To the relief of hospital executives but the dismay of emergency physicians, the Joint Commission on Accreditation of Healthcare Organizations agreed that hospitals can only do so much to attack the problem of emergency room overcrowding and should focus instead on managing patient flow generally within a facility, including the ER.
The JCAHO issued a proposed standard in May 2003 requiring a series of improvements in ER patient management to reduce the odds of catastrophic delays in treatment stemming from overcrowded conditions. The proposal grew out of a national symposium on ER problems convened by the commission in February 2003, which followed an alert it issued in July 2002 tying treatment delays to more than 50 deaths.
But the final standard, published without fanfare in the February issue of the JCAHO's Perspectives, relieved the nation's hospitals of direct responsibility for troubleshooting patient-capacity problems that originate with community agencies that send the ill and injured to an ER or receive hospitalized patients after discharge.
The revisions also removed directives specifically intended to curb practices in and around the ER that contribute to unsafe conditions, such as putting patients in hallways or other locations near the emergency area until an actual bed becomes available.
First proposed as "Emergency Department Overcrowding Standards," the original draft went through a metamorphosis so complete that the heading on the final version did not mention the emergency department at all.
"We're very disappointed. We do feel the final standard was watered down," said J. Brian Hancock, president of the American College of Emergency Physicians. "The Joint Commission had an opportunity to take a major step forward in eliminating a problem, and they fell short," said Hancock, an emergency physician on staff at 268-bed St. Mary's Medical Center, Saginaw, Mich.
Not so, said Paul Schyve, the JCAHO's senior vice president. The original draft was intended to highlight the crucial role of high-level planning in resolving logjams affecting patient movement in and out of the ER, but the language was sending the wrong message-that hospitals were being held responsible for a community problem that extends beyond their capabilities, he said.
It also focused too much emphasis on the ER at the expense of the whole-hospital nature of the problem, Schyve said. In revising the standard, "We deliberately want to get people to think of this as a patient-flow issue," he said.
The new standard, which takes effect Jan. 1, 2005, expands responsibility for fixing the patient-movement problem to all departments in which patients are held, transferred and discharged during a hospital stay, Schyve said. "The ER is one example of a place that would benefit from this but not the only one."
All units affected now
Hospitals now are on the spot to fix similar problems in the intensive-care unit, step-down units that relieve overcrowding in areas such as the ICU and other critical inpatient areas where delays can have a domino effect, said Karen Fernandes, director of quality management at Tenet Healthcare Corp., who represented the Federation of American Hospitals in industry attempts to rewrite the standard. "From the federation standpoint, we feel (the JCAHO) accepted the input from the field as they recrafted it," she said.
"It doesn't take the institution off the hook for eliminating problems in the ER as far as moving patients through," said Don Nielsen, senior vice president of quality leadership at the American Hospital Association. At the same time, it "focuses on what the hospitals are able to have control over and able to improve," he said.
The campaign to alter the requirements and approach of the standard started soon after the JCAHO unveiled it during a publicity blitz on the growing dangers of operating emergency facilities as proliferating ER volume overtaxes available space and resources (May 19, 2003, p. 6).
The Oakbrook Terrace, Ill.-based accrediting agency had adopted the issue of ER overcrowding as the third in a series of public policy initiatives it began in 2002 to influence areas of patient safety in which the causes went beyond its ability to demand changes through the accreditation process.
The symposium early in 2003 identified a host of causes, from staff shortages and scarcity of both inpatient and post-acute beds to the use of the ER for minor health problems and as recourse for the uninsured.
A white paper addressing the breadth of the ER problem is scheduled to be released, but no date has been set, a JCAHO spokeswoman said.
Draft focused on ER
Meanwhile, the discussion within the agency led to suggestions for actions it could take within the scope of accreditation to start making an impact, Schyve said.
The resulting draft called on hospital leadership to plan for the efficient movement of patients through a healthcare facility, but it homed in on several ER-specific situations that were compromising patient safety.
One directive applauded by emergency physicians dealt with the delivery of care to patients who must be placed in temporary beds. The original proposal dictated that these beds had to be located "outside of the emergency department and in an appropriate patient-care area."
But that element was gone from the final version. The revision also dropped a directive for coordination with nursing homes, home health agencies, other hospitals and similar "community resources" to expedite discharges from the ER. And it no longer required planning with emergency medical services such as ambulances and fire departments to minimize the incidence of bypass alerts, in which vehicles are diverted from ERs because the facility can't accept any more patients.
Hospital representatives posed a basic question, Fernandes said: "Can the Joint Commission with their standards correct an industry problem? It's not just hospitals."
"No one in emergency medicine would say this is not a systemwide issue that needs to be addressed," Hancock said. But the JCAHO, he asserted, did not take a stand on some of the safety issues it could have.
"The most visible and apparent symptom of the overcrowding problem in the ER is the situation where emergency patients can't budge," he said. A big part of the problem is the backlog of patients in the ER waiting to be admitted or transferred elsewhere, a practice the doctors call "boarding," Hancock said. "They've continued to allow boarding in the emergency department, and that's where the standard fails us," he said.
Moving these patients out of the ER and close to the unit they're waiting to enter would put their care in the hands of workers better prepared for their needs instead of with ER personnel and physicians trying to handle the next wave of incoming illnesses and injuries, he said.
As long as hospitals are permitted to hold patients in the ER, "There is little or no pressure on having hospitals actually solve the problem," Hancock said. "The way to have hospitals solve the problem is to spread the pain (to other departments)."
If patients were required to be moved upstairs, other areas of the hospital would have to confront the problem more urgently, he said.
Right now, "We're hiding them," said Hancock, referring to the overflow of patients. Recently, for example, ER workers at St. Mary's had to open up the decontamination room during the winter's spread of influenza and fill it with patients on stretchers, he said.
Fernandes agreed that the ER overflow into hallways and other spaces is a problem, but added, "If you house them upstairs you have other issues." The same staffing shortages would exist, along with lack of equipment, patient privacy and other consequences of insufficient bed space, said Fernandes, a former ER nurse who serves on a JCAHO nursing advisory council. She also chaired a hospital professional and technical advisory committee to the JCAHO during the time the standard was formulated.
The AHA's Nielsen said the final standard will prompt hospital executives and managers to turn their attention to process changes that have been widely identified as key elements of better patient-flow management-for example, more efficient scheduling in diagnostic areas; making sure surgeries start on time; and better turnaround on tests and treatments to speed up the course of a patient's care and ultimately reduce the length of a hospital stay.
Schyve said the modifications were well-received by hospital representatives consulted late last year, because they struck the proper level of accountability but "didn't lead to harmful misperceptions that this issue of emergency overcrowding was just something for hospitals to do something about." Other community stakeholders will have to pitch in, too, he said.
But Hancock said the changes send a different signal. "The Joint Commission has not fully addressed the issue of crowding and boarding in the emergency department," Hancock said. "Despite our hope that they would use their considerable influence, they appear instead to have backed off."
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