Issue 1 : Hallway Beds

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The Problem


1. Define in 10-20 words.

“Patient Circulation - Hallway Beds” refers to the problems of patient flow in the ER. A resulting problem is ER using hallways to treat patients. Hallway beds are a common practice in many ERs due to a lack of rooms.


2. Research: What information were you able to find on the web or from readings?

The real issue is overcrowding or patient circulation in the ER. There are many issues/variables in the hospital that cause issues with patient circulation in the ED. Numerous studies have been conducted to identify patient circulation (flow) issues within the ED. Most studies indicate that the ED backs up due to a lack of bed availability in the hospital. The articles commonly refer to this link between the ER and the hospital as the "whole hospital" approach.

A study conducted in Miami's Mercy Hospital (Garcia 1995) used modeling to attempt to improve patient flow. The study catagorized patients (triage) into 5 groups. They targeted the least acute patients who typically had the longest wait times. Using a "fast track" patient flow they were able to reduce the wait time by 25%.

Another study conducted in Barcelona, Spain (Miro 2003) concluded the ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. The study identified several factors that caused these internal factors.


To narrow down the patient circulation problem we focused on hallway beds. Most EDs use hallway beds due to overcrowding in order to admit more patients into the ED. Other factors that cause ERs to use hallway beds are a lack of beds in the hospital to admit ER patients, nurse/doctor preference, and ability to observe the patients.

Hallway beds increase the possibility of spreading communicable diseases. There are a limited number of studies on hallway beds. There are many studies on the issues caused by hallway beds including contageous diseases in the ER. Most ERs are refered to as the most dangerous place in the hospital due to spread of disease.

Nurses often place patients in the hallway because it is easier to observe multiple patients. This results in a lack of privacy for both the patients and the medical staff. According to a Nurse at Crawford Long, a patient recorded medical staff conversations and threatened to sell the tape to the news.

A study in 2005 (Viccellio 2005) discovered that hallway beds were effective in increasing patient satisfaction by 80% on Press Ganey surveys when used in the hospital in order to move patients out of an overcrowded ER. There were rules for admitting patients into hallway beds. "Patients transferred from intermediate care or intensive care unit beds or who have serious conditions are not placed in hallway beds, Viccellio stressed, noting the beds are not allowed to obstruct hallway traffic and should be located near restrooms when possible."

The Department of Emergency Medicine at the University of Pennsylvania (Garson 2008) conducted a survey to determine patient preference of hallway beds in the ER or hallway beds in the hospital. This survey offers another alternative to ER hallway beds by allowing patients to be admitted to the hospital even if it is full.

One blog by an Emergency Physician in the Pacific Northwest summed up the issues of hallway beds in a comical blog entry titled Movin' Meat. [1] Although somewhat comical, the number of responses to the blog from former "hallway bed patients" and hospital staff shows the problem with "Hallway beds."

3. How can the problem be measured?

There are several metrics for this problem:

Number of patients in hallway beds verses rooms

Patient flow chart

Nurse flow charts (daily patterns)

Average wait time with and without hallway beds

Time study - volume of patients in the ER, surge operations

Statistics on types of patients placed in the hallway

Risk of communicable disease

Noise level in the ER

Patient satisfaction surveys (Press Ganey)

References

Garcia, M; Centeno, M; Camille R; DeCario, N; Reducing Time in an Emergency Room via a Fast-Track. 1995. [2]

Miro, O; Sanchez, M; Espinoza, G; Coll-Vinent, B; Bragulat, E; Milla, J; Wardrope, J; Analysis of patient flow in the emergency department and the effect of an extensive reorganisation. Emergency Medical Journal. 2003 March; 20(2): 143–148. [3]

Viccellio, P; Santora, C; Perfect Patient Flow: Proven Solutions to ED Crowding. Urgent Matters 2005 Regional Conference. 2005. [4]

Garson, C; Hollander JE; Rhodes KV; Shofer FS; Baxt WG; Pines JM; Emergency department patient preferences for boarding locations when hospitals are at full capacity. Annals of Emergency Medicine - 01-JAN-2008; 51(1): 9-12, 12.e1-3. [5]



COMMENTS: Ackerman From a clinician's standpoint "Hallway beds" are not a problem. They are simply a poor solution.

Hallway beds don't have to exist if you have other locations for patient's to go or patient's can be seen and dispositioned (discharged or admitted and moved to a bed elsewhere in the hospital) efficently. Alternatively all patients can stay in the waiting room until an actual bed is available. The issue of hallway beds has a ton of literature. Most of it is listed under the term "crowding".

If you insist that the hallway beds are in fact the problem than you need more of a sense of why they are a problem. Here are a sampling - infection control, noise, poor traffic flow, privacy, ability to complete examination and procedures, patient monitoring, inappropriate patient/visitor, patient/patient or patien/staff interactions... there is a very long list! You can then eliminate the excess load on the ED in a variety of ways or alternatively you can redesign the hallway bed to eliminate the problems assocaited with them.


[Chung's Comments] The shortage of space is not the major problem here. It is better to look at the fundamental issues before we jump into conclusion:

1) visualization (how hospital staffs watch patients in a careful and safely way)

2) inpatient holding pattern

3) circulation patterns from waiting room to triage and exam rooms,etc. It is not just a "crowding" issue.