Crowding and Boarding

ED Boarding and Crowding

Crowding is defined as "the need for services exceeds an ED's capacity to provide these services." Many things contribute to crowding including more patients with lack of access to other forms of care, inefficient ED processes, inadequate staffing, or short supply of inpatient beds. 

Crowding is a problem as it has been linked with worse patient care. One study conducted showed that crowded EDs are associated with longer door to needle times in STEMI patients by 23 minutes. Another study showed similar results with respect to stroke patients getting CT imaging. Another study showed similar results with respect to sepsis measures (longer time to fluids and antibiotics). 

Many EDs use the Input-throughput-output model to identify areas that can be improved in an effort to reduce crowding. Input is dictated by the patients. While measures like improved outpatient access, freestanding EDs, and more urgent cares can influence this, ultimately the ED itself has minimal control over these factors. 

The next part of this model is throughput, which is defined as all the activities that happen during the ED visit for a patient. This includes triage, registration, labs, imaging, specialist access, charting, social work. This is largely dictated by staffing and processes. This is the most modifiable by the ED. Certain models can influence this - split flow models that are designed to quickly see and disposition patients with less emergent presentations. Appropriate staffing levels makes crowding easier to navigate. Improved charting models can also decrease the amount of time a patient is in the ED.

The final influencing factor is output which is determined by whether the patient is admitted, discharged, or transfered. Split flow models can help with faster dicharges. Having hospital bed managers efficiently move admitted patients can also help. 

Ultimately if the hospital is full from an inpatient bed perspective, there will be more patients boarding in the ED. Boarding is considered to be the biggest contributor to ED crowding. Boarding is defined by the Joint Commission as the "practice of holding patients in the emergency department after the decision to admit or transfer has been made." Recommendations state that this should not be longer than 4 hours. Boarding patients often require 

Boarding patients can pose a problem as they often require resources and attention of nursing staff - timed medications, timed lab draws, timed neuro checks, respiratory support, titration of drips. There is also the issue of the patient being admitted to an inpatient team that is not persistently available like the ED physicians. Coordinating care can become challenging, and all these factors can lead to worse patient outcomes. 

•Crowding and boarding. Crowding and Boarding EMRA. (n.d.). https://www.emra.org/books/advocacy-handbook-2019/crowding-and-boarding

•Savioli G, Ceresa IF, Gri N, Bavestrello Piccini G, Longhitano Y, Zanza C, Piccioni A, Esposito C, Ricevuti G, Bressan MA. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J Pers Med. 2022 Feb 14;12(2):279. doi: 10.3390/jpm12020279. PMID: 35207769; PMCID: PMC8877301.

Who to contact after a patient expires

I wanted to touch on a subject that is important but often not laid out in a concise manner - the protocol after a patient expires. 

I want to break this down into responsibilities of each of the staff. For residents (like myself) this often seems like a seamless process that happens in the background, but the reality is, multiple members of the ED are all coordinating together to progress this process.

Physicians- 

1. Attending physician must pronounce dead.

2. Admitting must be called with time of death, cause of death, whether or not the medical examiner will accept the case (more on that in a bit). Admitting will then process this info, and upload info to NYC Certify. The attending will then have to go into NYC Certify and certify the death.

3. The patient's family must be notified. Hopefully they are in the hospital, as it is more appropriate to have this conversation with the patient's family face to face, in private and to give them time to grieve with the patient.

4. Medical examiner must be notified in certain instances. The ME will take the following types of cases - trauma arrests, homicides, suicides, younger patients that are not terminally ill. Typically the ME will not take older patients with comorbidities. When in doubt, call the ME and they can decide.

5. Finally, the death note needs to be completed. 

Nursing- 

1. Charge nurse will call the expeditor / patient rep (more on that in a bit).

2. NYC LiveOn. This is the organ donor group. In our ED, nursing typically calls them. This requires answering questions about time of death, cause of death, medical comorbidities. 

3. Nursing and PCTs are typically responsible for post mortem care in patients that are not Jewish (more on the Guardians of the Sick in a bit). This involves removing lines, ET tubes, cleaning the patient, etc. This is NOT to be done in ME cases.

4. There is a written nursing protocol, on the MMC intranet site, I have shared the link below.

Expeditor/Patient Rep-

1. If the patient is Jewish, the expeditor will contact the operator, who contacts the Guardians of the Sick, who come and do post mortem care.

2. The patient rep may go to the family and offer support and comfort. Cannot provide suggestions regarding funeral homes (this is a conflict of interest).

3. Contact transport if the patient is going to our morgue (sometimes the family will arrange for the patient to be transported to a funeral home instead). 

Hope this helps outline the process and responsibilities during these stressful situations!

http://intranet.mmc/Main/DocumentLibrary/Post_Mortem_Care_2762.aspx

POTD: Tips for writing your CV

I wanted to share some tips for creating an excellent CV. I thought this might be helpful as PGY-2s start thinking about writing their CVs over the summer for jobs/applications. It’s easier to slowly add a line or two over time rather than to frantically create one over 3 days.

Formatting:

• Keep it organized and professional. Use a simple font and clean headers. Don't try to be original.

• Put the most important stuff at the top.

• Order it in reverse chronology – most recent at the top for each section.

• As a general rule of thumb, try to keep your resume within 1 page. However, your CV can be longer since it is more comprehensive. In medicine, they’ll ask you for your CV, but if you’re applying for something corporate, then they will likely want your resume. (Or both.)

• Be consistent throughout with your formatting.

• Save the doc / send it as a pdf

• Label your pages with your last name & page #.

• Use bullet points, and try to keep things succinct.

The sections:

• Of course, start off with some of your personal information. At the minimum, include your name, phone number, and best email address.

• Organize your CV by having clear headers. As a resident, it’s appropriate to start off your CV with a “Training and Education” header with your residency, medical school, and undergraduate schools listed.

• Presentations & lectures: include your morning reports, M&Ms, grand rounds presentations, etc. If you’ve presented at national conferences, include that too! Consider breaking out your presentations & lectures as “National” (where you presented at conferences) and then “regional/local” (Maimo/med school presentations.)

• Publications: designate if it’s peer reviewed vs non-peer reviewed. Use proper citation style.

• Include your residency & leadership activities. You can group them however you find appropriate, but take some time to brag about your chiefdom, research and QI projects, and extra-clinical stuff (e.g. event medicine, scholarly tracks, med school clubs, etc.) The majority of my interviews were spent on talking about this section. If it's still in progress, just say where you are in the process.

• Awards - Gold Humanism, AOA, etc.

• Professional affiliations - SAEM, ACEP, etc.

• Certifications - don't ask me why, but they want your random certs listed like ACLS, ATLS, etc.

• Include a hobbies section! People want to get to know you, and it’s okay to be honest and quirky. It can be endearing and a great ice breaker.

Other random tips:

• For each project or leadership related bullet point that you have, make sure you include the following:

  • What was the deliverable

  • Who was it for

  • What was the impact

  • Your methods

• Tailor it to the job. For example, I created a little bucket called “International experiences” since I was applying for a Global Health fellowship. Remember, a community job CV will look different from an academic position.

• Unless it’s super notable, I think high school is too far back to include. But the cool stuff you did in college or med school is great.

Final touches:

• Get feedback. I sent my resume to 5-6 friends, and 3-4 attendings before ultimately submitting it. You don’t have to take everyone’s advice, but you’ll find most tips to be generally helpful.

• Be neurotic - people use your CV as a harbinger for your attention to detail and your professionalism. Keep your grammar, spelling, and formatting perfect.