, establishing turn-around-time (TAT) goals for procedures and patients, can go a long way to begin to cure the problem of overcrowding (ACEP, 2008, p. 10). Full-capacity protocols. Here is a typical full-capacity protocol from Stony Brook University Hospital and Medical Center in New York:

"POLICY: When an adult patient requires admission to an Acute Care Unit from the Emergency Department and that area cannot accommodate that patient because of lack of sufficient beds, the patient will be admitted to the next most appropriate bed. In the event appropriate hospital bed utilization has been maximized, and the number of admitted patients holding in the Emergency Department has prohibited the evaluation and treatment of incoming patients to the Emergency Department

in a timely fashion, the admitted Emergency Department patients already awaiting in house acute care bed assignments will be admitted to acute care unit hall beds"

(Stony Brook Policy Review Committee, 2001, para. 4).

The one-page policy goes on to define "full-capacity" as anytime the "main" department is occupied with patients and admitted ED patients have been awaiting in-house placement for two hours. It also addresses patient priorities as to who should be placed in hall beds outside ED and what the requirements are for any department boarding patients. The precise step-by-step process to move a patient is listed and who would be in charge of the move. Finally, it spells out, in clear terms which patients cannot be considered for a move to an inpatient hallway hospital bed, and it limits the number of hallway beds -- two -- that can be utilized in any department.

As a result, Stony Brook has found that not only are patients more satisfied with their overall experience with the hospital, but that most in-hospital stays utilizing this policy of getting patients out of ED to an inpatient bed reduces the average stay by one full day. and, of course, the ultimate result of that "one less day" is that it frees more beds sooner at the in-patient departments to move more ED patients more quickly out of emergency rooms and reduces the waiting time for those not yet treated. In other words, full-capacity protocol is not just a theory -- it is working in hospitals today (Stony Brook Policy Review Committee, 2001).

Many state Departments of Health are now adopting standard policies for these protocols to be utilized when necessary rather than leaving it up to individual hospitals to come up with their own policy and procedures. New York state was the first one to do so. Other states, like California, are passing legislation to mandate it.

Improved Triage. Triage is the management of patients by the level of treatment they require. This is the first step when a patient walks in the door of an ED. A patient who has a migraine headache may have to wait for the heart attack victim. An accident victim in serious condition will take priority over a patient suffering from a gall stone. Triage establishes the priorities for any ED, and it begins the patient flow process. If done insufficiently or too slowly or by untrained personnel, it can take too much time or establish the wrong priorities. Triage also involves the use of an extensive form for evaluation which, even when done by a properly trained nurse, takes time. The ultimate problem is not only less successful treatment of patients, but more time added to patient waiting times, and an increase in the time it takes to "flow" patients through ED. In other words, it contributes to the patient boarding crisis.

"Triage bypass" is the corrective process that some hospitals are not utilizing to alleviate patient boarding situation. If a patient arrives with only a minor problem, he or she is separated and taken to an area designated as "fast track." Vital signs are then taken. If that patient is found to be more serious than first assessed, they are moved back into the ED. Since many patients fall into this category, it frees up a nurse from performing time-usurping triage and improves the flow of patient's through the entire ED. It is estimated that up to 30% of ED patients never need to get to an ED or hospital room at all (ACEP 3, 2006).

Bedside Registration. This efficient process allows a patient's charts to be available without having the patient or whoever is registering with him wait in line to register at the ED front desk. This process, though proven a time-saver in the patient flow process, does require the purchase of additional equipment such as laptop computers, patient ID card generators, and perhaps additional printers. Studies have indicated that bedside registration is an effective way to reduce the necessity for excessive patient boarding and that it can lead to an improvement in the overall length of hospital stay (ACEP 3, 2006).

Patient Tracking and Informatics Technology. A relatively simple interface between hospital

and ED computers to allow access to the patient's medical record number, which is the key identifier for a hospital patient, would eliminate the necessity...

Such a tracking system could also monitor the check-in times of patients and thus be aware of developing bottlenecks. Interface with laboratory computers and x-ray technicians could alleviate the slow process of phone calls and increase the efficiency of obtaining test results and, as a result, dispositioning patients more quickly (ACEP 3, 2006).
Improving Laboratory Turn-around Times

Laboratory results are crucial in an ED to determine the health of the patient. And the percentage of ED patients who require lab testing is high. So it makes sense that any process to enhance this process will significantly impact patient flow and decrease the necessity for patient boarding. There are several functions in this process that the American College of Emergency Physicians (ACEP) recommends:

Faster transport of lab specimens and results through the use of pneumatic tube systems.

Ensuring the labeling system of specimens includes a designation notifying lab technicians that the "stat" or urgent specimens should be tested first.

Monitoring the turn-around-time (TAT) of lab tests. It does little good to improve technology and processes if those improvements are not evaluated and improved over time. Only by becoming aware of the average time it takes to process a lab test, can steps be taken to decrease it. Again, lab TATs impact the length of stay for a patient, and they also affect the level of quality care the hospital delivers.

(ACEP 3, 2006, pp. 5-6)

Conclusion

Lack of inpatient beds -- and the resultant overcrowding that it causes EDs -- is the foremost contributor to the crisis of patient boarding and to the need for full-capacity protocols and other corrective actions at our hospitals.

Full-capacity protocols that specify levels at which various actions are triggered and intercessions at significant levels up to full capacity, and which are reviewed and implemented several times each working day need to be standard policy.

The crisis is beyond the creativity or workload of each hospital. Each state's medical associations, hospital organizations and departments of health must band together to enforce those measures to fix the crisis of patient boarding in ED departments. Criteria must be established, and legislative measures taken if necessary, to establish formulated programs that hospitals must implement as each trigger point is reached.

The critical problem of emergency room overcrowding is only going to become more exaggerated as more and more patients require both necessary and unnecessary ED assistance.

As budgets shrink and EDs are closed down, at some point in the not too distant future this serious situation will become disastrous.

Patients die due to ED overcrowding and patient boarding that leads to lack of proper medical care. Lawsuits will explode and hospitals will close their doors due to the legal financial drain. And where will that lead us?

The corrective actions are available. The processes have been identified. Many hospitals have implemented them and they have significantly improved ED overcrowding. in-patient boarding to alleviate ED patient boarding succeeds where all else seems to fail.

Bibliography

ACEP. (2008, July 25). Emergency department crowding: High-impact solutions. Retrieved September 18, 2009, from American College of Emergency Physicians: http://www.acep.org/workarea/downloadasset.aspx?id=37960

ACEP 3. (2006, September). Approaching full capacity in the Emergency Department. Retrieved October 9, 2009, from American College of Emergency Physicians: http://www.acep.org/workarea/downloadasset.aspx?id=8852

American Hospital Association (AHA). (1999). Hospital statistics. Health Forum. Chicago, IL: AHA.

Bachenheimer, E. (2008, December 4). A necessity, not an option: Rethinking ED systems.

Retrieved September 11, 2009, from Health Leaders Media:

http://www.healthleadersmedia.com/content/225297/topic/WS_HLM2_QUA/a-Necessity-Not-an-Option-Rethinking-ED-Systems.html

Bernstein, R. (2008, April 16). Finding the root causes of emergency room overcrowding.

Retrieved October 8, 2009, from Productivity Press:

http://leaninsider.productivitypress.com/2008/04/finding-root-causes-of-emergency-room.html

Chance, a. (2009, August 21). VP Operations. (P. Djegal, Interviewer)

Committee on Pediatric Emergency Medicine. (2004). Overcrowding crisis in our nation's emergency departments: Is our safety net unraveling? Pediatrics, 878-888, Vol. 114, Issue 3

(doi:10.1542/peds.2004-1287).

Epstein, R. (2009, March 4). ER overcrowding killing 1500 a year. Retrieved October 8, 2009, from abc.net.au: http://www.abc.net.au/lateline/content/2008/s2534802.htm

GetInsideHealth. (2008, October 23). Uninsured not responsible for emergency department overcrowding, study finds. Retrieved September…