Crowd con­trol

Pro­posed bill could help ease over­flow­ing EDs

Modern Healthcare - - The Week In Healthcare - Mau­reen McKin­ney

Cal­i­for­nia is at the cen­ter of a na­tional ef­fort to ease emer­gency depart­ment over­crowd­ing. The state Leg­is­la­ture is one vote away from send­ing the gover­nor a bill that would re­quire hos­pi­tals to use scor­ing as­sess­ments and set hos­pi­tal­wide pro­to­cols to ad­dress the prob­lem.

The pro­posed leg­is­la­tion comes at a time when emer­gency de­part­ments across the coun­try are strug­gling to man­age a grow­ing hos­pi­tals to eval­u­ate crowd­ing lev­els in their emer­gency de­part­ments ev­ery four to eight hours us­ing a scor­ing sys­tem with vari­ables such as the to­tal num­ber of pa­tients in the ED and most re­cent wait times. It would also man­date im­ple­men­ta­tion of a full-ca­pac­ity pro­to­col that would de­ter­mine what spe­cific ac­tions hos­pi­tals would take to im­prove through­put at each stage of crowd­ing.

One of the biggest driv­ers of over­crowd­ing, in Cal­i­for­nia and else­where, is board­ing, re­sults seen at 676-bed LAC/Uni­ver­sity of South­ern Cal­i­for­nia Med­i­cal Cen­ter, Los An­ge­les, which uses the Na­tional Emer­gency Depart­ment Over­crowd­ing Score sys­tem on which the Cal­i­for­nia bill is based.

An­other strat­egy men­tioned in the video was the one de­vel­oped by Peter Vic­cel­lio, vice chair and clin­i­cal di­rec­tor of the depart­ment of emer­gency medicine at 542-bed Stony Brook (N.Y) Uni­ver­sity Med­i­cal Cen­ter. In 2001, frus­trated by over­crowd­ing and “ad­mit­ted pa­tients, stacked in the ED wait­ing for beds,” Vic­cel­lio made a phone call, he ex­plained. Al­though, like many clin­i­cians, he be­lieved it was against the rules to move pa­tients else­where in the hos­pi­tal, he called the state health depart­ment and found out he was wrong, Vic­cel­lio said.

“We got the health depart­ment to write letters telling hos­pi­tals that mov­ing pa­tients to other floors is al­low­able in times of high ca­pac­ity,” Vic­cel­lio said. “If we be­come over­crowded and we have 20 pa­tients to dis­trib­ute, we try to put two on each of 10 floors so the bur­den is shared. It’s pretty ob­vi­ous and I find it rather odd that it took so long to fig­ure it out.”

The ap­proach has led to shorter lengths of stay, quicker ad­mis­sions and safer care, Vic­cel­lio said. Per­haps more im­por­tantly, it has en­cour­aged the en­tire hos­pi­tal to view ED over­crowd­ing as an in­sti­tu­tion­wide prob­lem that needs to be ad­dressed by ev­ery­one. An­other more proac­tive so­lu­tion, he added, is to smooth sur­gi­cal sched­ul­ing and re­dis­tribute work through­out the work week, mak­ing beds avail­able more reg­u­larly.

“The 800-pound go­rilla in the room is that hos­pi­tals con­tinue to look at their busi­ness like it is a 9-to-5 event, and that’s where these traf­fic jams come from,” Vic­cel­lio said.

For now, the fu­ture of Cal­i­for­nia’s over­crowd­ing bill is un­cer­tain. De­spite sup­port from the CMA and CAL/ACEP, the state’s pub­lic health depart­ment op­poses the bill, con­tend­ing that the scor­ing sys­tem would sad­dle be­lea­guered emer­gency de­part­ments with yet an­other task.

The Cal­i­for­nia Hos­pi­tal As­so­ci­a­tion is neu­tral on the bill, said Debby Rogers, CHA’s vice pres­i­dent of qual­ity and emer­gency ser­vices, and is cur­rently pi­lot test­ing its own mod­i­fied scor­ing scale with a group of 26 hos­pi­tals. Los An­ge­les County’s depart­ment of health ser­vices is also neu­tral, ac­cord­ing to Carol Meyer, chief of op­er­a­tions, de­spite the fact that county-run USC Med­i­cal Cen­ter has used the scor­ing sys­tem ef­fec­tively.

What­ever the fate of the bill, one thing is for sure, said Vic­cel­lio: Some­thing must be done and quickly. “The fail­ure to act in a se­ri­ous way has clearly been hor­ri­ble for pa­tients and I find it in­ex­cus­able be­cause the so­lu­tions re­quire min­i­mal re­sources.”

Over­crowded emer­gency de­part­ments in Cal­i­for­nia will soon have pro­to­cols to fol­low to help ease over­flow­ing if pro­posed leg­is­la­tion passes.

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