Background
Methods
Study design
Selection of participants
Representative role |
N
|
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Chief Nursing Officer | 5 |
Nurse Manager | 3 |
Chief of Emergency Medicine | 2 |
Vice Chair of the ED | 1 |
ED Medical Director | 3 |
Associate Medical Director | 2 |
Medical Director | 13 |
Director of Operations | 3 |
Theoretical framework
Data collection
Data analysis
Results
Characteristics of study subjects
Main results
FCP core components (i.e., what is FCP?)
We designed our own version (FCP). We call it capacity protocol, and we have three levels. For each level, there is a series of criteria that we have set and at each level there are various things that happen. We also have the ED flow coordinator, which is a position that we created alongside with doing the capacity protocol. The flow coordinator has the capability to activate the protocol early if they recognize that things are soon going to reach a level two.×
FCP adaptation framework
There’s reluctance at the hospital administration level to put patients in the hallway upstairs, so that would happen, but very, very rarely, probably once or twice a year. So what would happen more often is pressure being placed on the upstairs people to get patients discharged or to move into a discharge lounge to wait for their ride.
Green | |
Things that can be changed: | |
•Name of the protocol (e.g., escalation policy) | |
•Time of morning safety huddle | |
•Incentives for participation | |
•Format and wording of the protocol | |
Yellow | |
Things that can be changed/modify with caution: | |
•Number of levels (generally 3 or 4 levels) | |
•Activation triggers for each level | |
•Actions in each level | |
•Order of actions in each level | |
•Add other ED crowding interventions (e.g., use of discharge lounges, surgical smoothing) | |
•Generally aim to place no more than 1 to 2 patients on any one-inpatient hallway. Hospitals cautiously can change this to whatever is needed, depending on crowding situation, the physical environment on each inpatient unit, and available staff and resources in inpatient units. | |
Red | |
Things that cannot be changed/ignored: | |
•Do not change the order of the levels (sequence) | |
•Do not delete an entire level of the protocol | |
•Place patients in areas with access to a bathroom | |
•Place patients in areas that least obstruct flow | |
•Do not transfer patients who are not eligible to transport to inpatient hallways including: | |
1. Patients need intensive care unit (ICU) or cardiac care unit (CCU) bed | |
2. Patients requiring negative pressure room | |
3. Patients requiring 4 L or greater of oxygen | |
4. Patients that require suctioning | |
5. Patients with unstable vital sings | |
6. Patients with Glasgow Coma Score < 15 | |
7. Mechanically ventilated patients | |
8. Psychotic patients | |
9. Patients that have diarrhea or are incontinent of stool | |
10. Patients at immediate risk of seizures | |
11. Patients with open wounds | |
12. Patients at high risk of bleeding | |
13. Children and patients who are 75 years and older | |
14. Patients with recent high-risk coronary artery disease | |
15. Patients with history of heart failure, stroke | |
16. Patients with history of peripheral arterial disease | |
17. Patients with chronic obstructive pulmonary disease |
Determinants of FCP adoption and implementation sorted based on CFIR domains
Domain: intervention characteristics
We had a couple of other things that were already going in parallel to this, but it actually decreases our walkouts. It decreases our left without being seen because it facilitates our ability to see our emergency patients. It improves the entire hospital operations. Inpatient staff began to work with case management, they worked with social services to find ways to get people out of the hospital early.
The one sort of challenging part of it was we wanted Epic ... So we use Epic as our electronic medical record. We wanted them to be able to create these additional spots. So you had to have them create a virtual spot to put the patient into on the floor, so that way the nurses could chart and the doctors could write notes and et cetera, et cetera. So they had to get all that built in Epic.
We actually have physical inpatient beds that are just not staffed. So we, on any day of the week, have 30 or so physical beds that could be used for patients, but we don’t have nurses for them. So I don’t think that we wouldn’t need to even put people in the hallway. We could just put them in the beds that aren’t staffed.
Domain: inner setting
You know our hospital system is like a city, so any change in that scale needs tons of paper works and meetings to get all the players on the board. We have a joke here that said passing a law in the Congress is easier than making a change here.
People in our health system just seem to be too comfortable having patients wait for their care and we were not comfortable with that. So just trying to overcome that culture, both from an inpatient point-of-view as well as an emergency department point-of-view, to be honest, that’s a big challenge as well.
No, it (ED crowding) is not a hospital problem. The ED crowding because of the nature of the emergency department, the front door is always open. We cannot close the front door of our ER. The back door of our ER closes all the time. So, the ER has for years, been able to manage that accordion style flux and surge without really having any kind of offshoot, or any kind of mechanism to take the capacity. So, as it stands now, we’ve done so well at managing it, and we continue manage it without complaining or without making a big deal. It’s not a hospital problem, it’s solely an ER problem.
I mean I think we have a collaborative culture that’s very based around the patient and trying to do the right thing for the patient. I think there are good relations with the inpatient and administration. I don’t think we always necessarily agree on the best way to go about things, but I certainly think if we were able to make a compelling argument, then we may be able to make grounds on it.
You need complete support from the executives in the hospital, they have to be willing to be champions and truly eliminate barriers and you have to have a mechanism to develop relationships between the different departments and the staffs in the different departments, because if you don’t have those relationships and you haven’t built the groundwork and they haven’t felt involved in the process, then the process is going to hit a lot of resistance or may fail.
Despite our efforts such as meetings, grand rounds with national leaders on this topic to advance the adoption of a full capacity protocol we have not been able to convince the hospital to do this. It was essentially blocked by our CNO, who was in place for years.
I don’t think that there was a lot of training necessary on the ED and inpatient side of things. And really, it was just the training that was necessary with the proper selection of the patients who are going upstairs and that was for sort of the shift supervisor of the ED and that’s about it. I think it was just the persistence of being exposed to this multiple times and the repetition probably helped and just soaked into the culture.
They (hospital leaders) have helped to create it. They wish they didn’t have to deal with it, so they don’t like it in that sense, but this takes up an enormous amount of their time and energy. I think, they like the process and are proud of it when they saw the diversion rates go down significantly.
Domain: outer setting
There was a local hospital that’s one of our competitors did it, approximately a year ago. And they had the fire Marshall called in, in short order and it was shut down. So that has kind of remained an anecdote of why we can’t do this.
There are rules about nursing ratios on floors. When you’re over that, there will be a ton of pushback on that.
One of the things that were brought up by the faculty and the nurses was that, when we were crowded it puts significant strain on them to accept more patients, especially ambulances. The walk-in patients will walk in, and there’s no way to deter them, but as long as we continue to be successful with that (FCP), we also accept all ambulance patients diverted from other hospitals. To some extent, we’re victims of our own success.
Domain: process
So it was buy-in at the nursing leadership level that was very important and the most influential people in this actually were those nurse managers. Because it’s the nurse managers that need to go back to the nursing staff and say we are doing this for our patients. If they had gone back to their nurses and say listen to what they’re making us do now, putting patients in hallways, this would have never worked.
You can’t tell a patient in the ED, Oh, we’re sending you to your floor now. They are expecting a nice bed and a room and they get a bed in the hallway. They have to know where they’re going, so those are all training components for us there.
Discussion
Barrier | Recommendations |
---|---|
Inability to reach the consensus about the criteria for activation of and actions in each FCP level | •Collect and analyze operational data to create a predictive model and patient flow map. A predictive model and patient flow map gives a hospital the opportunity to appropriately plan resource allocation and prepare to address patient flow variability. Adapt the criteria for activation of each FCP level based on hospital unique flow variation [31] and identified hurdles. |
Lack of knowledge and information about FCP | •Disseminate knowledge and train various stakeholders about the FCP. Hospital stakeholders should be aware of the protocol and their new operational responsibilities. For example, clearly defining that once an admitting physician has accepted a patient, that admitting physician is responsible for the patient throughout the admission, regardless of patient location. |
•Key staff members such as nurse managers should be trained to participate in FCP implementation. These trained staff members can then become champions and coaches for others in the hospital. | |
Limited resources | •Provide adequate staffing and resources to inpatient units. Some examples of resources necessary to successfully implement FCP may be central telemetry monitoring, privacy screens, a wireless call system, portable monitor/defibrillator, portable suction equipment, and appropriate bathroom facilities for transferred patients. Remember, “adequate staffing” is relative to the patient’s viewpoint. Moving a patient upstairs may yield less than optimal ratios; but it may improve patient satisfaction. Reorganize hospital resources (e.g., EHR modification), revise existing operational procedures, and/or create new structures in line with FCP. |
Lack of leadership support and commitment | •Ask hospital leaders to personally visit the ED to view the crowding first-hand. |
•Tell a compelling story about what is going on with boarded patients and why they are not getting the care they need—how they are suffering because of crowding. | |
•Change some of the verbiage when sending information to the executive team and across the hospital. Describe the problem as a hospital capacity issue instead of an ED crowding problem. | |
•Take responsibility; do not blame other parts of the hospital. | |
•Make crowding a priority for hospital leaders. | |
•Present hospital leadership with studies that demonstrate financial opportunities lost due to crowding and ED profitability. Emphasize that crowding could indirectly damage the hospital by hurting the hospital’s reputation, increasing hospital length of stay, adversely affecting mortality and clinical outcomes, putting the hospital in danger of losing other certifications, and decreasing atient satisfaction. Many of these can affect CMS reimbursement. | |
•Hospitals tend to abandon the entire idea of FCP because of concerns about placing patients in inpatient hallways. Try to include inpatient hallway placement in the protocol, but do not sacrifice the entire FCP for this component. | |
•Outline the pros and cons of FCP over other known ED crowding interventions. | |
•Remind leaders that adopting both FCP and other ED crowding interventions are not mutually exclusive. One option could be to implement a combination of ED crowding interventions based on the hospital culture, needs, and resources. | |
•Do not oversell FCP. Be clear that it is not ‘the solution’ for crowding. Rather, FCP has been demonstrated to successfully reduce crowding. | |
•Hospital leaders should provide a consistent message about adhering to the protocol by providing tangible assessment and appreciation. Hospital administration should offer a modest but visible reward program. Reward systems may include informal celebrations, small denomination gift certificates, and senior leadership personally thanking staff on the floor for their efforts. | |
Cultural resistance | •Explain the benefit of FCP to all providers, specifically inpatient nurses. |
•Involve all hospital members in FCP planning. Pre-implementation involvement helps reduce barriers to change by creating psychological ownership, promoting the dissemination of critical information, and encouraging employee feedback for fine-tuning the change during implementation. | |
•Let key stakeholders know the appropriately assigned thresholds. For example, the higher level of FCP should rarely be activated (if ever). | |
Inpatient nursing resistance | •Listen to, acknowledge, and respect the concerns of nurses. Common concerns have been a lack of monitoring and threats to patient privacy and safety. |
•Emphasize that transferring patients to inpatient hallways is a last resort in dealing with crowding. The main purpose of FCP is for patients, not the ED. It is designed to optimize patient care in suboptimal circumstances. | |
•People are more receptive to participate in change when they perceive potential for personal and organizational benefit after weighing the strengths and weaknesses of change [32]. | |
•Ask nurse managers to help you address the problem. Show them that their efforts will not only help patients but also improve the work environment for ED nurses by more evenly re-distributing the workload throughout the hospital. | |
•Emphasize that FCP is not about room versus hallway; it is about which hallway. | |
•Work with CNOs to create an environment in which the floor nurses “pull the patient up” rather than the ED nurses “pushing the patient to the floor.” | |
Concerns about domino effect | •Communicate with local organizations. Consider inviting competitors to observe your processes. |
•Host town halls with community hospitals to present your metrics and process improvements. | |
•Educate local community hospital directors and nursing leadership about FCP. Ask them to join you. | |
External policies and regulations | •Before officially adopting FCP, address relevant regulatory guidelines that would have an impact on hallway boarding policies, such as those from the Joint Commission and the appropriate state regulatory bodies. It may be necessary to obtain approval from relevant regulatory bodies prior to FCP implementation. Joint Commission has not typically required prior approval, as long as fire safety regulations are addressed. |
•Work with the local fire marshal to determine how to safely implement the FCP. It is only through consulting with the fire marshal that one may determine how to overcome regulatory obstacles to inpatient hallway boarding. | |
•Justify FCP to fire marshals with two key concepts. First, describe how patient safety concerns are equally as critical in the ED as in the inpatient setting. Both should be viewed as acceptable. Second, describe how the risk of keeping a patient in an ED hallway is much greater than transferring that patient for a short period of time to an inpatient hallway. | |
•Conduct fire drills that involve transferring patients, how transfers are to be carried out, and actions to take in the event of a fire. |