Saturday, February 25, 2023

Boarding Patients in Your Emergency Department?

Is your hospital no longer the best place for your sickest patients?
You are not alone.

Check out the recent article from the American Academy of Emergency Physicians here

How did this happen?

1. It happens due to staffing holes exacerbated by poor working conditions;

2. Efforts to manage patients' lives by benchmarks and ratios.

3. Weak staffing pool development needed to cover all shifts with high experienced crew engaged in longer, meaningful career ladders.

4. Misguided efforts to thin support staff, supervisors / Charge RNs and front-line management to curb costs.

5. Focusing disproportionately on low acuity / high margin patients.

6. EHR workflows, bed management tools and task lists sold to help workflow but which segment, section, silo and stack patients. Now people work to their work lists, not with each other.

7. The decision to use median throughput time values in the Emergency Department, erasing boarder patients from the Emergency Length of Stay calculations, erasing accountability: It was never "just" an Emergency department problem. But now it's also not an Inpatient one's problem but the patient.

8. These are all the result of weak Emergency / Inpatient / Support / Clinical Diagnostic consulting by an army of "Subject Matter Experts" blinkered to cut costs within the siloes of each department.

9. Poor or non-existent work engineering.

These have only worsened the Emergency Boarding Patient problem. And an unsolved problem leads to blaming the victims, your patients.

When this happens staff, management and executives begin to burn out, leading to anger and denial, which never solved anything. Then blame and burnout become your culture, with all the power of the status quo behind it. At that stage no solution is supported.

The biggest secret of all? Blame isn't the answer, understanding is. No blame is needed. Ever. It's a Systems Thang: Emergency departments are downstream of the hospital, functionally, not upstream. Patient flow doesn't begin with a new patient at the Emergency Department door or the call from the ambulance team. It begins at the moment the inpatient nurse confirms their patient is likely to be ready for transfer or discharge.

It is not an Emergency Department problem. It's a Hospital and Health System problem.

Stop the old thinking that makes things worse.
Find real solutions here..

And the best consulting support in the nation to help you get there:
And if you need more inspiration that boarding was fixed decades ago in our best Emergency Departments before, during and after a national pandemic, read more than a dozen Emergency and House-wide Patient Flow and Patient Satisfaction case studies here

Become the number one hospital again.

#hospitalmanagement #populationhealthmanagement #emergencymedicine #nurseleaders

Do Nurse Practitioners Really Help Emergency Department Care?  Yes! if Coordinated Well!

Research on the effectiveness of Nurse Practitioners in Hospitals appears mixed.

Some studies indicate improvements in cost, patient care and throughput outcomes...

In Primary Care Settings:

And in the Emergency Department:

This coincides with our experience working with Emergency and Inpatient departments.

We have found that Advanced Practice RNs, in a well-coordinated team approach optimizes their strengths, reduces LWOT, Elopement, Length of Stay, and Readmissions; and raises Patient Satisfaction. Indeed, in the right model, their presence improves Physician outcomes.

However, recent research at Stanford using three years of VNA data indicates worse clinical and throughput outcomes by Advanced Practice RNs who had sole clinical responsibility for patients, compared to Emergency Physicians:

The actual paper can be downloaded here:

And there is some precedent for these findings:

Here is our take on the difference:

The problem can be found in this sentence from the new Stanford study: " In December 2016, the VHA granted full practice authority to NPs, allowing them to practice without physician supervision."

In every high functioning Emergency Department no one works without collaboration and supervision. The Charge RN functionally supervises all the professionals when things work, including the APRN and the MD. The APRN doesn't provide a lesser function but a different one.

The Emergency Physician is often the Clinical Specialist. But often times a more experienced RN better fills the role of the primary Clinician.

Effective Emergency care is a synthesis of talent, a synergy of different skills, and a synchronization of professions who collaborate in real time patient by patient. APRNs actually fill a skill gap that the Emergency Physician Specialist cannot, and in part that is because their practice has changed in Emergency Medicine from initial eyes-on-patient assessment to post-labs assessment. They created a gap in an effort to be efficient. That's OK. Because APRNs are filling it, assuring patient safety. The problem is assuming anyone is above supervision and collaboration.

What is the short course conclusion? If you aren't going to develop the management of your teams, you will need more Physicians, and even there quality is no guarantee. And your staffing will continue to be unreliable.

If you are willing to develop your people, analyze the work, and help them synchronize their collaboration, create systems of accountability and transparency, then skyrocketing patient satisfaction and dramatically improved quality outcomes are yours.

#hospitals #hospitalmanagement #nursingleaders #emergencymedicine #criticalcare