The problem of ED overcrowding began appearing

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1 CLINICAL A Strategy to Manage Overcrowding: Development of an ED Holding Area Author: Laura T. Gantt, RN, PhD, Greenville, NC Laura T. Gantt, ENA Eastern Tarheel Chapter, is Research Chair, State Council, North Carolina ENA, and Administrator, Division of Emergency and Transport Services, Pitt County Memorial Hospital, Greenville, NC; formerly, Manager, Adult Emergency Department, WakeMed Emergency Services, Raleigh, NC. For reprints, write: Laura T. Gantt, RN, PhD, 2100 Stantonsburg Rd, Greenville, NC 27835; ltgantt@pcmh.com. J Emerg Nurs 2004;30: /$30.00 Copyright n 2004 by the Emergency Nurses Association. doi: /j.jen The problem of ED overcrowding began appearing in the medical literature 10 to 15 years ago. 1,2 A variety of answers have been proposed by local, national, and government agencies. However, authors writing about overcrowding have pointed out that changes will not occur overnight and that individuals, institutions, and professional organizations must continue to identify policies and operational changes that will help alleviate ED crowding. 3 Emergency medicine, nursing, and popular literature reflect an ongoing and escalating crisis related to ED overcrowding, but research related to its effects or descriptions of strategies for managing ED overcrowding remain scarce. This article will describe, in detail, the successful experience of developing an ED holding area (EDHA) at WakeMed Emergency Services in Raleigh, North Carolina. Background ED holding units have evolved a great deal over the years since the problem of ED overcrowding began. What once was called an ED overflow area was for a while a more clearly defined observation area, evaluation unit, or chest pain unit (CPU) before some part of it again became an overflow or holding area. Typically, holding units have been developed to help emergency departments cope with flow issues resulting from a shortage of hospital beds for admitted patients, and currently, most ED professionals agree that holding units seem to be here to stay. Despite the many variations on holding areas, a search of the literature reveals only a few citations concerning them. Sobie and colleagues 4 researched whether ED holding patients received a different standard of care compared June :3 JOURNAL OF EMERGENCY NURSING 237

2 with ED direct admit patients. Based on the frequency with which vital signs were obtained, timeliness of the administration of antibiotics, and certain documentation measures, the authors found no statistical differences in care between the 2 groups. Clark and Normile, 5 on the other hand, researched critical care admitting order delays in the emergency department and the effects on inpatient length of stay. Their study demonstrated that ED nurses are frequently caring for both inpatients and emergent patients simultaneously, causing them to overlook items on admitting order sets at times. Not surprisingly, the longer the length of stay, the more missed or delayed orders there were. Ganapathy and Zwemer 6 described grouping admitted patients in the emergency department to allow the use of mid-level practitioners to provide care. However, their article does not discuss use or staffing of a separate holding area. Case Study: The WakeMed Experience WakeMed Emergency Services, like many other emergency departments, has been working for several years on a variety of solutions to ED crowding. Emergency services at WakeMed includes separate adult emergency (AED), children s emergency, and holding areas. Systemwide, intradepartmental, and interdepartmental performance improvement projects have been implemented to decrease internal and external delays as they affect flow through the emergency department. These projects have addressed delays from the beginning of the patient s ED encounter and movement through the system, including laboratory and radiology turnaround times, to discharge or inpatient admission. The EDHA is one of several successful initiatives undertaken as part of Emergency Services Performance Improvement. These initiatives have collectively resulted in a nearly 15% reduction in time in our departments and a 74% reduction in the number of patient elopements, even as patient volumes have increased. The need for more space and systems to take care of both high-acuity emergent patients and admitted patients has been an ongoing concern as the Raleigh area has grown and as WakeMed continues to provide tertiary care to a growing number citizens of central and eastern North Carolina. The opportunity to consider a holding area arose when the CPU, which had previously been housed in the emergency department, moved to another location during the summer of The CPU space was underutilized because of fluctuating demand and a lack of dedicated staff. Interestingly, the patients complained only occasionally about having limited visitors and less privacy because they appreciated having the nurses and technicians so close to them that call lights were nearly unnecessary. SPACE: TAKE WHAT IS OFFERED The objective of the EDHA was to provide a staffed area where inpatient admissions could be cared for pending availability of an inpatient bed. The CPU space was right in the emergency department, an ideal location. 7 The EDHA opened in the year 2000 in a cramped 7-bed area at the rear of the then 24-bed emergency department. The emergency department has since expanded to 34 beds and the EDHA is now 18 beds. For the first 9 months of its existence, the EDHA had only a small nurse s station and one patient bathroom in close proximity to the 7 narrow cubicles divided only by curtains. Interestingly, the patients complained only occasionally about having limited visitors and less privacy because they appreciated having the nurses and technicians so close to them that call lights were nearly unnecessary. In 2001, the proposed remodel of the holding area became the new addition to the AED. The holding area then moved out of the first floor AED to the fifth floor of the hospital and expanded to 12 private patient rooms. Although the AED and EDHA staff had some initial concern about the distance between the units, both staff groups recognized the improved environment for patient care and comfort. Patient complaints about noise and lack of privacy stopped entirely when patients had their own rooms, bathrooms, and televisions. Admitting physicians were very confused by having the EDHA so far from the emergency department in the first few months after the relocation, but they adjusted over 238 JOURNAL OF EMERGENCY NURSING 30:3 June 2004

3 time. From the beginning, all of the EDHA beds had monitors, because the majority of patients being held for admission require monitoring for a variety of diagnoses, including congestive heart failure, possible myocardial infarction, and stroke. Other common diagnoses include pneumonia and abdominal pain. Most patients in the holding area are adults, but the area also occasionally houses late school-aged and adolescent patients. STAFFING: SELECTION, FLEXIBILITY, CROSS-TRAINING The EDHA has remained under the direction of Emergency Services. The unit does not have a need for its own physician staff because each patient has an admitting doctor for either regular inpatient or observation status. Originally, the manager of the AED also managed the holding area; as the holding area expanded, the hospital elected to hire a separate manager for the area in the interest of fully developing the area and staff. Although the AED and EDHA are discreet units with separate staffs, the holding area staff cross-trains in the adult department and cares for patients there when the holding area census is low. AED staff members are required to work in EDHA occasionally in the event of extremely high census or staff sick calls. Although AED staff initially were resistant to working in the EDHA, they became more comfortable with the idea as they got to know their EDHA counterparts who worked alongside them on many days in the AED. In addition, the management team encouraged a sense that both groups must help one another based on patient care and throughput needs. The priority for orienting holding area staff is to the holding area, but the cross-training opportunities for the EDHA staff enable the holding area staff to learn ED skills over time. Hiring the right type of staff for the EDHA has been paramount because the goal has been to have staff members who can work flexibly between areas, sometimes several times per shift. The best potential registered nurse (RN) staff for our holding area have been those with solid medical-surgical or telemetry nursing backgrounds, good organizational skills, and the ability to master basic arrhythmia management skills. Successful completion of advanced cardiopulmonary life support within the first 6 months of employment in the EDHA is an expectation. The nurse-to-patient ratio is 1 RN to 4 patients. Because there may be as few as 2 technician/secretaries for 18 patients, the holding area RNs also learn order entry during their orientation period, which usually lasts 4 to 6 weeks for the holding area alone. Although ancillary staff support has always been important, the role of the technician/secretary has become increasingly crucial as the unit has grown. Because all emergency services staff are responsible for drawing blood for laboratory studies and performing EKGs, all nurse technicians are trained to perform these functions. Early in the development of the EDHA, the decision was made to hire persons capable of dual technician and secretarial functions in the interest of staffing efficiency. These staff members are certified nursing assistants who already have clinical secretary skills or who can easily be cross-trained to this function. The EDHA schedule has provided opportunities for retention of those staff who prefer to have weekends off or longer summer vacations. These are the times when census is typically low... AED and EDHA staff report to the same location for pre-shift report at the beginning of each shift. Based on AED and EDHA census and acuity, the AED charge nurse determines if any or all dedicated holding area staff members should report to the EDHA. A team leader is designated for each shift in the EDHA. The team leader typically takes a full patient assignment; this practice will require re-evaluation as the area continues to grow and potentially takes on other functions. EDHA census is predictably lower on holidays, weekends, and during the summer months. During these times, AED orientation is planned for staff who have not previously been oriented. If the EDHA begins a shift without any patients, EDHA staff receive AED assignments. Those assignments are ones that make it possible for them to leave the AED easily at the point at which patients are sent to the EDHA. EDHA staff assist with transport of holding patients from the AED to the holding area on a frequent basis. June :3 JOURNAL OF EMERGENCY NURSING 239

4 The EDHA schedule has provided opportunities for retention of those staff who prefer to have weekends off or longer summer vacations. These are the times when census is typically low, so staffing numbers are maintained at lower levels at those times. Because the EDHA staff are cross-trained to the AED, some elect to transfer to the AED. Initially, we did not anticipate that the holding area patients would be on the unit long enough to need discharge planning, but many patients are, in fact, being discharged from there. The AED clinical coordinators, who perform discharge planning functions and help facilitate appropriate inpatient or observation bed assignment for the AED, assist with these same functions in the holding area on the fifth floor. The AED social work staff also cover the holding area. Our EDHA has experienced similar difficulties justifying its existence on a financial basis because the unit s census is so variable, especially during the spring and summer months. Fortunately, reimbursement for patients held in the area is roughly even with expenditures. Policies and Procedures: Increasing Options for All Patient Types Whereas chest pain observation units generally have admission criteria limiting the intensity of medical services required by and anticipated length of stay for each patient, the EDHA has evolved in such a way as to be able to take any type of patient except those who are medically unstable, on ventilatory support, or without admission orders and an admitting physician. The holding area staff take pride in being able to care for intensive care stepdown patients, including those requiring nitroglycerin, heparin, and other intravenous medications. Patients who become unstable during their stay in the EDHA are relocated to an appropriate intensive care bed, or, if absolutely necessary, back to the emergency department. Although code blue calls in the EDHA are handled by the same team that responds for other inpatient units, the AED staff provides support to the holding area when patients require shorter term intensive procedures such as cardioversion. Policies and procedures have been developed to allow direct admission patients who arrive at the emergency department with admission orders to go directly to the EDHA when inpatient beds are not available. Budget and Funding: The Challenges of Variable Census Although there are many great reasons to open and continue a holding area, financial reimbursment for services may not be one of them. Data from one study 8 failed to demonstrate justification of an ED observation unit on the basis of closure of inpatient beds and transfer of resources. The authors attributed this finding to inconsistent usage of the unit; very strict criteria were used to determine appropriateness of admission. Even though it accepts patients with a wider range of diagnoses, our EDHA has experienced similar difficulties justifying its existence on a financial basis because the unit s census is so variable, especially during the spring and summer months. Fortunately, reimbursement for patients held in the area is roughly even with expenditures. The reimbursement for holding area services is the same as that for inpatient admission or observation. However, the holding area s highest census is typically during the evening hours before patients from other areas are discharged. Inpatient reimbursement at our hospital is tied to the midnight census, which may be the point of the lowest census for the holding area. The midnight census in the holding area is not at all reflective of the number of patients who may have come and gone from the area in the previous 24 hours. Opportunities for Research and Improvement: Future Directions Although we have not studied patient satisfaction within the holding area itself, the AED has seen improvements in patient satisfaction scores during the past 2 years. As the holding area has expanded and facilitated more timely movement out of the AED, wait times to be seen have decreased, as have complaints. 240 JOURNAL OF EMERGENCY NURSING 30:3 June 2004

5 The physicians who admit patients to the holding area have had various concerns that we have had to address during the past 3 years. Initially, staff were not familiar enough with inpatient order sets, and orders for consultations frequently were omitted when staff could not easily sort out whether a patient would be in the holding area long enough for the consult to be initiated. There has been pressure from various physician specialists to transition the holding area to an inpatient unit like, the orthopedic, telemetry, or whatever favorite familiar area a particular physician prefers. Because the holding area is meant to be a transitional unit rather than a regular inpatient unit, we have not succumbed to the pressure to have it be like other inpatient units. Another issue that will need to be revisited is whether to have the holding area continue to use the same online documentation system that the rest of emergency services uses or whether to return to paper documentation, as is currently used throughout the rest of the hospital. We have had to make certain adaptations because of online documentation, such as printing the nursing documentation every 4 hours for placement in the chart so that it is easily viewed by admitting physicians. Historically, the online documentation was only printed at the time of the patient discharge from the AED or EDHA. Having all of the patient tracking and documentation on one system allows the charge nurse in the AED to be able to view the charts and keep track of the patients in the holding area. There has been pressure from various physician specialists to transition the holding area to an inpatient unit like, the orthopedic, telemetry, or whatever favorite familiar area a particular physician prefers. Our performance improvement projects for the holding area to date have been limited to chart reviews to ensure timeliness of medication administration and appropriate pain management, although the literature has provided us with some idea of indicators for potential improvement projects. For example, Clark and Normile 5 found that delays in implementation or follow through of admission orders were associated with an increased length of hospital stay. Our Acute Coronary Syndromes Performance Improvement Committee found that length of stay for patients in the chest pain observation unit and patients with comparable diagnoses in the holding area were roughly the same. However, patients with similar diagnoses who were held in the AED were discharged sooner; we do not know whether this is because this group of patients had less complex diagnoses and work-ups or because the patients were under more vigilant surveillance by the ED staff and physicians. We also are replicating the study discussed earlier in this article by Sobie et al 4 as a quality assurance or research project to include a third group of stable ED patients held physically within the AED rather than in the separate holding area. We believe that patients who go to a holding area will fare better than those kept in the emergency department. As we move forward, proposals for changes to the functions of the holding area have included each of the following: Observation. Currently, the only designated adult observation unit in our hospital is a CPU, consisting of 6 beds devoted to ruling out myocardial infarction in patients with chest pain. The EDHA has accepted observation patients but has not been a designated observation unit. The CPU often is closed when there are insufficient chest pain patients to make assignment of nursing staff to that area cost effective. At other times, the CPU is not large enough to accommodate all of the chest pain patients. In times of low or high census, CPU patients are held in EDHA or the AED, which leads us to speculate that we could designate beds in the EDHA for varying types of observation. A benefit of observation units is better definition of the patient s problem with resulting reduction in costs and inappropriate dispositions, reduced ED workload, improvement of patient flow in the emergency department, and reduction in liability by allowing more time to adequately diagnose difficult problems and additional time for initiation of outpatient management strategies. 7 Patient satisfaction with an observation unit may be June :3 JOURNAL OF EMERGENCY NURSING 241

6 greater than with an inpatient unit when patients perceive that they are moving more quickly toward discharge. 9 The challenge with observation patients, however, is close monitoring of patient progress and testing outcomes to ensure timely discharge. In a unit of varying patient diagnoses, acuity, and medical complexity, such as is the case in the holding area, observation patients tend to become regular inpatients if staff are not attuned to the 23-hour observation timetable. Procedural Treatment. When the holding area has not been as full with admitted patients, we have used the space for treatments such as blood and iron infusions. Some persons have suggested that the objective of the holding unit may be to manage treatments like these, including chemotherapy. 7 One study 10 found that procedural patients actually experienced shorter length of stay while being cared for on an observation unit, perhaps because of the unit focus on expedited flow. 4. Sobie J, Graves D, Tringali A. ED hold patients: is there care also being held? J Emerg Nurs 2000;26: Clark K, Normile L. Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-atlantic states. J Emerg Nurs 2002;28: Ganapathy S, Zwemer FL. Coping with a crowded ED: an expanded unique role for midlevel providers. Am J Emerg Med 2003;21: Brillman J, Mathers-Dunbar L, Graff L, Joseph T, Leikin J, Schultz C, et al. Management of observation units. Ann Emerg Med 1995;25: Sinclair D, Green R. Emergency department observation unit: Can it be funded through reduced inpatient admission? Ann Emerg Med 1998;32: Rydman R, Zalenski R, Roberts R, Albrecht G, Misiewicz V, Kampe L, McCarren M. Patient satisfaction with an emergency department chest pain observation unit. Ann Emerg Med 1997; 29:109-15, Poss M, Naylor S, Compton S, Gibb K, Wilson A. Maximizing use of the emergency department observation unit: a novel hybrid design. Ann Emerg Med 2000;37: Staging. As the holding area expands, it may be possible to use a limited number of holding beds for staging of patients requiring hydration therapy, discharge planning or education, or resolution of complex psychosocial issues such as nursing home placement. Each of these proposals, if implemented, would have an effect on flow through the AED and the holding area and our ability to provide quality patient care. During the 3 years that the EDHA has been in use, WakeMed has considered expanding its capacity even further. Like many areas of the hospital, the EDHA has been challenged to provide care to increasingly higher acuity patients while trying to decrease length of stay. Our holding area is a working concept, as well as a work in progress, and we will continue to explore its potential as one solution to maximizing ED flow. REFERENCES 1. Lynn SG, Kellerman AL. Critical decision-making: managing the emergency department in an overcrowded hospital. Ann Emerg Med 1991;20: Nordberg M. Overcrowding: the ED s newest predicament. Emerg Med Serv 1990;9: Richardson L, Asplin B, Lowe R. Emergency department crowding as a health policy issue: past development, future directions. Ann Emerg Med 2002;40: JOURNAL OF EMERGENCY NURSING 30:3 June 2004