In Which I Lose It, Just a Little, Over Emergency Department Overcrowding

My style as charge nurse could be described thusly: keep it smooth, keep it light. No fuss, no muss, no stress. Don’t worry about the externalities. Embrace the suck. All crises eventually pass. Three codes and a multi-system trauma? No problem! Bring it on! Our core competency is extreme competency at whatever is dumped on us. We’ll handle it.

Except for the other day, when I lost it, just a little, on the Bed Flow Facilitator. Her job, as her exalted title suggests, is to keep the patients moving in and out of beds, specifically to prevent patients from piling up in the Emergency. Theoretically, anyway.

In my ED there are 27 beds, 22 of which are monitored. When 25 beds are taken up with admitted patients boarding in Emergency, there’s a problem. The problem is exacerbated when I’m told at the bed flow meeting there “might be” only two beds upstairs available later — much later. The problem becomes dire when six ambulances roll in with six more-or-less critically ill patients, all of them in various stages of decompensation. I need beds. I need the admitted patients to go upstairs, so the ED can operate like, well, an emergency department.

I page the Bed Flow Facilitator.

No answer.

Page again.

Ten minutes later she calls back. She’s annoyed. ‘I’m in a meeting,” she says. Meanwhile across from my desk on an ambulance stretcher, my hypotensive esophageal varices is puking blood while the Resus room nurses and the porters scramble to make room for him.

I explain the situation. She blows me off. She doesn’t seem to grasp that the lack of emergency department space puts patients at risk. “I’ll see what I can do,” she says, “after the meeting.” She hands up.

Forty-five minutes later she calls back. Things are not better. We got the esophageal varices off-loaded — no Blakemore tube, thankfully, but an octreotide drip and a blood transfusion– but I still have a couple of active chest pains on ambulance stretchers, as well as a probable CHFer. There is no one else I can pull out to my impromptu and fire-department-prohibited hallway unit I’ve set up in front of the nursing station.

“Well,” she says. “I can’t do anything else for you.”

I calmly explain again that our ability to function is severely impinged by having no effective space to do our jobs.

She huffs. “It’s not my fault.”

Take note, reader. This is where I lose it.

“Then who’s friggin’ fault is it? No one ever takes responsibility for anything. It’s never anyone’s fault, and no one ever does anything about it! So, are you going to do your job, and try to to facilitate some movement upstairs, or what?”

“Stop wasting my time,” she says, and hangs up. I’ve made an enemy, I think. But wait: by end of shift, not two but eight beds miraculously appear. With three discharges, I actually have empty stretchers. Assertiveness (or losing it) sometimes works.

But the point is, I shouldn’t have to scream at hapless Bed Flow Facilitators to get patients upstairs. And the problem of emergency department overcrowding is not just limited to my ED: my sources tell me nearly every hospital in the Toronto region has been in a kind of gridlock since before Christmas, filled to capacity on a daily basis with admitted patients. Hospital administrators view the situation as an ED problem, not a hospital problem, as if we can somehow control the flood of patients coming through the doors. There are consequences. Sick time, for example, is going up in my ED, because of the stressful working conditions, and a couple of nurses have left the department altogether. Patient care is definitely suffering. It’s only a matter of time before someone dies because we can’t get them treated fast enough. Whose fault will it be then?

[UPDATE: minor grammatical and syntactical corrections. If I had a million dollars, I'd buy me an editor. A ten-year-old would do.]

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  1. #1 by GothamNurse on Wednesday 02 March 2011 - 1157

    Don’t you have an Emergency Department Chairman(or Chairwoman) or a Director of Nursing for the ED that can go to bat for you? Or don’t they take the appropriate responsibility either?

  2. #2 by Joni Watson on Wednesday 02 March 2011 - 1227

    Sounds like your (and all other hospitals dealing with overcrowding) need to take a serious look at elective procedures and surgeries – those that impact the facility the most (also those that bring in the most revenue). It takes a massive collaborative effort, but from what I heard from one case study at a conference, it is well worth it – improving patient safety and patient and employee satisfaction, which we all know impact the bottom line, as well. Check out Transforming Care at the Bedside, or TCAB, (http://www.rwjf.org/pr/product.jsp?id=30051 & http://www.rwjf.org/pr/product.jsp?id=31512) or the Institute for Healthcare Improvement (http://www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAtTheBedside.htm) for more ideas. Here is a link to their “Improving Patient Flow” page: http://www.ihi.org/IHI/Topics/Flow/

    AJN has a *great* collection of TCAB articles, too. http://journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalCollectionId=3

    • #3 by torontoemerg on Wednesday 02 March 2011 - 1235

      Hey Joni

      Thanks — I’m actually doing a project related to this.

  3. #4 by torontoemerg on Wednesday 02 March 2011 - 1229

    Hmmm. We do. She was away that day, unfortunately. I am not clear however her presence would had made much difference. Not her fault really, but her influence is somewhat limited.

    The interesting thing is that I can complain to managers — even senior managers — and they consider it typical nursing whining. If a physician complains, it’s a different matter altogether.

  4. #5 by Zoe on Wednesday 02 March 2011 - 1319

    The problem isn’t limited to Toronto, either. There are gridlocked ER’s everywhere. Here’s an interesting story from my neck of the woods:

    http://www.vancouversun.com/health/Overflowing+hospital+spills+into+nearby+Hortons/4370441/story.html

  5. #6 by Miss-elaine-ious on Wednesday 02 March 2011 - 1332

    Sounds like my ED as well! Although the morale of our department is so bad we’ve lost about 5 nurses to other areas, and a bunch to sick leave. We can’t even fill the spaces we lost because no one wants to work here anymore.

    Offload delays of 7-8 hours are ridiculous, nursing in the hallways of very sick people is ridiculous, and still 20+ admits.

    Le sigh.

  6. #7 by Jenn Jilks on Wednesday 02 March 2011 - 1751

    That story is criminal. How someone in a meeting could refrain from working with you.
    There are so many answers to this problem, a big one being ALCs who shouldn’t have been admitted in the first place. Many physicians are truly failing seniors in this regard.

  7. #8 by whitecap nurse on Wednesday 27 April 2011 - 2236

    It sounds as if you don’t even have the option of going on ambulance diversion. What’s up with that? There is always the fantasy solution of taking the admitted patients and putting them in the hallways upstairs on the floors. That might make some beds “open up.”

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