Acute ED Decompression Plans

An important management element to consider whenever we attempt to improve ED operations is the implementation of acute ED decompression plans. This involves the design of pro-active strategies that are aimed to facilitate prompt movement of ED admitted patients and/or Holdovers to non-typical or underutilized areas of the Hospital which may be able to take care of these patients at the time. The purpose is to avoid ED overcrowding by promptly redistributing a limited number of patients across several areas of the Hospital without overwhelming any particular unit involved.

Even though operationally efficient Emergency Departments can manage and control the flow of about 80% of their daily patient load, they are still at the mercy of inpatient capacity for the other 20%. As such, even the best managed Emergency Departments can occasionally run into trouble if inpatient capacity is fully maxed out or floor processes are misaligned with the acute needs of the ED. That’s why these Acute ED Decompression Plans are necessary.

Now…just as the ED has underutilized areas than can be tapped to promote ED patient flow, all Hospitals tend to have untapped capacity that could be allocated to support the ED on an occasional basis at particular hours of the day. For example…a limited number of stable ED admitted patients waiting for telemetry beds might be able to be divided between the unused capacity of a PACU and a Cath Lab Recovery Unit during the early operational hours of these areas. A limited number of ED admitted patients waiting for a Med-Surg bed might be able to be divided between the unused capacity of an Endoscopy Recovery Unit, an Ambulatory Care Center, a Maternity unit, and even a Pediatric inpatient unit during particular times of the day...and so forth…

Regardless of which of those areas or services may or may not be available at your Hospital, you are always bound to find some similar staffed areas which can be used to acutely decompress ED admitted patients. The problem is not usually finding them but rather, creating a viable plan that can be executed “on-a-dime” whenever the need arises. I am going to now describe some of the general steps necessary to come up with such a plan…

1st…We need to identify the thresholds for activation. This is obviously going to depend on the size of your ED, the extent of the boarding problem you are experiencing and the capacity of your institution. For the sake of argument, let’s say you have a large ED and your thresholds for activation will be having more than 24 holdovers in the ED at any time and any location. Your team might also consider activating the plan, regardless of the number or holdovers, if all beds in the Main ED are occupied or expected to be soon all occupied based on the number of expected ambulances.

2nd…Your team needs to identify the specific Units or areas that could help decompress the ED including …the types of ED patients each of those individual areas can take care of…the hours during which each of these areas could safely receive those kinds of patients…the number of patients each individual Unit or area could potentially absorb and; the limits beyond which each unit or area should never go over.

3rd…Your team needs to declare who will be allowed to identify the need to activate the ED Decompression Plan and who they need to contact next. These Activators might include the ED Charge Nurse, the ED Nurse Manager, the ED Case Manager…etc. After these “activators” have been identified, your team needs to also identify the people that will facilitate and manage the execution of the plan. These facilitators might include your Inpatient Flow Coordinator or Bed Czar, the inpatient nurse managers, the Director of Inpatient Case Management…etc.

4th…Your team needs to solidify the procedures, protocols and managerial elements of the plan including all the anticipatory steps that must be undertaken every day to prepare the institution in case the plan might need to be activated. For example…your institution might have your Patient Flow Coordinator review the OR schedule, and the expected utilization of all the areas involved in the plan every morning and communicate to all the activators and facilitators which of these areas can be expected to have available capacity in case the ED meets the thresholds for plan activation. In addition, other housekeeping elements and requirements of the plan need to be spelled out. For instance…your team might require that before any ED patients can be moved to a decompression area a verbal “Hand-Off” of care between an ED Provider and the admitting MD still occurs; that a nurse to nurse report take place, that the patient arrives to the decompression area with at least basic admission orders documented, that only patients deemed clinically stable be sent to any of the acute decompression areas…etc…etc.

One of the things that should be evident is than an acute ED Decompression plan must be orderly and unhurried in its execution…not a “knee-jerk” reaction. That’s why it is called a decompression plan instead of a surge capacity plan. In fact, a properly implemented ED Decompression plan (pro-actively activated whenever threshold is met and deactivated after the ED goes back under threshold) can obviate the need for reactionary and resource consuming institutional surge capacity plans from having to be activated as often.

Most of the time…all an Emergency Department needs to regain control of patient flow is to be able to turnover just a few beds within a short period of time before the next bolus of demand presents for service. Institutional Surge Capacity Plans, which are mostly reactionary and move at glacial speed, cannot provide this ability. By the time the bed meeting is accomplished, the Surge Capacity Plan is approved to be activated, the institution receives communication that the Hospital is in surge mode; and some capacity is starting to be freed up…the ED is so far down into the weeds that all these reactionary institutional efforts are basically powerless in arresting ED overcrowding. In contrast, Acute ED Decompression strategies are designed to meet the needs of the ED in almost “real-time” and decrease the need for the institution to implement highly disruptive, resource intensive and even unpopular surge capacity plans and actions…

To illustrate this point, one of the things some of our clients find surprising when they first meet us is the fact that we don’t advocate sending admitted ED patients to the inpatient hallways unlike many consultants and Emergency Medicine Societies currently suggest. These people base their recommendations on the typical model most Emergency Departments operate under, nevertheless…the asset utilization, turnover, efficiency and increased functional capacity that is achieved through operational transformation strategies provides a significant operational cushion against overcrowding and reduces the extent of decompression the ED might require to avoid patient flow issues. As such, whenever a hospital implements these strategies they find that the ED can still operate efficiently with a number of ED admitted patients and holdovers that would have crippled ED flow and cause significant overcrowding in the past.

In other words, the threshold whereby the ED can get into trouble becomes much higher than before and the number of ED admitted patients the inpatient side will need to absorb to prevent ED operational decay becomes much lower. Most find that the simple Acute ED Decompression strategies we just mentioned usually suffice and that the institution doesn’t need to go into surge capacity mode as often. In fact, we have been involved with institutions that prior to our arrival were either thinking or already placing ED admitted patients into their inpatient hallways yet; after changing their patient flow processes, they haven’t found much use for this.