Overcrowding in the emergency department increases wait time, lowers patient satisfaction, puts patient safety at risk and burdens ED physicians and staff. St. Rita's Medical Center in Lima, Ohio, has an average annual ED volume of between 55,000 and 60,000 patients. In 2011, it began major construction that put capacity constraints on the ED. To anticipate and minimize the effects of overcrowding, St. Rita's Medical Center instituted a program using the National Emergency Department Overcrowding Score in January.
NEDOCS in action
NEDOCS calculates the level of ED crowding based on seven variables, including the number of ED patients and the number of ED and inpatient beds. NEDOCS categories range from normal to busy, overcrowded, severe and disaster, each of which has an associated color. Every two hours, an ED staff member calculates the NEDOCS score using an online calculator and documents the score in a spreadsheet that all staff can access. When the score is red (severe) or black (disaster), the ED charge nurse uses the PerfectServe communication platform to alert staff members throughout the hospital of the ED's status, triggering actions to improve patient throughput and decrease crowding.
Since the ED is often the front door to the hospital and coordinates with multiple departments, such as radiology and surgery, many staff members are alerted when the ED passes red on NEDOCS. The house supervisor — a nursing leader overseeing patient care and staffing — nursing unit managers, the rapid response team and staff in physician services, medical services, patient services, housekeeping and transportation are all notified when the ED is overcrowded, and they each have specific responsibilities for severe and disaster NEDOCS statuses.
For example, the ED charge nurse is responsible for contacting all relevant staff and optimizing treatment spaces in the ED. The house supervisor decides whether to divert ambulances to another hospital or divert patients from a transferring hospital for a certain time. Housekeeping sends extra staff members to the ED to turn over rooms more quickly, and the rapid response team facilitates admitting critical care patients. In addition, the medical director works with hospitalists to ensure they round on inpatients regularly and maximize inpatient capacity. The day after a NEDOCS alert, the ED team, inpatient managers and other key stakeholders meet to discuss their response and what could be improved.
Patient satisfaction
When the ED is on severe or disaster NEDOCS status, the patient relations department also sends a representative to the ED to manage patients' expectations and resolve any complaints. Including patient services in capacity management is a proactive step taken to maintain patient satisfaction, which can decrease due to long wait times and crowding.
"We try to anticipate when we may have a complaint coming through, such as long wait times or a delayed surgery," says Jodi Pahl, CNO of St. Rita's. "If we're able to solve any issues or problems while patients are still here, they'll be more loyal to us in the long run."
Breaking down silos
In addition to reducing crowding, the combination of having both the NEDOCS program and the PerfectServe platform in place has helped break down silos between departments in the hospital, leading to more coordinated care, according to Ms. Pahl. "Having inpatient managers and staff realize how important our ED is to the rest of the hospital" was critical to breaking barriers between the ED and inpatient care, she says. "When the ED is overcrowded, it's not just the ED's problem; it's a hospital issue and all hands on deck need to get involved."
The objectivity and transparency of the data helped gain buy-in from all staff, according to Ms. Pahl. Working toward a common goal and providing feedback on progress was also important in aligning everyone's actions, according to Robb Recker, director of emergency services at St. Rita's. "We have one common goal of decompressing a surge in the emergency department." By coordinating actions throughout the hospital, the ED can respond to crowding effectively and efficiently.
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