SummaryIn instances of institutional overcrowding, Stony Brook University Medical Center implements a protocol that allows patients admitted to the hospital but boarded in the emergency department to be transferred to beds located in inpatient unit hallways. The protocol outlines the criteria for determining when the medical center is at full capacity, the process for implementing the transfer, the types of patients eligible for hallway bed placement, and guidelines for discontinuing the practice. After patients are transferred, unit-based clinicians initiate inpatient care and quickly move patients into a room once beds become available, leaving emergency department clinicians free to treat newly presenting patients. The protocol has led to quicker room placement, lower length of stay, and higher staff and patient satisfaction; no negative clinical outcomes have resulted from use of the protocol.Moderate: The evidence consists of pre- and post-implementation comparisons of hospital length of stay; post-implementation data and anecdotal reports on time to bed placement; anecdotal reports from staff; and survey data from patients.
Developing OrganizationsStony Brook University Medical Center
Date First Implemented2001
Problem AddressedHospitals across the nation have experienced a steady increase in emergency department (ED) patients. In hospitals operating at full capacity, ED patients who need to be admitted are typically “boarded” (or held) in the ED until inpatient beds become available, leading to potentially negative consequences for patient safety. Boarding these patients in inpatient hallways could yield safety and other benefits, but relatively few hospitals employ this practice.
- ED overcrowding and boarding of patients: Between 1996 and 2006, the annual number of ED visits in the United States increased from 90.3 million to 119.2 million; however, the number of U.S. hospitals operating EDs fell from more than 5,000 in 1991 to fewer than 4,000 in 2006.1 As a result, ED overcrowding has become quite common1; in hospitals with more than 300 beds, 90 percent of EDs have reported consistently functioning at or above capacity.2 Boarding patients in the ED, which occurs when all inpatient beds are full, is a major contributor to ED overcrowding and delays in care.3
- Negative safety consequences of ED boarding: ED boarding and associated care delays have many negative consequences, including increasing hospital length of stay (LOS),4 patient walkouts,5 adverse events, errors,6 mortality rates,7 and diversion of ambulances to other EDs (which delays care for those patients and represents a revenue loss for the diverting hospital).3 According to The Joint Commission, half of all sentinel events occur in the ED, with roughly one-third of these being due to overcrowding.3
- Unrealized potential of unit boarding: Boarding ED patients on inpatient units, which tend to be less crowded and chaotic than the ED, can increase patient safety and improve patient access, as patients can be monitored by unit clinicians and placed in rooms quickly as they become available. By distributing boarded ED patients across all units, each unit absorbs only a very small increase in workload. However, relatively few hospitals board patients anywhere other than in the ED.3
Description of the Innovative ActivityIn instances of institutional overcrowding, Stony Brook University Medical Center implements a protocol that allows patients admitted to the hospital but boarded in the ED to be transferred to beds located in inpatient unit hallways. The protocol outlines the criteria for determining when the medical center is at full capacity, the process for implementing the transfer, the types of patients eligible for hallway bed placement, and guidelines for discontinuing the practice once overcrowding eases. After patients are transferred, unit-based clinicians initiate inpatient care and quickly move patients into a room once beds become available, leaving ED clinicians free to treat newly presenting patients. Key elements of the protocol, which has placed more than 3,000 patients as of June 2010, are outlined below:
- Initial determination of ED overcrowding: The ED attending physician and charge nurse determine that the ED is close to full capacity, to the point where the care of subsequent presenting patients has become threatened. "Full capacity" is defined as all ED beds being filled and boarded patients having waited for a inpatient bed assignment for at least 2 hours.
- Neutral evaluation to confirm overcrowding: As a neutral party, the hospital’s bed coordinator evaluates the situation and triggers the full capacity protocol if appropriate; when the bed coordinator is unavailable (such as on nights and weekends), the assistant director of nursing assumes this role. (Initially, the bed coordinator first requested approval to implement the protocol from the hospital’s medical director, but this requirement was eliminated after staff became more comfortable and confident in the use of the protocol.)
- Assigning boarded ED patients to units: The bed coordinator notifies the hospital’s medical director that the full capacity protocol will be implemented, and the nursing staffing office notifies the nurse managers on the units of the need to prepare for hall bed patients. The bed coordinator assigns patients to the hallway beds, with units first receiving one hallway patient. If all units have received one patient, the bed coordinator may assign a second hallway patient (but no more) to a unit. (In these cases, a unit’s census rises from 30 patients to 32 patients.) If hall bed placement is maximized and the ED still has boarded patients, the bed coordinator notifies the hospital’s chief executive officer, chief operating officer, and medical director, who then make decisions related to capacity management, such as deferral of elective surgeries. To date, the system has become completely saturated (with every inpatient unit holding two patients) only once or twice each year.
- Prioritization of patients for hall bed placement: Only clinically stable adult patients are eligible for unit hallway bed placement, with priorities established as follows:
- First priority: Nontelemetry patients with little or no comorbidities represent the highest priority for inpatient hallway bed placement.
- Second priority: Nontelemetry patients with minimal to moderate comorbidities represent the second highest priority for placement.
- Third priority: Patients admitted for telemetry monitoring with little or no comorbidities and with minimal likelihood of a cardiac event can be assigned to hallway beds only with the approval of the ED attending physician and confirmation that the receiving unit has a telemetry box and central telemetry capabilities to monitor the patient. (Note: Telemetry patients constitute the overwhelming majority of patients placed in hallway beds.)
- Fourth priority: Adults age 18 to 20 years old can be considered for placement on a hallway bed in a pediatric unit.
- Ineligible for hallway bed placement: Patients ineligible for placement in hallway beds include those requiring or being transferred out of intermediate or intensive care units, patients on a ventilator, patients requiring greater than 4 liters of supplemental oxygen via nasal cannula, and patients requiring isolation or negative pressure room placement. Patients who require suctioning are considered to be poor candidates for hallway bed placement.
- Placement of hallway patients into rooms: Patients in hallway beds receive priority for an inpatient bed on that unit or any other unit where nursing competencies can meet that patient’s needs.
- Discontinuation of protocol: The protocol is discontinued when all unit hall bed placements have been maximized (two per unit) and/or the ED no longer requires hall bed placements. The ED attending physician, the ED charge nurse, and the bed coordinator must all agree to discontinue the protocol. At this point, the bed coordinator notifies the nursing staffing office, which, in turn, notifies all units.
References/Related ArticlesHospital Overcrowding [Web site]. Available at: http://www.hospitalovercrowding.com/
Robert Wood Johnson Foundation. Reducing Emergency Department Crowding Through the Full Capacity Protocol. June 4, 2008. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=28816
Contact the InnovatorPeter Viccellio, MD, FACEP
Vice Chairman, Department of Emergency Medicine
SUNY at Stony Brook
Health Sciences Center
Level 4 - Room 080
Stony Brook, NY 11794-8350
Phone: (631) 444-2928
Carolyn Santora, RN, MS
Associate Director for Patient Safety and Regulatory Affairs
SUNY at Stony Brook
Phone: (631) 444-4000
Innovator DisclosuresDr. Viccellio and Ms. Santora have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile
ResultsThe protocol has led to quicker room placement, lower LOS, and higher staff and patient satisfaction; no negative clinical outcomes having resulted from use of unit hallway boarding.
Moderate: The evidence consists of pre- and post-implementation comparisons of hospital length of stay; post-implementation data and anecdotal reports on time to bed placement; anecdotal reports from staff; and survey data from patients.
- Faster placement in room: Anecdotal information based on nearly 3,000 patients boarded on inpatient hallways since program inception indicates that unit bed placement occurs more quickly when patients are boarded on inpatient hallways than when boarded in the ED. Program developers suspect that the implementation of the full capacity protocol acts as a catalyst, prompting staff to be more aggressive with discharge planning, room cleaning, and other activities that lead to bed availability. Approximately 25 percent of patients sent to an inpatient unit for hallway boarding are actually placed in a bed immediately, while another 25 percent remain in the hallway for less than 1 hour. The remaining 50 percent spend an average of 8 hours in the inpatient hallway. Over the years, only a handful of patients have required unit hallway boarding for up to 24 hours.
- Lower LOS: As a result of quicker room placement, average LOS for the hospital has declined from 6.2 to 5.4 days since implementation of the protocol.
- Improved ED staff satisfaction, steady unit staff satisfaction: Anecdotal feedback from staff suggest high levels of satisfaction with the protocol. ED staff report being more satisfied with their work environment since implementation, while inpatient unit staff acknowledge that the inpatient hallways are a safer location for boarded patients than ED hallways, and report that the extra work associated with the care of one or two hallway patients has not meaningfully affected their workload or level of satisfaction.
- High patient satisfaction: In a survey, 87 percent of patients first boarded in the ED and then on an inpatient hallway felt that they were safer and received more attention and better care on the inpatient unit.
- No negative impact on patient outcomes: In no instance has boarding on the inpatient unit led to insufficient care or poor patient outcomes.
Context of the InnovationStony Brook University Medical Center, a 571-bed tertiary care institution, experiences approximately 81,100 ED visits annually. As the only tertiary care facility in Suffolk County, NY, the medical center does not have the option to divert ambulances to another facility in times of overcapacity. Institutional overcrowding had become a growing problem by 2000, causing concern among hospital administrators and clinical leaders who wanted to ensure that patients receive the safest care possible.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Creation of improvement team: The medical center created an interdisciplinary quality improvement team to consider how to manage institutional overcrowding and improve patient flow. Members included the nursing directors of inpatient care and the ED, the ED medical director, and representatives from inpatient and ED nursing, admissions, social work, housekeeping, and administration. Among other tasks, the team was charged with considering the safest location to care for ED patients awaiting an inpatient bed.
- Consideration of unit hallway boarding: As the team devised ideas to improve patient flow (e.g., earlier rounding, more proactive discharge planning), the ED medical director suggested moving patients boarded in the ED to the inpatient units. Team members initially resisted this idea; however, ongoing conversations led everyone to the conclusion that, in the absence of available beds, no better alternatives existed.
- Protocol development: Staff eventually agreed that boarding in the inpatient hallway was safer for the patient than boarding in the ED hallway, and wrote a protocol to guide the process.
- Discussions with inpatient nurses: The team held a series of meetings with the inpatient unit nurses; the meetings were held in the ED so that the nurses could see the problems and dangers of overcrowding and could be introduced to the concept of hallway boarding.
- Concurrent discussions with health department to garner support: Concurrent with the discussions held at the medical center, Stony Brook’s ED medical director met with colleagues from across New York State and state health department representatives to confirm that no state rule prohibited inpatient unit boarding. As a result, the health department sent a letter to all New York hospitals recommending use of inpatient unit boarding rather than ED boarding in times of overcrowding.
- Preparation of inpatient hallways: The team visited each inpatient unit to determine where to place boarded patients. Some units had natural areas, such as alcoves, that could be used, while others needed to use space in the hallway itself (often near the nursing station). The hospital purchased screens to create more privacy for boarded patients and wireless call bells to allow up to two hallway patients on each unit. In addition, the team reviewed and amended hospital evacuation plans to ensure safe evacuation of hallway patients if needed.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
- Costs: The protocol required minimal costs for development and implementation, such as the aforementioned purchase of privacy screens and wireless call bells. These costs are minor compared to the large revenue upside resulting from the ability to serve additional patients.
Funding SourcesStony Brook University Medical Center
Tools and Other ResourcesStony Brook University Medical Center’s full capacity protocol, along with related presentations and resources, can be accessed at: http://www.hospitalovercrowding.com/.
An April 2008 American College of Emergency Physicians report entitled, “Emergency Department Crowding: High Impact Solutions,” is available at http://www.hospitalovercrowding.com/.
Getting Started with This Innovation
- View overcrowding as institution-wide, not ED-specific, problem: The full capacity protocol should be presented as an institutional response to provide the best care to patients in situations of overcrowding. To emphasize that overcrowding is an institutional problem, initially involve high-level medical staff, such as the medical director, in the decision to trigger the protocol; this approach will also serve to increase staff comfort and ensure that the decision to implement the protocol is seen as unbiased. This involvement can end once staff become more comfortable with the protocol.
- Develop clear guidelines: The protocol should clearly delineate who will make the decision to implement the protocol, the criteria under which the protocol will be triggered, and which types of patients are appropriate for inpatient unit hallway boarding.
- Obtain support of inpatient nurse managers: Nurse managers may initially have a strong negative reaction to unit hallway boarding. However, they typically support the approach once they learn that it provides a safer location for admitted patients and enables care to be initiated sooner; that only low acuity patients will be considered for unit hallway boarding; and that their workload will not increase significantly.
- Encourage sense of ownership by inpatient staff, even when patients are in ED: Encourage unit nurses to visit the ED to view boarded patients and see that the ED represents a suboptimal location for a patient awaiting a bed. Unit staff should be reminded that they “own” these patients, even when they remain in the ED. The goal is to make the idea of hallway boarding resonate with unit nurses.
- Help staff visualize hallway boarding: Visit each unit to identify a reasonable location to place a hallway patient; staff who can visualize patient placement will be more likely to accept the concept of unit boarding.
- Give units flexibility: Each unit should be allowed to decide how it can most effectively incorporate the care of hallway patients into the nurses' existing workload.
- Plan for patient comfort: The patient will need a privacy screen, a call bell, and an identified bathroom to use; usually, the patient will also require telemetry monitoring, so an adequate supply of telemetry boxes is essential. Also, consider making books, magazines, or a portable DVD player available to the patient.
Sustaining This Innovation
- Expect that acceptance will come only over time: The protocol typically will be accepted over time as nurses realize that unit hallway boarding results in only a minor and temporary increase in workload.
- Emphasize rationality of boarding decisions: Education of staff regarding patient safety issues is crucial. The ED must focus on incoming emergencies and cannot perform emergency care and manage admitted patients simultaneously. The best care of the patient is reflected in the best staffing ratios, by the right staff with the right expertise, which means moving the admitted patient to the location where this care can be provided.
- Understand the limitations of the boarding protocol: The sickest patients (i.e. ICU and stepdown unit patients) continue to board in the ED if there is no appropriate inpatient bed available; however, multiple studies suggest that these patients fare worse by remaining in the ED. This remains a substantial patient safety issue in the absence of a full complement of appropriate staff to care for such patients. Institutions should continue to seek solutions other than ED boarding for the care of such patients.
Additional Considerations and LessonsProgram developers believe that institutional overcrowding should not be viewed as a crisis, because hospitals need to run at or near full occupancy on a consistent basis to be financially viable. Thus, patient backups will inevitably occur, most often in the ED. The question becomes how to manage these backups in a way that maximizes safety and ensures appropriate care for the patient. Because admitted patients are cared for most appropriately on inpatient units, where staff members have specialized expertise and can initiate treatment as needed, inpatient unit hallway boarding should be viewed as a planned accommodation to overcrowding rather than as a crisis measure.
Use By Other OrganizationsOther institutions who have concurrently developed procedures to board ED patients on unit hallways include Duke University Hospital, William Beaumont Hospital, Yale University Medical Center, the St. Barnabus Health System, and the New York University Hospital.
Burley G, Bendyk H, Welchel C. Managing the storm: an emergency department capacity strategy. J Healthc Qual. Jan/Feb 2007. [PubMed]
Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179(10):524-6. [PubMed]
Weiss SJ, Ernst AA, Derlet R, et al. Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med. 2005;23:288-94. [PubMed]
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Service Delivery Innovation Profile
Original publication: September 29, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 17, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 11, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.