Freeing up beds is key to managing more emergency patients
By Deborah L. Shelton and Jaimi Dowdell
St. Louis Post-Dispatch (Missouri)
Copyright 2006 St. Louis Post-Dispatch, Inc.
All Rights Reserved
About 15 doctors and nurses huddled in a second-floor staff lounge at St. Louis University Hospital in early 2003 trying to figure out how to deal with crowding in the emergency room.
Up to that point, their solution had been to turn away ambulances.
The hospital was logging some of the highest hours on diversion among medical facilities in the St. Louis region, rerouting ambulances almost 13 percent of the time, or about 97 hours a month.
The image of a seriously ill or injured person in the back of an ambulance, being driven up and down the highway as paramedics searched for a hospital, troubled Helen Sandkuhl, the emergency department’s director of nursing services.
“We had a long discussion with our staff and asked them: ‘Would you want that happening to your mother?’” she said. “I told them, ‘We are going to have to suck it up.’”
Since then, hospital administrators have changed the way they operate and, as a result, diversion hours have plummeted.
In 2003, St. Louis University Hospital ranked third among the 22 area hospitals that went on bypass, rerouting ambulances 660 hours. That’s almost four weeks. This year it ranked eighth, diverting ambulances 176 hours between January and the end of July.
Barnes-Jewish Hospital in St. Louis experienced the biggest percentage decline from 2001 through 2005, reducing its diversion hours 96 percent.
Other hospitals reducing diversion hours by more than 50 percent were St. Alexius Hospital, Christian Hospital and Northwest HealthCare.
Of the hospitals that showed improvement, only officials at St. Louis University Hospital, Barnes-Jewish Hospital and Missouri Baptist Medical Center agreed to be interviewed about their diversion statistics.
The Post-Dispatch first reported on ambulance diversions in a series of articles more than five years ago. At the time, some paramedics were having to scramble to find an emergency room that would accept a patient.
Recently, the Post-Dispatch reviewed data on hospital diversions for the past five years, collected by the Missouri Hospital Association. The newspaper also analyzed hourly reports from the most recent 40 months, the period for which the most detailed information was available.
A safety net
Officials at inner city medical centers such as St. Louis University Hospital can find plenty of reasons to redirect ambulances from their doors.
“You might have five shootings in your emergency department — or a stroke, a heart attack and a couple of shootings. Those are all very critical patients, so having one more could affect the quality of your care. It’s not the ideal situation,” Sandkuhl said.
“On the other hand, you have to look at the other side of it — the poor guy riding around in the back of an ambulance needing an emergency department. It’s kind of like Bethlehem — no room at the inn — and there has to be a better solution than that.”
Federal law requires hospitals to assess and stabilize every patient who comes in. Hospital officials can’t control the flow of walk-in patients. They can’t turn away trauma patients, those with life-threatening conditions, or those who can’t pay.
So, to manage crowding, they divert ambulances.
Data from the Missouri Hospital Association shows that after a dip earlier in the decade, the number of diversions regionwide has climbed. In the first seven months of this year, at least one hospital was turning away ambulances 48 percent of the time, according to a Post-Dispatch analysis.
A growing number of people from both Missouri and Illinois are seeking care in the emergency room at St. Louis University Hospital. On average, 92 patients a day are being treated in 2006, compared with 85 in 2003.
St. Louis University Hospital also is one of four Level One trauma centers in the area, receiving some of the most critically ill and injured patients.
The number of people treated for traumatic injuries rose to 989 in 2005, from 471 in 2002.
Officials say patients also are older and sicker, requiring longer work-ups. Twenty-seven percent of patients treated in the emergency room are admitted.
“We have an aging population, resulting in more medical problems,” Sandkuhl said. “And we’ve really become the safety net for a lot of people.”
Diversion was an easy way to relieve pressure whenever emergency room staff felt overwhelmed, officials said. But administrators have since put into place a system based on objective conditions in the emergency room, which allows them to be less reactive and more proactive, they said.
“We raised awareness and put triggers in place so we can plan ahead instead of waiting until we are too saturated and too deep in a hole to get out,” Sandkuhl said.
A communications system, called Stoplight, was developed to monitor the availability of beds throughout the hospital. Green indicates beds are available. Yellow alerts administrators to start looking for patients that can be moved safely out of the intensive care unit or discharged.
“Avoiding diversion means not waiting until you get slammed,” said Dr. Karen Webb, emergency room medical director. “When you are at the yellow level and use the rest of the resources of the hospital, it keeps the emergency department from getting to that point where the halls are filled and the staff is overwhelmed.”
Two patients are identified on every floor who can be discharged by 9 the next morning — 10 beds that can serve as a safety valve.
“When the emergency department starts heating up in the afternoon, we’ve already got that little stash of beds available that we can start moving patients into,” Webb said.
A special discharge area was opened so patients ready for home have a place to wait, freeing up much-needed beds.
Studies report that the primary cause of emergency-room crowding is a shortage of beds in the hospital where emergency-room patients can be transferred.
The hospital renovated the emergency department in 2004 and increased the number of beds to 26 from 16, which helped with patient flow, Webb said.
Once a bed is freed up, administrators say, they try to get a housekeeper assigned as quickly as possible to get the room ready for the next patient.
Administrators are working on a plan to bring in nurses as reinforcements from inpatient floors, particularly the intensive care unit, to care for patients waiting for a bed in the ward.
Other options to make room include holding emergency patients in a recovery room, set up like a mini-intensive care unit.
Making a commitment
Despite all the changes, however, diversions still take place.
In July, St. Louis University Hospital logged 68 hours on diversion. It was the first time since 2003 that the hospital had more than 60 hours in one month.
“Diversion is not something you fix once and then it stays fixed,” Webb said. “You have to work on it every day.”
Barnes-Jewish Hospital opened up a new emergency department and trauma center in 2003, consolidated services to streamline operations and made changes in how it staffed its facilities. It also utilized an electronic tracking system to keep track of bed availability and turnaround time and to analyze ambulance arrival times, among other things.
“Everything we do in the hospital needs to be as efficient as possible,” said Judy Paull, patient care director of the Barnes-Jewish Hospital emergency department. “All of those gains help to free up beds and free up time, and that’s what’s needed to manage the increased demand for health services.”
Officials at Barnes-Jewish, the largest emergency department in the region, expect to treat about 80,000 patients this year, up from 77,000 last year, Paull said.
“This organization has made some commitments to the community to limit and, hopefully, eliminate as much as possible the need for any diversions,” she said.
Missouri Baptist Medical Center is opening a new, state-of-the-art emergency room in January, expanding to 18 beds from 13. It also is setting up a holding area for patients waiting for beds, and has made changes in how it staffs the emergency room and orders tests.
“When we go on diversion, we analyze why, what we could do to improve the system and how we can prevent it the next time,” said Dr. Leonard Winer, Missouri Baptist chief of emergency medicine.
Winer said that although officials had lowered the number of hours on diversion, they were not satisfied. The hospital’s diversion hours fell 30 percent from 2001 to 2005.
“We want it to be zero,” he said. “But it is better than it was three years ago.”