack of inpatient beds is a direct result of various scheduling practices throughout the hospital -- front-loading of surgeries in the early part of the week, etc.
Interesting reading - you may want to check it out.
Also -- don't be too quick to assume that patients who are evaluated in the ER could simply be transferred to other hospitals if it weren't for managerial greed. EMTALA makes it very, very difficult to do such a transfer except in cases where the patient requires a higher level of care and/or a specialized service not available at the original hospital. And having worked at both small community and tertiary care hospitals I can tell you -- patients & their families generally HATE being told that they have to leave their closest hospital, the one they perceive as being "theirs."
I'm just saying that the inpatient side of the hospital CANNOT simply shut their eyes to the nightmare of boarded patients in the ER and say, well, that's their problem - we won't accept patients in OUR hallways.
I'm just saying that the inpatient side of the hospital CANNOT simply shut their eyes to the nightmare of boarded patients in the ER and say, well, that's their problem - we won't accept patients in OUR hallways.
i read the acep link, and found most of it to make sense.
however, i still don't agree that inpt units should receive the extra burden of pts.
these extra pts are being encouraged to be placed in conference rooms, hallways, solaria??
do you think admin will authorize add'l nurses/staff to work in receiving these extra pts?
while i clearly agree these admitted pts need to be moved away from the er, i'm not agreeing that placing these extra pts on an already-burdened floor (typically speaking), is the answer.
A hospital near me (not the one I work at) recently started taking these "admitted" patients from the ED to a holding area where they could wait for an inpatient bed to open up, while being cared for in the same fashion that they would be on the floor rather than the ED. Typical holding time is 8-12 hours, but instead of sitting on a stretcher in the ED, you are in a ward-type bed with a central nurse's station. The area looks similar to PACU. Of course that plan requires the space to put the beds in, plus nurses and techs to staff the beds... probably not what the administrators of your budget minded hospitals had in mind when they planned on making a normally 25 bed inpatient floor into a 30 bed unit without increasing staffing.
I'm just saying that the inpatient side of the hospital CANNOT simply shut their eyes to the nightmare of boarded patients in the ER and say, well, that's their problem - we won't accept patients in OUR hallways.
I hear what you are saying but I also think you're twisting the words of the replies. No one said it's "ok" to hold these patients in the ER halls, they said it was "more OK"......not at all the same thing (I explained my rationale earlier so I won't repeat myself). I don't think those of us that are "inpatient" nurses are shutting our eyes to the problem, blowing it off with a, "it's their problem" attitude, either. It's a complicated issue with no good solution. I still consider the ER to be a temporary stop vs an inpatient room, and regardless of the time held, psychologically it feels like a temporary stop, so a patient is going to be more accepting of it. More than a day (heck, more than a matter of hours) just isn't acceptable/OK for a patient to be held in the ED.
My hospital must not be the norm, because people are not kept in the ED for days. We start getting hounded when it's been an hour (after admitting orders are written), and if the intended floor is full, they get put on another floor. We're not a small hospital, either, we're a level 2 trauma center; we get patients (not just traumas) from the next state over, due to the level of care we can provide compared to other facilities. We have a CDTU (Clinical Decision Treatment Unit) that can keep a patient over night (to r/o MI, for example), but that's a different thing. There is no way an admitted patient would be in the ER for days. I guess that's the exception to the rule?
Call the fire marshal... this is BS... The marshal will have a heyday with it!
Of course we did it in the ER when we had to, but we were able to go on diversion. We NEVER do this with inpatients.
The same rules apply to the ER so the fire marshall will have a heyday there too. I think the article made sense because the gyst of it was to spread the patients out so as not to overburned one area. In the example I gave earlier with the 8 boarded patients. We have 2 floors with 3 units on each. if each unit had taken just one of the patients (leaving 2 in the ER) then the ER wouldn't have been left to bear the entire load.Surely one extra patient isn't going to cause a unit to self-destruct. Diversion really doesn't work unless you are able to close the doors to the walk-ins as well. There are times when we have 50 ambulatory patients in the waiting room waiting for an ER bed. Not all ambulatory patients are low acuity. 9 years ago when I first started in the ER boarded patients were a rarity and didn't cause too much trouble. Now it's rare to not have boarded patients and sometimes we are overwhelmed with them to the point that we can't take care of them and the ER patients at the same time.
My hospital must not be the norm, because people are not kept in the ED for days. We start getting hounded when it's been an hour (after admitting orders are written), and if the intended floor is full, they get put on another floor. We're not a small hospital, either, we're a level 2 trauma center; we get patients (not just traumas) from the next state over, due to the level of care we can provide compared to other facilities. We have a CDTU (Clinical Decision Treatment Unit) that can keep a patient over night (to r/o MI, for example), but that's a different thing. There is no way an admitted patient would be in the ER for days. I guess that's the exception to the rule?
You are definitely an exception to the rule. I want to work in your hospital!!!!!!
You are definitely an exception to the rule. I want to work in your hospital!!!!!!
They want to implement a system to get admissions up even faster. Plan is to send a written report, and then 15 minutes later, send the patient. We have fought this for a few reasons, one being that if they don't tell us they've tubed or faxed report, it may not be seen right away. I can see patients being dropped off and left, without someone being told (stranger things have happened ). There have been enough times that I've been getting phone report on an ER patient, and the more I'm told, the more I wonder....is this patient appropriate for our floor? I'll usually let the ER know if I question the placement, and then get on the horn with the nursing supervisor (one incident that sticks in my head was a pediatric (16 year old, I think) BURN patient, that the MD~a trauma/general surgeon known for trying to put ALL of his patients on my floor, no matter what their dx~the nursing sup, the ER nurse, all said was appropriate for us. We're not peds, and while we ARE trauma, we don't take burn patients (in the words of that nursing sup, "you guys take burn patients all the time"........NO, we don't! LUCKY for me, a nurse I'd been on a committee with was working in the ER that night, and she got the patient put in PICU (which was the appropriate placement). Another time was a transfer from another hospital...young guy, again, but with an abscess or some other throat issue....report from the tx'ing hospital said the CT showed 1 MM of patent airway (he was surprisingly stable, sats good on RA, etc). Great, he's stable NOW, but if he crashed, it would have obviously been quickly. I had to call the accepting doc myself to get him put in the IMCU. With this written report deal, I'm afraid we're going to end up with unstable patients before we can even ask questions.
Anyway.
I just can't get over this thing with admitted patients being in the ED for days. We get yelled at for not taking them when we have no open/clean rooms, and we get them cleaned as soon as we can (yea, I'm not doing housekeeping myself, too). They may be in the ER for several hours, if we're bad off census-wise, but not days.
i live in ma, and wasn't aware of the "no divert" rule.
as a matter of fact, i (very recently) heard about a boston hospital diverting its pts to a bigger, boston hospital.
would still love to know about how pts are cleaned, changed, toileted, etc...
leslie
We have a no diversion law in MA, it is about a year old, or so. We can send patient's via medflight to a trauma unit, cardiac cath lab, etc but cannot divert patients because of an overflow. We used to have about 600 diversions a year because we are a small communitiy hospital. Now patient's line the outer hallways of the ER
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). There have been enough times that I've been getting phone report on an ER patient, and the more I'm told, the more I wonder....is this patient appropriate for our floor? I'll usually let the ER know if I question the placement, and then get on the horn with the nursing supervisor (one incident that sticks in my head was a pediatric (16 year old, I think) BURN patient, that the MD~a trauma/general surgeon known for trying to put ALL of his patients on my floor, no matter what their dx~the nursing sup, the ER nurse, all said was appropriate for us. We're not peds, and while we ARE trauma, we don't take burn patients (in the words of that nursing sup, "you guys take burn patients all the time"........NO, we don't! LUCKY for me, a nurse I'd been on a committee with was working in the ER that night, and she got the patient put in PICU (which was the appropriate placement). Another time was a transfer from another hospital...young guy, again, but with an abscess or some other throat issue....report from the tx'ing hospital said the CT showed 1 MM of patent airway (he was surprisingly stable, sats good on RA, etc). Great, he's stable NOW, but if he crashed, it would have obviously been quickly. I had to call the accepting doc myself to get him put in the IMCU. With this written report deal, I'm afraid we're going to end up with unstable patients before we can even ask questions.
FlyingScot, RN
2,016 Posts
I'm going to have to respectfully disagree with you here Leslie. It isn't okay anywhere. We all known that not everyone who is admitted is a high acuity patient and the likelihood of regularly having truly high acuity patients on a general med/surg floor is not very high. When I speak of high acuity I mean those with evolving MI's, impending intubations, etc. the type of things we get multiples of in any given shift in a busy ER. In addition when does a "temporary stopover" become not so temporary? Remember, we are holding admitted patients for days. In fact I have admitted a patient into a hold bed in the ER, had 2 days off only to return to discharge the patient who never actually made it to a floor. It clearly is not optimal in any situation for anyone but I think the floors are going to have to step up especially if the number of hold patients are crippling the ER's ability to take care of ER patients. In some cases it's a case of "out of sight out of mind". If you don't have to actually look at the problem then you are less inclined to do something to fix it (not you personally Leslie ;-) )Case in point. We had 8 hold patients in the ED because there were no available beds. Our administration demanded that an in-patient nurse come down to take care of them.We were even willing to give them one of our techs. The in-patient nurses did not want to do this because they were uncomfortable being out of their comfort zones and we didn't have the kind of supplies they needed. In less than an hour 8 beds magically became available and the patients were moved up. It was amazing how quickly things changed when it suddenly became their problem. Now I'm not saying that this would be the case everywhere, every time but it does make you think doesn't it? Maybe sometime in the future when ERs aren't being overcrowded it will be okay to board patients for extended periods of time but unfortunately that time isn't now.