S h a r i i n g c c a p a c c i i t t y i i n a c u t t e h o s s p i i t t a l l s s
A P r r o p o s s a l l t t o r r e s s o l l v e a s s s s e s s s s m e n t t a n d r r e s s u s s c i i t t a t t i i o n d e l l a y s s f f o r r p a t t i i e n t t s s i i n N S W E m e r r g e n c y D e p a r r t t m e n t t s s
Introduction
Emergency Department (ED) crowding is a barrier to the delivery of timely emergency care in NSW EDs. EDs have delayed offload times for ambulance arrivals, and EDs accommodate unstable patients on chairs or in other non treatment areas, pending the availability of an emergency department bed.
Review of ED occupancy, ambulance offload delays and ovetime payments to
“Ambulance Release Teams” demonstrates that NSW EDs are unable to immediately accommodate a new patient on an acute bed for the majority of their operating hours.
While emergencies must wait, often suffering adverse consequences
1
, all EDs have beds occupied by fully admitted patients awaiting inpatient placement
2
. These are patients for whom the ED phase of care has finished, and they are essentially
“boarder” or “overcensus” patients, whose occupancy of an ED bed prevents the delivery of emergency care to unassessed unstable new arrivals.
For these boarder patients, delay in transfer to the destination ward has been shown to adversely affect patient outcome 3 , especially in the seriously ill. Patients who experience access block had a mean inpatient (after ED) LOS 0.8 days longer than those who had no access block in recent Australian studies
4
.
Full Capacity Protocol
1 http://www.smh.com.au/news/national/hospital-death-riles-coroner/2005/11/09/1131407700524.html
http://www.parliament.nsw.gov.au/prod/PARLMENT/Committee.nsf/0/6205d997513c2d09ca2573b70
0013575/$FILE/071220%20Final%20Report.pdf
2 Point prevalence study of access block Sept 2007 The Road Trauma and Emergency Medicine Unit Australian
National University on behalf of the Australasian College for Emergency Medicine Report prepared by Prof Drew
Richardson
3
Rivers E, Nguyen B, Havstea S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M for The Goal-
Directed therapy Collaborative Group. Early goal-Directed Therapy. N Engl J Med 2001;345:1368-1377;
Rapoport J, Teres D, Lemeshow S, Harris D. Timing of Intensive Care Unit admission in relation to
ICU outcome. Crit Care Med 1990;18:1231-1235.
4
Richardson DB. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. MJA 2002; 177:492-495; Liew et al. Emergency Department length of stay independently predicts inpatient length of stay. MJA 2003; 179:524-526
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February 2008 Dr S McCarthy for NSW Emergency Care Taskforce
This strategy has been proposed previously: 2003 South West Sydney AHS; ECT DOH 2003; 2004 SESIAHS

Perhaps not unexpectedly, a reduction in LOS for these patients has resulted from a new approach: boarding admitted patients on their destination wards instead of in the
ED. This process has been termed a “Full capacity Protocol” in The State University
Hospital in Stony Brook, Long island (one of the top 15 major teaching hospitals in the US), a centre with just over 500 beds. The ED provides services to > 60,000 pts annually:
Bruce Schroffel, Director and Chief Executive Officer, Stony Brook University
Hospital. July-August 2003: "Full Capacity Protocol" A National Model: “Stony
Brook University Hospital, like many similar institutions from coast to coast, has suffered from serious overcrowding in the Emergency Department (ED).
Conventional wisdom, and perhaps a misconstrued sense of what health law would allow, said that patients should be kept in the ED until an inpatient room with a bed was cleared for admission.
Excessive waits for inpatient beds clearly demanded a solution for removing admitted patients from the ED. The solution that Stony Brook developed is a triumph of common sense. Known as the "Full Capacity Protocol," it is being recognized nationally at meetings, in professional societies and publications, and in other hospitals.
The solution is this: admitted patients in the ED will be assigned to inpatient hallway beds. Each unit will be assigned one hallway patient. If there is still a need, a second hallway patient will be assigned to each unit. No unit is to receive more than two hallway patients. Criteria for hallway placements and priority of their placements are stringent.
Our results are dramatic. Patient and ED staff satisfaction improved, as did resource utilization, access to emergency care, and the ability to provide appropriate inpatient standards of care. Another important finding is that patients who wait in a hallway bed have a lower length of stay than case-matched patients who stayed in a bed in the
Emergency Department hallway (5.4 days compared to 6.2 days).
It is good to see that when different departments with differing situations and needs work together, common-sense solutions benefit both patients and the hospital staff.”
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It is proposed that a similar “Full Capacity Protocol” be instituted in NSW hospitals
Emergency Department Criteria for implementation:
1.
Triage category 2 or 3 patient on chair > 10 minutes OR ambulance off load delayed > 45 minutes
OR
2.
Department has no vacant resuscitation bed
AND
3.
Admitted patients suitable for immediate transfer are occupying beds in ED
5
Ric Bukata, Emergency Medicine and Acute Care Essays, Emergency Medicine Abstracts, vol 27, no. 8 August
2003
2
February 2008 Dr S McCarthy for NSW Emergency Care Taskforce
This strategy has been proposed previously: 2003 South West Sydney AHS; ECT DOH 2003; 2004 SESIAHS

Procedure :
4.
Hospital patient flow manager, duty emergency physician (or delegate) and senior emergency nurse agree on requirement for Full Capacity Protocol and notify Administrator on call (usual avenues to free ED space have already been exhausted eg. Patients are transferred to next available bed in the hospital, wards and inpatient teams have expedited discharges etc)
5.
ED boarded inpatient moves to ward bed space or corridor, becoming an overcensus ward patient, rather than an overcensus ED patient. The decision of patient placement by the Patient Flow Manager after discussion with the
Emergency physician (if indicated) shall be binding.
6.
Chair, waiting room or ambulance patients off loaded to now vacated bed space/s in ED
7.
Emergency Department maintains operational status whilst boarder inpatients are now accommodated in hallways within the hospital, OR inpatient units place pre-discharge patients in chairs / hallway beds to accommodate new patients in ward bed
8.
A maximum of 2 hallway patients will be accommodated in any single ward
Further Escalation
Once all boarded inpatients are transferred from ED to wards and no further boarder admitted patient are identified, and ED remains at full capacity, the
Hospital Chief Executive Officer or delegate, the patient access administrator on call, and the hospital ED Director will be notified. Decisions on implementation of deferral of elective and urgent surgical cases and further Emergency Department
Diversion will be made.
Proposed priorities for hallway placement
All unoccupied ward beds should be utilized before hall beds are used.
1.
Pre-discharge ward inpatients should be prioritised for movement to ward hallway beds / chairs so that ward bed space is available for new transferred patients from
ED.
2.
Non monitored patients with little or no co-morbidity will be first considered for hall bed placement
3.
Non monitored patients with minimal to moderate risk factor co-morbidity will be the second patient population to be considered for hall beds
4.
Patients admitted for Telemetry monitoring with little or no co-morbidity and with minimal index of suspicion for a cardiac event will be the next patient population to be considered for hall bed placement, and hallway placement will be contingent upon the ward being able to deliver monitoring in this situation
5.
Patients requiring oxygen will arrive to the unit hall bed assigned with a full tank of O2. (Any equipment exchange will be prearranged prior to transporting the patient.)
6.
Patients admitted to hallways on in-patient units will be placed as much as possible according to service. Each unit will receive one hall bed patient. After all
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February 2008 Dr S McCarthy for NSW Emergency Care Taskforce
This strategy has been proposed previously: 2003 South West Sydney AHS; ECT DOH 2003; 2004 SESIAHS

applicable units have received one patient a second hall patient may be assigned.
No unit will have more than two hall bed patients.
7.
Patients admitted to hallways on in-patient units will be prioritized over the
Emergency Department (once ED is not at Full Capacity) for admission to the first available bed on any unit where nursing competencies meet patient needs.
Hallway patients need not be admitted to the unit on which they are boarding.
Exceptions to prioritisation
If hall bed utilization has been maximized and the ICU/ HDU is full, and there is one or more ICU/HDU patient waiting in the Emergency Department, the next available ward bed will go to an ICU/HDU patient transferring out of ICU/HDU (not to a hall bed patient).
Any "exception" to the above will be with the individual approval of the Director of
Clinical Services or delegate.
Hallway Bed Exclusions
Admitted Emergency Department patients that will not be placed in hall beds:
1.
Patients requiring the HDU or the Intensive Care Unit will not be placed in hall beds
2.
Patients requiring Isolation or Negative pressure room placement will not be placed in hall beds
3.
Other exclusions will be by negotiation and approval of the Director of Clinical
Services or delegate.
NOTE:
4.
Mental Health patients are INCLUDED in this strategy ie principles for maintaining ED operations apply to ALL patient diagnostic categories.
Procedure for Discontinuation
Criteria:
All unit hall bed placements have been maximized (2 per unit)
AND/ OR
The Emergency Department no longer needs hall bed placements.
Hospital patient flow manager, duty emergency physician (or delegate) and senior emergency nurse agree on requirement for stand down of Full Capacity Protocol and notify Administrator on call. If the Emergency Department remains at full capacity, the Further Escalation procedure will be followed.
The Emergency Department will thus remain operational and have the capacity to receive new emergencies. No hallway patients will be returned to the ED.
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February 2008 Dr S McCarthy for NSW Emergency Care Taskforce
This strategy has been proposed previously: 2003 South West Sydney AHS; ECT DOH 2003; 2004 SESIAHS

Advantages of the Full Capacity proposal:
 ensures NSW EDs are able to receive and treat emergencies, whether arriving by ambulance or not
 spreads risk for the organisation by diluting the acute bed availability problem
 recognises the primary cause of network access difficulties is access block
 recognises access block is an organisation problem not an ED problem and shares the load of overcensus patients across the organisation
 ensures emergency undifferentiated patients are cared for in the ED, whereas stabilised patients with identified disorders are appropriately transferred to inpatient units
 addresses ambulance service difficulty and delayed offloads
 incentivises inpatient areas with respect to patient flow
 has the potential to deliver increased quality of clinical outcome for ED admitted patients and result in reduction in average LOS and increased efficiency for the organization
 will result in improved working environment and staff retention in ED
 dovetails with the current NSW DOH focus on so-called “third doors”
Disadvantages of this proposal:
 spreads the burden of access block across the hospital whereas presently the organisation has focused the burden of access block on the ED
 will require organization wide education and support to ward area staff unaccustomed to the demands of overcensus patients
 implementation will provoke disquiet from inpatient units formerly accustomed to controlling workload by controlling bed availability (as distinct from EDs which must receive and treat patients whether they have capacity or not, 24 hours / 7 days).
February 2008 Dr S McCarthy for NSW Emergency Care Taskforce
This strategy has been proposed previously: 2003 South West Sydney AHS; ECT DOH 2003; 2004 SESIAHS
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