March 2010 was a turning point for the emergency department at Baylor All Saints Medical Center in Fort Worth, Texas. The 525-bed full-service hospital, like many hospitals in the country, had seen its ED volume grow exponentially over the past few years, with almost 35,000 visits logged in 2010. The conversion rate of ED visits to inpatient admissions was averaging around 25 percent. This was not only putting a tremendous strain on the facility, it also was presenting serious challenges to the patients and staff.
For the ED, surge is defined as a temporary increase in demand for services. A surge can occur at any time in the hospital. Most often, a surge is associated with the need for critical care beds.
Creating an action plan based on the results produced by the NEDOCS tool has enabled the medical center's surge management program to:
The NEDOCS score coupled with root cause analysis, provided keen insight into where the problems existed. Specifically, problems were broken down and traced to their point of origin: (1) at the front end (e.g., EMS, walk-ins, triage, etc.), (2) internal to the ED (e.g., gridlock, physician call-back times or work-ups), or (3) at the back end (e.g., getting patients out via discharges, admission to the hospital or transport).
Based on a continually updated data set entered by a NEDOCS designated nurse in the medical center's ED, the tool created a current status score and matching color code. Color codes were categorized as follows:
The data set included information such as number of beds in the hospital, number of beds in the ED, number of patients in the ED including the waiting room, number of patients waiting for an inpatient bed assignment, number of patients ventilated in the ED and longest patient wait time.
We collected data for 90 days with the NEDOCS nurse manually recording the information every 30 minutes. This nurse also constantly monitored patient flow, communicating frequently with the unit secretary to make sure orders were entered and evaluating the promptness of physicians calling back to the ED. Data was trended to provide a baseline to gauge realized and potential improvements. Surprisingly, the results showed Monday evenings had the highest spike in patient volume, often resulting in a black disaster status.
From the outset, we knew we needed to get every department in the hospital involved in surge management planning and implementation. We realized that surge in the ED was influenced by and was influencing every department in the facility, so it was an organization-wide problem. We created a multi-disciplinary team including the CNO and directors of the ED, critical care, bed board, medical surgical, housekeeping, surgical services, cardiac catheterization lab, radiology, laboratory and case management. The team met weekly to create the plan and clearly define roles and responsibilities. Action plans were devised for each color status. Job action cards were developed for each department. The cards briefly outlined each task assigned to specific departments and proved to be extremely valuable for staff as the higher-intensity status levels developed. In addition, the team created a plan to notify and update all parties prior to, during and after the surge, defined as a NEDOCS score of 91 — a code yellow.
The results
As the medical center changed processes based on the NEDOCS tool, the ED quality measures began to show immediate improvement. Fast forward from March 2010 to October 2010 and the improvements were impressive:
Additionally, our efforts have been recognized as runner-up in this year's Genesis Cup awards competition sponsored by EmCare. The award honors organizations' ED physicians and staff for their creativity and innovation in their never-ending pursuit of improving the delivery of patient care.
The surge management plan, with the NEDOCS tool at its heart, is producing the results we had envisioned. The NEDOCS nurse is available from 1 to 11 p.m., seven days a week. Since implementing our action plans, we have learned many valuable lessons. House supervisors are critical to appropriately responding to changing status by reallocating resources. Continual communication and evaluation of the initiative are vital to maximizing it value.
Plans are in place to expand the NEDOCS process in other areas of the medical center including the operating room and labor and delivery. The entire process is being integrated as a component of the organization's overall disaster plan.
Nick Zenarosa, MD, FACEP, is EmCare’s system medical director of emergency services for the Baylor Health Care System in Dallas. He is board-certified in emergency medicine and internal medicine, completed his emergency medicine residency at Carolinas Medical Center in Charlotte, N.C. and his internal medicine residency at Parkland Memorial Hospital in Dallas. Dr. Zenarosa earned his medical degree from the University of Illinois at Chicago College of Medicine, his master’s degree in Molecular Biology from the University of Illinois and his undergraduate degree in Human Physiology from the University of Illinois.
Dahlia Hassani, MD, FACEP is EmCare’s medical director of emergency medicine for Baylor All Saints Medical Center at Fort Worth. She previously served as an EmCare emergency physician at Baylor Regional Medical Center at Grapevine and Richardson Regional Medical Center. Dr. Hassani has also acted as director of postgraduate education, assistant professor and chief resident for Emory University Department of Emergency Medicine, where she also completed her emergency medicine residency. Her medical degree is from the University Of Illinois College of Medicine and she received her B.A. with honors in psychology from Northwestern University.To view a video of Dr. Hassani discussing ED surge management, click here.
The challenge
First, a bit about what it was like in the Baylor All Saints emergency department in March 2010. All available beds were full. Patients were being placed on beds in the hallways. Staff was running from patient to patient. Lab and x-ray reports were difficult to track down. Patients were in a holding pattern waiting for available inpatient beds. Patient call lights were ringing incessantly. Families were anxious and pacing about. Administrators reported to the ED to help in any way they could. Unfortunately, this scene probably describes many EDs on busy days. For us, it was a wake-up call. Things had to change.The solution
In a debriefing meeting a few days later, the chief nursing officer suggested that we evaluate using the National Emergency Department Overcrowding Scale as a way to measure and improve the ED's performance. Known as NEDOCS, the online tool provided a convenient, standardized, nationally-recognized means of measuring the ED's status and enabled the medical center to create an action plan for improvement. It was just what the doctor ordered to help us manage the peaks and valleys of patient volume through a "surge management" process.For the ED, surge is defined as a temporary increase in demand for services. A surge can occur at any time in the hospital. Most often, a surge is associated with the need for critical care beds.
Creating an action plan based on the results produced by the NEDOCS tool has enabled the medical center's surge management program to:
- Improve patient access to safe and timely critical care;
- Allow for an escalated response through a standardized framework;
- Mobilize and use all the hospital’s resources including staff, equipment and technology; and
- Use data to determine where new or additional resources are needed.
The NEDOCS score coupled with root cause analysis, provided keen insight into where the problems existed. Specifically, problems were broken down and traced to their point of origin: (1) at the front end (e.g., EMS, walk-ins, triage, etc.), (2) internal to the ED (e.g., gridlock, physician call-back times or work-ups), or (3) at the back end (e.g., getting patients out via discharges, admission to the hospital or transport).
Based on a continually updated data set entered by a NEDOCS designated nurse in the medical center's ED, the tool created a current status score and matching color code. Color codes were categorized as follows:
- Not busy — light green
- Busy — dark green
- Very busy — yellow
- Overcrowded — orange
- Dangerous —red
- Disaster — black
The data set included information such as number of beds in the hospital, number of beds in the ED, number of patients in the ED including the waiting room, number of patients waiting for an inpatient bed assignment, number of patients ventilated in the ED and longest patient wait time.
We collected data for 90 days with the NEDOCS nurse manually recording the information every 30 minutes. This nurse also constantly monitored patient flow, communicating frequently with the unit secretary to make sure orders were entered and evaluating the promptness of physicians calling back to the ED. Data was trended to provide a baseline to gauge realized and potential improvements. Surprisingly, the results showed Monday evenings had the highest spike in patient volume, often resulting in a black disaster status.
From the outset, we knew we needed to get every department in the hospital involved in surge management planning and implementation. We realized that surge in the ED was influenced by and was influencing every department in the facility, so it was an organization-wide problem. We created a multi-disciplinary team including the CNO and directors of the ED, critical care, bed board, medical surgical, housekeeping, surgical services, cardiac catheterization lab, radiology, laboratory and case management. The team met weekly to create the plan and clearly define roles and responsibilities. Action plans were devised for each color status. Job action cards were developed for each department. The cards briefly outlined each task assigned to specific departments and proved to be extremely valuable for staff as the higher-intensity status levels developed. In addition, the team created a plan to notify and update all parties prior to, during and after the surge, defined as a NEDOCS score of 91 — a code yellow.
The results
As the medical center changed processes based on the NEDOCS tool, the ED quality measures began to show immediate improvement. Fast forward from March 2010 to October 2010 and the improvements were impressive:
- The percentage of patients leaving without being treated plummeted from 11 percent to one percent.
- The door to treatment time fell from 116 minutes to 30 minutes.
- Length of stay post-admission to the ED significantly decreased from 700 minutes to 250 minutes.
- Satisfaction scores from patients, staff and physicians showed a marked improvement.
Additionally, our efforts have been recognized as runner-up in this year's Genesis Cup awards competition sponsored by EmCare. The award honors organizations' ED physicians and staff for their creativity and innovation in their never-ending pursuit of improving the delivery of patient care.
The surge management plan, with the NEDOCS tool at its heart, is producing the results we had envisioned. The NEDOCS nurse is available from 1 to 11 p.m., seven days a week. Since implementing our action plans, we have learned many valuable lessons. House supervisors are critical to appropriately responding to changing status by reallocating resources. Continual communication and evaluation of the initiative are vital to maximizing it value.
Plans are in place to expand the NEDOCS process in other areas of the medical center including the operating room and labor and delivery. The entire process is being integrated as a component of the organization's overall disaster plan.
Nick Zenarosa, MD, FACEP, is EmCare’s system medical director of emergency services for the Baylor Health Care System in Dallas. He is board-certified in emergency medicine and internal medicine, completed his emergency medicine residency at Carolinas Medical Center in Charlotte, N.C. and his internal medicine residency at Parkland Memorial Hospital in Dallas. Dr. Zenarosa earned his medical degree from the University of Illinois at Chicago College of Medicine, his master’s degree in Molecular Biology from the University of Illinois and his undergraduate degree in Human Physiology from the University of Illinois.
Dahlia Hassani, MD, FACEP is EmCare’s medical director of emergency medicine for Baylor All Saints Medical Center at Fort Worth. She previously served as an EmCare emergency physician at Baylor Regional Medical Center at Grapevine and Richardson Regional Medical Center. Dr. Hassani has also acted as director of postgraduate education, assistant professor and chief resident for Emory University Department of Emergency Medicine, where she also completed her emergency medicine residency. Her medical degree is from the University Of Illinois College of Medicine and she received her B.A. with honors in psychology from Northwestern University.To view a video of Dr. Hassani discussing ED surge management, click here.
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