Patients In Hallways Research Articles

164 The Impact of Hallway Placement on Emergency Department Operations for Discharged Patients with Abdominal Pain

Emergency department (ED) crowding is a constant and relentless operational challenge facing hospitals across the country. In response to limited capacity many EDs increasingly care for patients in hallways to provide timely access to ED evaluation and facilitate ED flow. We sought to examine the impact of patient placement in the hallway on common ED throughput and quality measures for discharged abdominal pain patients.

37 Inequities Among Emergency Department Hallway Utilization

Emergency department (ED) crowding is a constant and relentless operational challenge facing hospitals across the country. In response to limited capacity, many EDs increasingly care for patients in hallways to provide timely access to ED evaluation. However, hallway placement can also lead to lower patient satisfaction and lower quality of care. We sought to explore social risk factors and ED operations features that may be associated with the hallway placement decision.

65 Provider Patient Satisfaction Scores Unaffected by Hallway Patients in the Emergency Department

65 Provider Patient Satisfaction Scores Unaffected by Hallway Patients in the Emergency Department

Is hallway care dangerous? An observational study

ObjectivesIn response to crowding the use of hallway beds has become an increasingly prevalent practice in Emergency Departments (EDs). There is limited research on whether caring for patients in hallways (HP) is associated with adverse outcomes. The goal of this study was to examine the effects of HP triage on 30 day outcomes for ED return, readmission, and mortality. MethodsWe performed a retrospective cohort study at an urban, academic ED comparing HPs (defined as HP for ≥30 min) to matched controls triaged to standard ED beds from 9/30/14 to 10/1/15. We analyzed data from the hospital's clinical data warehouse. Matched controls were selected by gender, age, ethnicity, and language. We used McNemar's test to assess the association between triage location and 30 day study outcomes. We also examined adverse outcomes by triage severity using McNemar's test. ResultsA total of 10,608 HPs were matched to control patients. Compared to controls, HPs had 2.0 times the odds of returning to the ED in 30 days (95% CI: 1.8–2.1), 1.6 times the odds of inpatient readmission (95% CI: 1.4–1.9), and 1.7 times the odds of readmission to observation (95% CI: 1.4–2.0). The odds ratio for mortality in HPs versus controls was 0.80, (95% CI: 0.50–1.3). ConclusionsPatients initially triaged to the hallway have an increased odds of 30 day return to the ED, observation and inpatient admission. After adjusting for ESI, the increased odds for return remained similar. The small sample size precluded testing effects of HP status on mortality.

Abstract 18377: Prospective, Multi-center Trial to Determine the Effect of Viewing a 60-second Video on Emergency Department Patients and Their Companions Willingness to Perform Compression-only Cardiopulmonary Resuscitation

Introduction: Bystander CPR is uncommonly performed in out-of-hospital cardiac arrest patients transported to our ED. Previous studies suggest adults without formal CPR training can retain compression-only CPR skills with a single viewing of a 60 second, AHA training video. We sought to determine the impact of viewing this video on the willingness of ED patients and their companions to perform compression-only CPR. Hypothesis: Watching a 60 second AHA CPR training video is associated with a 10% increase in willingness to perform CPR. Methods: A convenience sample of adults age 18-70 from two urban, academic EDs with socioeconomically diverse patient populations was recruited. Patients in hallways and non-english speakers were excluded. Subjects were asked to complete a pre-video survey to assess baseline knowledge and willingness to perform CPR on a stranger and on family/friends, watch a 60 second, previously validated AHA CPR instructional video, and then complete a post-training CPR survey. Willingness was scored as 1 (not at all likely) to 5 (extremely likely). An answer of 4 or 5 was considered “willing to perform CPR”. A sample size of 110 subjects from each hospital was determined necessary to detect at 10% absolute difference assuming 0.80 power and one-sided alpha level of 0.05. Sign and McNemar's tests were used to compare pre and post video measurements. Results: Between 1/1/15 to 6/7/15, 281 patients and their companions were approached about study participation, of which 229 (82%) consented; complete data were available for 216 subjects. Subjects were mean age 47, 66% female, 68% black, and 69% college educated. After watching the video, willingness to perform CPR on a stranger increased by 29%, from 57% to 86% (p< 0.001). Willingness to perform CPR on family/friends increased by 19%, from 75% to 94% (p<0.001). Among subjects whose willingness to perform CPR changed (110 on a stranger and 67 on family/friends, respectively), 98% (108) and 96% (64) changed from less willing to more willing. Conclusion: In adult patients and their companions in two diverse, academic EDs, watching a 60 second CPR training video was associated with a significant absolute increase in willingness to perform compression-only CPR on a stranger (29%) and on family/friends (19%).

Abstract 18471: A Teachable Moment: Clinically Stable Emergency Department Patients and Their Companions are Willing to Learn Compression-only Cardiopulmonary Resuscitation

Introduction: Bystander CPR is uncommonly performed in out of hospital cardiac arrest patients transported to our Emergency Department (ED). ED visits are brief and complex, but represent a valuable opportunity to teach CPR to members of our community. Our objective was to determine what percentage of ED patients and their companions are willing to learn compression-only CPR. Hypothesis: The majority of ED patients and their companions are willing to learn compression-only CPR. Methods: A convenience sample of clinically stable adults age 18-70 from two urban, academic EDs with socioeconomically diverse patient populations was recruited. Patients in hallways and non-english speakers were excluded. Subjects were asked to complete a pre-video survey to assess baseline knowledge and willingness to perform CPR, watch a 60-second previously validated CPR instructional video, and then complete a post-training CPR survey. Consenting patients were asked if they thought their ED visit was related to their heart. All study subjects were categorized as: 1. patient or companion, and 2. cardiovascular or non-cardiovascular complaint. Subjects who did not consent were asked to share reasons for not participating. Data were entered into a REDCap database. Results: Between 1/1/15 to 6/7/15, 281 patients and their companions were approached about study participation. Mean age was 47, 66% female, 68% African American, and 69% had a college education. 73 believed their visit was related to their heart. 70% were patients, and the remainder were their companions. Overall, 229 (82%) were willing to learn compression-only CPR. 51 of 52 shared reasons for not participating. Reasons included: not feeling well (29%), already CPR trained (16%), and not interested (16%). Patients who thought their ED visit was related to their heart and their companions were equally likely to participate than those who did not (80% vs 83%). Conclusion: In two diverse, academic EDs, 82% of medically stable adult patients and their companions were willing to learn compression-only CPR.

Hallway Patients Reduce Overall Emergency Department Satisfaction

BackgroundPatient satisfaction impacts emergency medicine in multiple ways, including patient−physician rapport, patient compliance with medical recommendations, and individual physician and hospital reimbursement issues. ObjectiveThe objective of this study was to assess the differences, if any, in satisfaction scores among patients treated in regular treatment rooms vs. those treated in hallway treatment areas. MethodsA cross-sectional survey study of conveniently sampled participants from both regular treatment rooms and hallway treatment areas in an urban, adult community teaching emergency department (ED) was performed confidentially, measuring overall satisfaction, as well as satisfaction with regard to treatment location only, medical care only, and their willingness to return to or recommend the ED in the future based on their experience. Each of these four outcomes was measured on a 100-mm visual analog scale. ResultsOverall satisfaction scores were 8 mm lower for those patients treated in hallway treatment areas, and there was a 20-mm difference with regard to location only. After controlling for apparent baseline differences between the groups, a 7.6-mm difference for overall satisfaction remained. ConclusionsDespite differences between patients placed in regular treatment rooms vs. hallway treatment areas, overall satisfaction levels are lower for those patients treated in hallway treatment areas. This difference is likely attributable primarily to their hallway location, and stakeholders should therefore take appropriate steps to address such discrepancies.

Providing Care in Emergency Department Hallways: Demands, Dangers, and Deaths

Emergency departments (ED) worldwide have experienced dramatic increases in crowding over the past 20 years that now have reached critical levels. One consequence of ED crowding has been the routine use of ED hallways for patient care. This includes ED patients who are awaiting care but are considered unstable to remain in the waiting room, patients who are undergoing active medical and trauma treatment, and patients who have been stabilized but await transfer to an inpatient bed (boarding) or another institution. Compared with licensed hospital or standard ED beds, care in ED hallways results in increased patient morbidity and mortality, as well as patient and staff dissatisfaction. Complications experienced by hallway patients include unrecognized sudden respiratory arrest or unstable cardiac arrhythmias, delay in time-sensitive procedures and laboratory testing, delay in receiving important medications, excessive or unrelieved pain, overall increased length of stay, increased disability, and exposure to traumatic psychological events. While much has been published on the general problems of ED crowding, only recently have studies focused exclusively on the issues of providing care in ED hallways. This review summarizes the current issues, challenges, and solutions for hallway care.

Emergency department crowding in The Netherlands: managers’ experiences

BackgroundIn The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding.MethodsA survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow.ResultsSurveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners.ConclusionsDespite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.

The association between the transfer of emergency department boarders to inpatient hallways or off-service beds and the quality of oncology care.

113 Background: Emergency department (ED) crowding is an important issue in the delivery of high-quality medical care. At our quaternary care hospital a policy was implemented to ease ED crowding by moving suitable admitted patients into inpatient hallway beds or off-service beds. This study assesses the impact of off service and hallway bed admissions on patient care and satisfaction. Methods: Retrospective and prospective data were collected from Jan 1 to Dec 31, 2011, on admissions to the oncology service via the ED. Patient care data was collected as follows: chest/abdominal exams performed at first MD visit, number of MD visits within 48 hours, time to antibiotic administration, time to complete vitals, and mean time spent in the ED. Satisfaction surveys were also given to all patients. Results: One hundred and eighteen patients were admitted to a hallway bed (HALL). A random sample of 90 patients were used for comparison in the on service (ON) and off service (OFF) groups. Among HALL patients, 4% percent discharged themselves against medical advice (0% of OFF and ON patients). MD visits within 48 hours were the same among all groups (mean=6). Forty-two percent of hallway patients had a chest/abdominal exam during the first MD visit (32% and 33% for OFF and ON patients, respectively). Time to first completion of vitals was 1:05 (hh:mm) for HALL patients (1:21 and 00:34 for OFF and ON patients, respectively). Time to antibiotic administration was 15:34 for hallway patients (23:59 and 12:35 for OFF and ON patients, respectively). More HALL patients expressed dissatisfaction with their hospital stay (16.7%) compared to OFF (0%) and ON patients (0%). Mean time for admitted patients in the ED awaiting their HALL bed was 9:14, considerably longer than for OFF patients (3:08) and ON patients (4:19). Conclusions: Admission of oncology patients in hallway or in off-service beds did not appear to compromise the timeliness or frequency of medical assessments. However, delays in nursing care (completion of vital signs and drug administration) were noted and patient satisfaction was decreased. Moreover, the policy did not meet its intent to reduce patient time spent in the ED.

Investigating Rare Events and a Discussion on Waiting Room Chest Pain Evaluations: Answers to the November 2010 Journal Club Questions

Editor’s Note: You are reading the 18th installment of Annals of Emergency Medicine Journal Club. The questions and the article they are about (Scheuermeyer et al. Ann Emerg Med. 2010;56:455-462) were published in the November 2010 issue. Information about journal club can be found at http://www.annemergmed.com/content/journalclub. Readers should recognize that these are suggested answers. We hope they are accurate; we know that they are not comprehensive. There are many other points that could be made about these questions or about the article in general. Questions are rated “novice,” ( ) “intermediate,” ( ) and “advanced” ( ) so that individuals planning a journal club can assign the right question to the right student. The “novice” rating does not imply that a novice should be able to spontaneously answer the question. “Novice” means we expect that someone with little background should be able to do a bit of reading, formulate an answer, and teach the material to others. Intermediate and advanced questions also will likely require some reading and research, and that reading will be sufficiently difficult that some background in clinical epidemiology will be helpful in understanding the reading and concepts. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.

15: Satisfaction of Emergency Department Hallway Patients

15: Satisfaction of Emergency Department Hallway Patients

Pediatric Patient Safety in Emergency Departments: Unit Characteristics and Staff Perceptions

The goals were (1) to describe emergency department (ED) characteristics thought to be related to patient safety within the Pediatric Emergency Care Applied Research Network, (2) to measure staff perceptions of the climate of safety in EDs, and (3) to measure associations between ED characteristics and a climate of safety. Twenty-one EDs were surveyed to assess physical structure, staffing patterns, overcrowding, medication administration, teamwork, and methods for promoting patient safety. A validated survey on the climate of safety was administered to all emergency department staff members. Safety climate scores were compared to evaluate associations with ED characteristics. A total of 1747 staff members (49%) responded to the survey on the climate of safety. A minority of EDs had organized safety activities such as safety committees (48%) or walk-rounds (38%), used computerized physician order entry (38%), had ED pharmacists (19%), or had formal physician/registered nurse teams (38%). The majority (67%) treated patients in hallways. Most (67%) varied staffing on the basis of seasonal patient volume. Of the 1747 ED staff members (49%) responding to the survey, there was a wide range (28%-82%) in the proportion reporting a positive safety climate. Physicians' ratings of the climate of safety were higher than nurses' ratings, and perceptions varied according to work experience. Characteristics associated with an improved climate of safety were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee. Large variability existed among EDs in structures and processes thought to be associated with patient safety and in staff perception of the safety climate. Several ED characteristics were associated with a positive climate of safety.

The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: A 4-Year Experience

We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm. This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008. In 2001, a multidisciplinary team developed and implemented an institutional protocol in which admitted adult patients boarded in the ED were transferred to hospital inpatient hallways under select conditions. We extracted data from the electronic medical record system, measuring patient demographics, ED disposition (discharge, admit to floor, admit to hallway), ED length of stay, and inhospital mortality. We report ED length of stay, subsequent transfer to an ICU, and hospital mortality of patients admitted to standard and hallway inpatient beds. Of 55,062 ED patients admitted, there were 1,798 deaths. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48.2% and 50% female patients, respectively). The median (interquartile range) times from ED triage to actual admission in patients admitted to standard and hallway beds were 426 minutes (306 to 600 minutes) and 624 (439 to 895 minutes) minutes, respectively (P<.001). Median ED census at triage was lower for standard bed admissions than for hallway patients (44 [33 to 53] versus 50 [38 to 61], respectively, P<.001). Inhospital mortality rates were higher among patients admitted to standard beds (2.6%; 95% confidence interval [CI] 2.5% to 2.7%) than among patients admitted to hallway beds (1.1%; 95% CI 0.7% to 1.7%). ICU transfers were also higher in the standard bed admissions (6.7% [95% CI 6.5% to 6.9%] versus 2.5% [95% CI 1.9% to 3.3%]). Transfer of ED-boarded admitted patients to an inpatient hallway occurs during high ED census and waiting times for admission but does not appears to result in patient harm.

1000 Genomes Project Promises Closer Look at Variation in Human Genome

took issue with the use of boarding and crowding as part of a management strategy. “The financial incentives are out of sync for a variety of services hospitals offer for patients,” Steinberg said. “Hospitals are trying a variety of ideas to address overcrowding, but there is no one-size-fits-all solution.” But some potential solutions are being considered. For example, hospitals could try to reduce the traditional use of the early days of the week for elective surgeries, which limits the number of inpatient beds available at that time. “I see 180 patients a day, and I can’t get them an inpatient bed on a Monday, but I see the same volume on a Friday and have no problems,” said Judd E. Hollander, MD, professor and clinical research director in the Department of Emergency Medicine at the University of Pennsylvania School of Medicine. Using the inpatient services of hospitals on weekends and the evening hours during the week could also ease boarding, Hollander added. Another possible solution to ease crowding is to move patients boarding in the emergency department to hallways of inpatient areas of the hospital. “Instead of having 20 emergency department beds being used, you have 2 patients in hallways on each floor of a 10-story hospital,” said Kellermann, who noted such a scheme is viewed cautiously by inpatient nurses who worry of being overburdened. “What one often finds is the ‘miracle of the elevator’—by the time a patient gets to the floor, there’s a clean bed waiting,” Kellerman said. However, an impediment to trying such solutions is a fear of hospital administrators that being the first and perhaps only institution to do so in a community could lead to that hospital being flooded with uninsured patients, which might overburden the institution financially. Still, said Pines, while one can appreciate a hospital’s desire to be financially stable, the institution must remember why it exists in the first place. “Usually a hospital’s mission statement calls for it to provide the best care to any patient regardless of status,” he said.

Emergency department overcrowding: Patient preference for boarding hallway location

Study objectives: An unfortunate nationwide hospital patient flow epidemic exists. Emergency department (ED) outflow of admitted patients awaiting inpatient ward room placement contributes to this problem. One solution recognized in New York that was withdrawn from the Jointre Organizations (JCAHO) 2004 Hospital Accreditation Manual (draft version) was for admitted patients to wait outside the ED. We wish to learn what location patients prefer. Methods: A convenience sample of patients from the ED and inpatient ward in a tertiary urban center completed a survey differentiating boarding location preference, the degree they objected to boarding in each location, and rationale for their preference. None of the patients were actually in the hallway at the survey. The study was conducted from January to March 2004 after an institutional review board–expedited review. Results: Three hundred thirty-seven (96%) of 352 patients surveyed voiced a boarding location preference. Two hundred twenty-three (66.2%) patients preferred boarding in the inpatient ward hallway versus 114 (33.8%) in the ED. Two hundred sixty-four (75.9%) patients were surveyed on the ward and 88 (25%) in the ED. Boarding location preference was not affected by interview site. Less than a Commission on Accreditation of Healthca1.8% absolute difference existed across sites for ward and ED hallway preferences. A rationale for hallway preference was supplied by 146 (65.5%) who favored boarding in the ward and 80 (70.2%) who favored the ED. Of those preferring the ward, 74 (50.7%) patients desired to avoid the ED's high level of traffic, noise, commotion, or low level of privacy. Forty-three (29.5%) patients cited physical proximity to their room, to get in faster, or see your room. Seventeen (11.6%) pro-ward hallway patients' justification could be grouped under a common category characterized by feeling uncomfortable in the ED because it was too dangerous or rough, made them nervous, had more germs or weird people, and had less cosmetic appeal. Of the patients opting for boarding in the ED, 46 (57.5%) patients justified their decision by reporting that health care and treatment would be quicker or better or involve physicians. Fourteen (17.5%) patients thought that the ED was more comfortable, safer, private, and spacious, with less traffic and fewer people to look at me funny. The next most common justification was by 5 (6.3%) patients who believed they would reach their room in less time. When asked to choose their degree of objection, those desiring boarding in the ward and ED chose problem (27.4 versus 21.9%), minor inconvenience (30.9% versus 31.6%), (23.4% versus 26.3%), very dissatisfied but understand (7.2% versus 7.9%), very dissatisfied and angry (10.8% versus 9.6%), or had no answer (0.4% versus 2.7%). Conclusion: Nearly twice as many patients would prefer to be boarded in an inpatient hallway in contrast to the ED hallway. In suboptimal situations when there is no other care location than the hallway, administrators and the JCAHO should also consider the admitted patient's preference. Patients in our hospital were surprisingly forgiving of the potential of being placed in the hallway.

Frequent overcrowding in U.S. emergency departments.

To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five-point Likert scale. Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations < or =250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (+/-SD), causes of overcrowding included high patient acuity (4.3 +/- 0.9), hospital bed shortage (4.2 +/- 1.1), high ED patient volume (3.8 +/- 1.2), radiology and lab delays (3.3 +/- 1.2), and insufficient ED space (3.3 +/- 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding. Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.