Organizational Functions

Boarding increases malpractice claims, financial losses, mortality, sentinel events, medical errors, length of stay, diversions, waiting times and other issues, which result in crowding. Patient flow is a concern that should be solved by leadership of the hospital. The standards recognize that the reasons could be multifactorial and arise from the other areas, not just the Emergency Department (ED).

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Emergency Room (ER) overcrowding takes place in all the countries around the world. ER overcrowding can lead to severe consequences. Patients wait for hours before being transferred to a hospital bed or being seen by a doctor that results in inconvenience and degradation of the entire experience - cost of care increases, staff morale impairs, patient's safety becomes endangered and the quality of care suffers. Serious patients have to wait too long for treatment that could result in a more complicated condition, whereas patients with less severe illnesses leave without being examining by a doctor and their condition may also worsen as a consequence. In case of overcrowding, ambulances may be diverted to other EDs and healthcare workers may feel overwhelmed, overlooking some patient's problems in the general confusion. Therefore, the efficiency of care diminishes while costs rise.

The Joint Commission (JCAHO) recommends strategic planning ahead for the patients in a similar way to planning of elective hospital admissions or elective surgery. Their recommendations include incorporating ER overcrowding concerns into overall performance of the improvement goals, coordination with home health agencies and long-term health facilities to expedite hospital discharges and planning of delivery of care to the patients who should be directed in temporary bed locations (Trzeciak & Rivers, 2003).

The necessary changes depend on certain challenges that ED faces. Therefore, it needs to conduct a thorough investigation in order to identify the important bottlenecks as well as certain no-regret measures that may drive a quick short-term impact within the Department. These quick wins send a strong signal that improvement is possible and it provides immediate relief to the staff. However, in order to reduce the overall burden of work and achieve the long-term success, an end-to-end transformation of all the hospital procedures is required. A strong reduction of over-crowding in the emergency room requires also an improvement in visible leadership, performance management, stronger staff skills and hospital culture.

Several hospitals have tried to improve the situation by reducing ER wait times, but they usually fail because of two reasons. The first reason is that ED improvement programs focus only on the processes, disregarding staff attitudes that leads to short-term results. The staff must be willing to collaborate across organizational and physical divides, creating the teamwork culture. The second reason is the narrowness of many performance improvement programs, focused only on the Emergency Department. Hospital represents a high-stress, complex system, which always requires significant cross-role and cross-departmental coordination. The only way to improve the process is to implement corresponding changes in other parts of a hospital, which are beyond the ED control. According to the JCAHO standards, the hospital should have a process that supports the flow of patients throughout the medical center. Processes may include opening an overflow unit in each of the departments and a stat clean of rooms for patients who are waiting for the bed to be ready (JCAHO, 2012).

In general, sustainable and substantive improvements in ER performance will be achieved if the average wait time is lowered at least by one-third. There is no a flexible way for all the hospitals, but several elements are considered to be essential for achieving success. Significant effort should be put into the wider hospital organization, as well as a cultural shift by way of enhancing the hospital staffs capabilities and refining the performance-management systems. The staff must understand how seemingly their actions could influence patient care in the hospital. In addition, the hospital's senior executive team and CEO should strongly support the programs as well as clinicians must promote the necessary changes.

This problem could be solved through the implementation of "lean principles", used in manufacturing. Streamlined registration and triage procedures can reduce the unnecessary administrative work for nurses. Better matching of typical patient volumes with staff levels may prevent patients from waiting long in the ER because of the lack of porters, who transport them to the wards.

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There are four primary causes of overcrowding in ER, which the ER staff cannot control directly: difficulty getting results returned and diagnostic procedures scheduled, difficulty getting necessary consultations from non-ED doctors, a convoluted and lengthy admission process and a lack of free inpatient beds. In order to alleviate capacity constraints, it is necessary to eliminate the unnecessary delays that improperly extend the length of stay. Several discharge processes are quite simple: having nurses clean the beds more quickly once they are free, for example, or having physicians write discharge orders in the morning. JCAHO has a standard on patient flow, according to which the hospital requires that patients should be discharged home timely, leaving the beds for the new patients (JCAHO, 2012).

In order to reinforce the behaviors and encourage a shift in mind-set of the staff, some visual signals such as signs in each inpatient unit of the number of days until patient's discharge can be implemented. Certain process changes can require new skills or support structures. The nursing staff may develop checklists to ensure that all the paperwork is filled out, and all the appropriate steps are taken before a patient is sent home. In addition, a daily Web-based report or early-morning "bed meeting" can increase staff awareness about bed availability.

Similar types of changes can also be implemented to increase capacity in the diagnostic labs and radiology department, make consultations easier and streamline admissions. The changes can be used inexpensively; they do not require significant additional operating resources, unplanned capital expenditures or new staff positions. Their impact is that the ER can comfortably handle about 30% more patients than before, with the same level of resourcing and physical infrastructure. As the processes in the hospital will become more efficient, staff morale, quality of care, patient satisfaction and safety will rise.

The communication is critical for the improvement program. It begins with an inspirational clear message from the hospital's executive-management team and CEO, underscoring the necessity of the cultural change. The program's established goals such as a better work environment, higher quality of care and improved patient safety should be communicated clearly. In addition, it is necessary to conduct some surveys in order to identify the barriers to hinder change, explore the specific issues and gauge the employees' attitudes in general. If the information that the communication plan conveys is not something the staff is concerned with, then this plan will fail. Education is a crucial component of the improvement programs. Staff members must be educated not only for lean skills, such as root-cause analysis and process mapping, but they also should be educated how to build team trust and collaborate.

In addition, law enforcement agencies and local public health departments need information systems, which could integrate hospital capacity data and regional ED, detecting the threat of ED overcrowding. A civil emergency designation will trigger contingency plans to expand urgent care capacity. Early warning systems represent the effective public health measures, which may also be crucial in disaster preparedness. Temporizing measure that could help to alleviate the patient flow in the ER consists in providing an alternative place for the patients to go. ER will manage to control patient outflow due to the ER short stay observation units that have been shown to relieve overcrowding (Trzeciak & Rivers, 2003).

The Emergency Room represents a vital element of the health care safety net. ER overcrowding jeopardizes the reliability of the entire US emergency care system and compromise patient safety. The main reason of ER overcrowding is an inability to ensure proper inpatient capacity with an increasing disease severity. Reducing the overcrowding crisis requires a system-wide approach on multiple levels.

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