Welcome to ENA's Emergency Department Leadership Coffee Talk. Today's talk is entitled Patient Stuck in Limbo, Emergency Department Boarding Crisis. Before we begin, I do want to tell you a bit about our esteemed speaker, Zinkana Desai. Zinkana has over two decades of invaluable forefront emergency care experience. Her career has spanned 23 years, and she navigates the complexities of the emergency medicine with grace and resilience. Prior to joining ENA, Zinkana served as a patient care manager with an unwavering dedication to improving patient outcomes and enhancing operational efficiency. So prepare yourself to be inspired, informed, and empowered to evaluate your practice to new heights. It is my pleasure to introduce Zinkana Desai. Hello, Zinkana. Thank you, Nan. I am Zinkana Desai, your guide in navigating you through the turbulent water of ED boarding crisis. As a previous patient care manager, I understand the strain it puts on patients, staff, and the health care system as a whole. So here is my disclosure statement. I have no financial relation with the company and for the content I will be presenting today. And at the end of this webinar, you all will be receiving a 0.5 contact hours for attending this entire webinar. So let's get started. So throughout this webinar, I will speak to you about boarding, we'll present some data, we'll talk about the impact of boarding it has on patient care and the staff well-being, and then what you've all been waiting for, strategies and best practices to optimize ED flow. So what is boarding? Let's dive right in. There are so many definitions of boarding that are floating out there. Whether your institution uses time zero or 60 minutes, the patients are still boarding in the emergency department. Boarding clock starts when the decision is made to admit the departure timestamp. For example, joint commission also states that boarding patients more than four hours is a patient safety risk. And who's not boarding more than four hours these days? So framing this issue as ED boarding, thus an ED problem and for ED to solve is not the case anymore. It's clearly a patient flow and patient management issue. So in September, 2022, JAMA Network Open found that hospital occupancy greater than 85 to 90% correlated to increased ED boarding beyond four hours. So clearly we know that it's a hospital boarding issue. So let's look at a length of stay. Despite all the work that ED was doing, this time still went up to 211 minutes in 2022. And this is a median across all EDs. So if your ED is seeing a smaller volume, this number will be smaller. And if your ED is seeing a larger volume of 60K plus, this number will be twice the length at 284 minutes. So what are our boarding times? In 2022, it went up to 190 minutes. These boarding times crushed most ED operations. It impacted all areas of ED performances. So again, this time is very cohort dependent. If your ED is smaller, it will range anywhere between 116 minutes. And if your ED is larger, seeing 80K, this number will average about 295 minutes. So it's amazing to see how far this boarding time has come along. Let's look at some of the challenges that you are experiencing. I know that you know that population is aging. Patients are getting sicker. We're seeing a higher acuity in their ED. That means more testing and increased length of stay. We're also losing our highly skilled nurses due to burnout, nursing workforce aging, due to budget related COVID-19, whatever it may be, we're experiencing a high, high turnover. We're also experiencing a trifecta this winter season, COVID, flu, and RSV that brought in high volumes to your ED. And then not to mention our decreased funding for our inpatient and outpatient behavioral health facilities that brought in high psychiatric volumes to our EDs. And then also our lack of community resources, the lengthy times to see your primary care doctor. I know when my daughter was sick and I called the primary care doctor, they couldn't get me in until July. So what did they tell me to do? Go to the emergency department. And same thing with our outpatient services, our primary care and outpatient services do not have off hours, weekend hours for our working population. So the chronic illnesses and the decompensated illnesses are presenting to the ED. For previous literature actually shows that increased surgical volumes, hospital closures, increased hospital length of stay, and decreased hospital staffing all have contributed to worsening ED boarding. And these are just to name a few. And there's lots more challenges that you are facing out there. So what does boarding, how does that have an impact on patient care? We know that there's patient safety events, delayed care, missed care, medication errors, medical errors, all because of overcrowding and due to increased nurse to patient ratios. Not to mention the high morbidity and mortality because of increased length of stay. And then our nurses and physicians are experiencing high levels of stress, increased workload, prolonged shifts, trying to manage these crowded EDs. So they're experiencing burnout. And then because of this, it's leading to staff turnover, which is further complicating the system even more. It also has decreased patient satisfaction scores because our patients are not happy that they're waiting a long time or they're waiting on stretchers in a hallway. And also increases their risk to workplace violence. And then the financial implication has on our healthcare system. It reduced reimbursements, increased costs, penalties for poor performances, not to mention the left without being seen rates, which is a stunning 4.9%. And the impact it has on your productivity because you're boarding set for long periods of time. And that also impacts your ED budget. So this long brewing problem with boarding is not the result of the pandemic anymore, but rather the function of the way the healthcare system has evolved that does not suit our patients anymore. So let's look at why are we having some inpatient barriers. Remember, I said it was hospital boarding. And ED admits about 13% to 15% of their patient. And then the average length of stay for hospitalization is five and a half days. How many times have you heard, we don't have an inpatient nurse to take care of those patients anymore? Or I have to close a unit down because I don't have any more nurses. Or my nurses are allocated to overflow areas. So there is a delay in discharging my patient. Or there's a delay in getting my patient his or her medication. So I can't get them discharged on time. Or the hospitalist hasn't come around to discharge the patient. Oh, wait, now there's a consulting physician here who ordered more testing on the patient so I can't get the patient out on time. Insufficient communication between your care coordination team that could get the patient out on time. And then now your patient is a difficult placement to skilled nursing facility, nursing home, or a psychiatric facility that you can't get your patient out on time. And then also our surgical cases. There's increased number of surgical cases to open beds. So these inpatient units are operating at or near capacity. And hospitals are struggling to accommodate new admissions from the ER, the OR, or the transfers. So continuing to follow this more lucrative path will fail our patients. So what do we need to do? So solution to ER boarding is not a one size fit all. It does require people to do things differently. Addressing ED boarding requires a coordinated effort from everyone, not just the emergency department. It needs a multifaceted approach, a strong leadership, and a hospital culture change. So here's what you've all been waiting for. Let's fix our shop first, right? And how do you do that? Start off with direct bedding, full-to-full and bedside triage and registration. This will keep things moving and flowing from your emergency waiting room. But this requires a good coordinated effort, communication effort between your triage nurse and your charge nurse or your clinical coordinator. Keeping lines of communication open with your leadership team regarding your NEDAC score can help move things along in your ED as well. However, if you are chronically boarding, sometimes this NEDAC score can go on deaf ears. So create an overhead code or an alert when ED reaches a certain capacity to get some assistance for your ED. Make sure there is a surge plan that is put into place when you reach that certain NEDAC score. And this is to hope to get you additional help to the ED. It's not mass casualty, although it could be with the volume of patients that you're seeing, but it's sheer high volume. Sometimes for your smaller EDs, what you can do is provider and triage. Let's work out of that front end care. Create an area for that intake process, horizontal or vertical space where providers can begin seeing patients from the waiting room. Sometimes they can even discharge those patients in the waiting room or begin their testing. And by the time they get back into the room, their results have been already there and can be a quicker discharge or an admission process. To mitigate nursing staffing issues, team nursing is a great way to do that. Paramedics are a great resource for your ED if your state allows. Depending on their scope of practice, they can help with triage. They can help with discharge, IV starts, medication administration, also depending on their scope of practice in their state. EMS personnel, CNAs, PCTs, medical assistants, they all can help reduce the nursing work burden for their task as well and then can keep things flowing along and nurses can do more. Lab personnel, reach out to somebody in the lab and see if the lab personnel can come down and knock out those standing orders or even a diagnostic imaging staff member. Give them a space in your ED so they can knock out those imaging orders from the waiting room or from the patients in their room. Standing orders, nursing-driven protocols, and clinical pathways are very useful to keep things moving and guiding your admissions and your discharges sooner. Let's look at some patient-centered approaches. And this will involve redesigning your care process. And the way you can do it is create an internal results waiting room. It doesn't have to be anything fancy, chairs lined up in the hallway for patients to be waiting until they get their results. And this can also help decrease your left without being seen rates. Pull patients that are awaiting discharge into the hallway so you can put your critical patients into the room. Split flows or fast track models to see your lower acuity patients can also be very, very useful. Work with your supervisors and inpatient leaders to see if there's any disused area in the hospital so that you can move those boarded patients up to those area. Let's look at your staffing. Do you have an on-call staff member or even an on-call physician to come in for these peak volumes? Or maybe even a seasonal nurse or a contracted nurse that can come in and take care of your inpatient boarders. And then you can even cross-train them to take care of your ED patients when you don't have those boarded patients. Look at your resource team. Is there anybody available to come down and help in the ED? I know all hands will be on deck. You will be out there assisting your team. But are there any non-clinical nurses that can come down to the ED and round on patients in the waiting room? There could be nurses. They could be CNAs, MAs. From any outpatient areas, they're experiencing low volumes. And they can take vitals. They can update patients in your waiting room, a great patient satisfier, and can help boost your patient satisfaction scores up, too. Very, very important to do that. And then your case managers are very useful in the ED. They can help expedite those discharges and admissions from your ED, which can keep moving things along. Hospital-wide bedsars are also very important. They can assist with the flow. There would be a nurse that would receive, accept, and review all the patients that are coming in so they can prioritize placement and who's being discharged or admitted. You can also have an ED-specific bedsar. This person, this nurse, would be moving discharges from your ED, cleaning rooms, getting those rooms ready, pulling patients from the waiting room, updating your track board, however it can be to keep your ED moving. This person can be very, very useful. Let's look at how inpatient can help assist with you in your ED. I help you. You help me. Remember, I said this was hospital boarding, not ED boarding. Communication is paramount. Keep lines of communication open and make informed decisions in real time. And how can you do that? Bed huddles is a great way to do that. Have a real-time demand capacity dashboard, a digital dashboard for all divisions to prioritize patient care. This can help expedite early discharges. If patients are awaiting lab orders or diagnostic imaging orders before they get discharged, they can move things along to do that. Does your hospital also have a contingency staffing plan to keep beds open? For example, hospitals can increase inpatient nurse ratios from four to one to five to one so they can send a nurse down to the ED to help care for those boarded patients. Try to match those inpatient discharges with your ED demand. Do you monitor capacity management plan, red, yellow, black, bed red alert days to set the tone for the hospital, especially on those red and black days? Your bed management team can help with those early discharges and surgical cases. Can your hospitalist change their flow around and round in the way in the ED on your inpatient boarders first? Sometimes they can upgrade them, downgrade them, or even discharge them from your emergency departments. Ask your inpatient leaders or directors to come down and round on your inpatient borders. That will help their patient satisfaction scores tremendously because that's what they wanna know. They wanna know updates. Work with your resource team or your supervisors to see if they can send an inpatient nurse down to the ED to take care of your inpatient holds. This is a great way for cross-training opportunities and for recruitment and retention as well. I know there's some things that need to be communicated, but no report handoff, an SBAR tool in your EMR system can also help shave off some time. So if a patient has been assigned a room, send them straight upstairs, and the nurse can read the report in their EMR system. Observation units are also a great way to hold patients. Sometimes it's very important to keep your inpatient borders in one zone and pod, so that way, whoever their nurse is caring for these patients are not taking care of ED patients and your inpatients patients for patient safety. And observation units is a great way to do that. Here are high impact solutions. Your senior leadership support is very, very important. Let's say proactive and not reactive. Create a search plan with your senior leadership team so that a member of your senior leadership team can be on call for off hours and weekends. Get them involved in bed huddles and management meetings. The real-time demand capacity digital dashboard is going to be very, very useful. Make it transparent across your organization so when you or your senior leadership team member is not there, everybody can work together to make movement. Discharge lounge is another great way for patients that are waiting for a ride upstairs in the room. They can wait downstairs in the discharge lounge. Even your ED patients can go wait in the discharge lounge once they have those discharge orders. So that they can be, it can be just the front entrance of the ED and then they can just come and pick them up. Remember to build a guideline for those discharge lounge, some inclusion and exclusion criteria. Communicate those NEDAC scores with your team so that if there is overcrowding, they can consider opening up those overflow areas or even hold them in the PACU. Can those surgical patients be held in the PACU or if their ICU is full, can some of your ICU patients can go up into the PACU to await until those ICU rooms open up. We're holding patients in the ED hallways. Can you create an upstairs inpatient hallway beds? Again, build those inclusion and exclusion criteria only for those med surge units and not for your intensive care patients. Work with your chief medical officers to get those hospitalists and intensivists to discharge your patients sooner. Physically empty bed before 10 or 11 a.m. before your ED reaches those peak volumes. Hospitals are not a five-day operation anymore and it cannot continue to run that way. Work with your leaders to smooth out those elective surgical cases. The same number of cases throughout the week for your placement unit. And how can you do that? Look at your number of admissions that are coming from your ED. Compare that to your scheduled surgeries. Is it skewed or is it the same? Make sure you're matching them for your inpatient units. Other additional strategies that you can use is telemedicine for your low acuity patients. Sometimes for your rural hospitals, how can you do that? Making a designated telehealth room in your ED with an onsite nurse and an onsite tech to take care of those patients with an offsite physicians. That can keep moving your low acuity or even your soft three patients from your ED waiting room. Telepsych is a great way to move those psychiatric patients so that they're not holding up the space in your emergency department. You can also collaborate with your community partners, your skilled nursing facilities, nursing homes, primary care providers for ED utilization so that they can move things along. And especially for those weekend discharges so that they can smooth those out. Appropriate and timely primary care follow-ups for your chronic illnesses can also help. And case managers, especially for your high utilizer ED patients, they can give them referrals to community services and assist with those discharge planning. Effectively tell your stories, share your data. It speaks volume. You don't want turnover and ED nurses are not experiencing burnout due to working hard. They will work hard. There is burnout because they are not getting the support they need. Get them the support they need. Look at your ED budget, account for those boarded patients into your productivity. Look, this is a great opportunity for them to cross-train nurses to and from other areas. And this will help with your staffing. And how can you do that? Look at your number of hold hours, multiply that by your nurse to patient ratio, which will give you your required care hours. Or take those required care hours, divide them by your ED total volume in a pay period, which will give you your worked patient hours for your holding patients. And this is to get the nurse care that you need in your emergency department. So if you take anything away from this webinar, tell your stories, share your data, create effective interventions, redesign your care process. As we confront the challenges of ED boarding crisis, we must remember that behind the statistics and the headlines are real people. We need to work together. It takes a village to raise a child. It will take a village to fix this issue. Thank you guys all so much for attending this webinar. And then after this webinar, you will also receive a link to fill out a short survey and to claim your CEs. Thank you so much. Thank you so much. So we do have some questions that have come through that I wanna go ahead and ask you before we finish. So the first one I'm going to ask you is, how can the ED accommodate the appropriate nursing to patient ratio that is required on the type of patient, such as ICU, et cetera? Thank you, that's a great question. So I mentioned some of that in my webinar as well. Contingency staffing plan is a great opportunity to have that flexible staffing in your ED. So they can increase the nurse to patient ratio upstairs on med surge units from four to one to five to one. Flexible staffing plan in your ED is also a great way to accommodate appropriate nursing staffing ratios as well on call for your, especially during your peak volumes. Seasonal nurses or contracted nurses is also another great way. Prioritizing your resources, zones, pods, fast track or split models is another great way to move things along and increase or decreasing your nurse to patient ratios. Also efficient patient flow is another great way to do that. And then your surge plans, very, very important to create those surge plans with your senior leadership team to optimize that ED flow. So that's a great question. Great, thanks. Okay, next question. Does a discharge lounge or placing discharges in hallway work to decrease boarding? What are the top five key strategies for an organization to take to work to avoid boarding? Absolutely. Discharge lounge has been very, very effective to decrease boarding in the emergency department. And especially for those patients that are awaiting rides or they're awaiting a discharge and you put them out into the waiting room. And of course, this also depends on your hospital layout, depends on patient volume, and then also depending on if you have the staffing resources. But discharge lounge has been very, very effective to decrease that boarding time. And those five key strategies for your organization to avoid boarding, number one is optimize inpatient flow. Very important to match your discharges with your ED flow. We know that witching hour, that 11 a.m. witching hour where the ED starts seeing that high volume. So very important for your inpatient leaders to get those discharges out of their beds, physically empty beds before 10 or 11 a.m. Those capacity management, real-time digital demand dashboard so that everybody can see what's going on in the entire organization. How many surgical cases are there? How many admissions are there? How many discharges out there? How many ED patients are already waiting in the waiting room and are in the room themselves? So this will help optimize flow and keep things moving. Working with your community partners, so especially for your high ED utilizers, or we know that there's some patients that don't need to come to the ED, so work with those primary care, your skilled nursing facilities, your psychiatric facilities to keep them out of your ED. And then in the ED specifically, your rapid assessment and triage will help tremendously to move things along. So thank you for that question. That's a great question. Great, great. The next question actually starts first. This came in to us from one of our registrants that said, thank you for this webinar. So thank you. They're curious as to how other healthcare system administrations view the ED. So one is a pathway for admission, which leads to the care and the procedures and the income, or as an overhead that does not produce any funding and is a blip on their radars. Wow, yes. Great question. This will definitely depend on the healthcare administration itself. There are some hospitals that will view ED as a pathway for admissions, recognizing its role as a revenue generator. And then there will be some organizations that will preview ED as a cost center. So for example, rural EDs, they will have lots of patients that will come in through their EDs and then which will guide their admissions. And then there will be some that will have a lot of surgical cases. Remember I said that inpatient hospitals are at a high inpatient capacity because of those surgical cases and the surgical cases are very lucrative and are very revenue generators. So they will bring those up at a higher demand versus the EDs. So definitely will depend on your hospital organization themselves. Great, thank you. The next question, are there any other models or frameworks besides NEDOX to help expedite the flow of patients? What are some safe interventions we can utilize if our facility intermittently has surges of psych patients that significantly affect patient movement? Yeah, NEDOX score is very important to optimize that ED flow. And like I said, sometimes if you're chronically boarding, that will go on deaf ears. So working with your performance improvement team and maybe some lean healthcare projects to optimize flow in the inpatient and the ED department and the EDs. Also Six Sigma is another great way to optimize flow from the inpatient and the ED. And then some of those, for example, door to dock times, their discharge times, your door to CT times, or door to chest x-ray times, EKG times, all have helped to shave off times to optimize that ED flow. And then also creating that overhead or that alert when ED reaches a certain capacity so that everybody knows that ED is now very busy so that they need to either smooth out those surgical cases or work in the inpatient department to start bringing patients down to the discharge line so that they can make room upstairs for those ED admissions. Okay, thank you. Oh, and I forgot, I'm sorry. And I forgot one more. Tele-psych is another great way to optimize for the flow of your psychiatric patients. And then also creating maybe a psychiatric emergency service. So maybe you have a psychiatrist that can come along to the ED and round or do those consultations on their psychiatric patients in the ED and then so that they can move them along from your ED and that they're not waiting longer. Great, great. Thank you, Nan. You bet. So I'm gonna ask one more question, okay? How to get inpatient colleagues to collaborate or even better to take the lead on boarding in the ED? We know there likely isn't an ED only solution for boarding of admitted patients. Yeah, very, very good question. It's hospital boarding, not ED boarding. So we all do have to work together. Joint problem solving, bed huddles, the real-time demand capacity dashboard, getting your inpatient leaders to come down to the ED to round on those inpatient boarding patients. Also cross-training opportunities so that your inpatient nurses can understand, and empathy, have empathy with those ED nurses. Having those ED nurses sometimes cross-train upstairs to ICU or inpatient departments so that they understand their flow of the department. Data sharing is very, very important so that you can communicate, but keeping those lines of communications open with your senior leadership team, with your inpatient leaders and directors, cross-training opportunities, and making joint problem solving together with your leaders will definitely solve this ED boarding crisis. And then that way they understand what you're going through and you can understand what they're going through. For example, I used to have leaders that used to come down to the ED when their nurses couldn't come down to the ED to take their admissions upstairs for the nurses. So that's another great opportunity to work with your leaders as well. Great, thank you. Thank you. So I'm going to stop with the questions. Is there anything else you'd like to go over before we end our session today? No, Nan, thank you for hosting this. And I really want to thank you all for joining this webinar.

ED boarding crisis

patient flow

nursing shortages

hospital collaboration

telemedicine

systemic changes

real-time data