ED is focus of new JCAHO standard: Be ready for questions about patient flow
ED is focus of new JCAHO standard: Be ready for questions about patient flow
Surveyors expect patients in hallways, but they want evidence of solutions
Ten patients being held on gurneys in your ED’s hallways. Four paramedics bringing in patients on gurneys, with every room full. Patients eating meals and being given baths in treatment rooms.
This is what surveyors from the Joint Commission on Accreditation of Healthcare Organizations saw at Escondido, CA-based Palomar Medical Center’s ED. "It was the worst time to have the surveyors come through the ED — they saw all of our warts and moles," reports Kim Colonnelli, RN, BSN, MA, district director for emergency and trauma services for Palomar Pomerado Health. Palomar’s and Poway, CA-based Pomerado Hospital’s EDs were surveyed in March 2005.
However, the managers and staff were honest, Colonnelli emphasizes. "We didn’t put on our best party dress," she says. "They saw the way things really are every day."
The Joint Commission surveyors were unfazed by what they saw. "They weren’t critical that we had patients in the hallways, because they are seeing this all over the country," says Colonnelli. Instead, the surveyors were interested in seeing how the ED staff ensured that the patients received quality care, she says.
EDs are a key focus of the Joint Commission’s new patient flow standard that went into effect Jan. 1, 2005. "Surveyors were extremely interested in patient flow. It was a major thread throughout both our surveys," reports Colonnelli. "During our previous survey, we held our breath and hoped that everything was looking spotless. Fast forward three years later, here we are filled to capacity — and the surveyors saw the way things are when we are really strapped."
At New Hyde Park, NY-based Long Island Jewish Medical Center, ED patients were being held in hallways during a March survey, reports Mia Scaramuzzino, RN, the ED’s administrator for nursing.
"We have big issues with holding admitted patients — there’s just nowhere to put anybody," she says. "The surveyors were concerned about that, but by the same token, they were very pleased with the things we’ve implemented."
Surveyors will look for indications of patient flow problems, such as delays in treatment, inadequate staffing, lack of privacy, poor discharge planning, and high turnaround times for ancillary services, says Carol Gilhooley, director of survey methods development in the Joint Commission’s Division of Standards and Survey Methods.
Patient flow is very much a safety issue, she underscores. "The surveyor will be observing all of the care services as well as interacting with staff," Gilhooley says. "If patients are being held on gurneys in hallways, surveyors will be concerned if any hallways or exits are blocked."
Here are questions surveyors asked nurses at recently surveyed EDs:
- Do admitted patients receive the same level of care as they would on inpatient units?
When four or more inpatients are held at Palomar’s ED, an inpatient nurse comes down to care for the patients in a separate area. "That nurse makes sure that all the things that happen on an inpatient unit get taken care of," says Colonnelli. Those things include documentation on the standard inpatient record, faxing medication orders to pharmacy, and starting any necessary orders.
"If we are not able to get a nurse from the inpatient side, obviously the ED nurse must continue to care for the patient," she says. "Surveyors said that was acceptable as long as the nurse could articulate how orders are initiated, how medications are reviewed by a pharmacist, and overall, how we can demonstrate that we are striving to deliver the same standard of care to the patient regardless of their location."
Inpatient components such as medication management for stroke patients are included in ED competencies, Colonnelli adds.
An "emergency short-stay unit" for inpatients was created in a separate area of Long Island Jewish’s ED, staffed by a small group of nurses and physician assistants who complete multidisciplinary health assessments, expedite testing, and arrange for consults.
"The surveyors liked the idea that we had separated the patients out and that it wasn’t ED nurses taking care of the admitted patients," says Scaramuzzino.
- How are admitting orders handled for inpatients?
"Surveyors wanted to hear the nurse say that medications are faxed over to be reviewed by a pharmacist and that the medications then are delivered," says Colonnelli.
Nurses were asked how the lab knows to notify the ED if there are abnormal values. "They were very interested in that," she says. Nurses explained that when the unit secretary orders the lab electronically, she enters in "Inpatient Hold — ED" with a bed number, so that the lab knows to contact the ED and not an inpatient floor, says Colonnelli.
- Do patients being held have a way to call for help?
"If surveyors are seeing an increased length of stay in the ED and patients being held on gurneys, they will start to ask questions about what kind of services these patients have access to," says Gilhooley. "For example, if patients are in a holding area, do they have a way to call for help if needed, such as a call button? Frequently, the answer is no."
- What have you done to decrease length of stay?
For every patient traced who came through the ED, the surveyors had questions about patient flow, says Colonnelli. "They would ask how long they waited before being seen, how long it took to get the patient admitted, and how long it took to have orders written," she says.
ED nurses reported that an "access-to-care" task force is working to reduce length of stay, says Colonnelli. "Unfortunately, as our volume goes up and our capacity stays the same, we aren’t making much headway," she says. "However, we have not seen an increase in our length of stay despite an increase in volume."
To reduce delays, a security office in the front of Palomar’s ED was converted into a "rapid medical evaluation" area, staffed with a physician assistant and a nurse from noon to midnight. "They are seeing all the minor patients right next to triage, so we can use the beds we had previously designated for urgent care for regular ED patients," says Colonnelli. "The surveyors raved about this."
Surveyors were impressed by a new position of "post-triage nurse" added at Long Island Jewish’s ED to address longer wait times. "The nurse reassesses patients who are kept waiting over two hours, gets labs drawn, and facilitates getting them into beds," says Scaramuzzino.
- Are patients held in hallways given privacy?
Nurses at Palomar’s ED explained to surveyors that fold-up privacy screens are used as needed, says Colonnelli. In addition, signs are posted stating, In order to have you seen and treated quicker, we will start your treatment here. However, we are concerned about your privacy. If you prefer to wait until a room is available, please let your nurse know. Your patience is greatly appreciated. Thank you.
"They were happy that we had signs saying that the patients don’t have to be seen in the hallway," she says.
- How are psychiatric holds handled?
Specially trained inpatient nurses now care for psychiatric patients being held in Long Island Jewish’s ED. "We have a huge psych population here, and we recognize the need to improve care of these patients," says Scaramuzzino. "The psychiatric nurses know the medications better and can de-escalate patients and expedite getting them discharged."
Surveyors wanted to know who observes psychiatric patients held in the ED for an extended length of time, says Colonnelli. "Our policy at both hospitals is that security stays with patients on psych holds until they are admitted or transferred," she says.
Sources
For more information on the new patient flow standard, contact:
- Kim Colonnelli, RN, BSN, MA, District Director, Emergency and Trauma Services, Palomar Pomerado Health, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3320. Fax: (760) 739-3121. E-mail: [email protected].
- Mia Scaramuzzino, RN, Administrator for Nursing, Emergency Department, Long Island Jewish Medical Center, 270-05 76th Ave., New Hyde Park, NY 11040. Telephone: (718) 470-7501. E-mail: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.