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The 48-year-old woman entered Stony Brook University Medical Center's ED with numbness and tingling on the right side of her face and right arm. After she was admitted to the Neurology Unit, the nurse checked her vitals, took her history, and performed a physical assessment while awaiting test results.

A routine encounter — except that it took place in the hallway. To make space in the Emergency Department, the patient was moved up to the Inpatient Unit hallway until a room became available.

Stony Brook, on Long Island, N.Y., is one of hundreds of U.S. medical institutions improving patient flow in the ED by temporarily housing admitted patients on inpatient unit hallways when the hospital reaches full capacity, according to Peter A.W. Viccellio, MD, professor of Emergency Medicine, vice chairman and clinical director of Emergency Medicine at Stony Brook.

"Over the past few decades, we've allowed the Emergency Department to become the Best Western for admitted patients. When we board admitted patients, emergency departments grind to a halt, with no beds, no monitors, and no space," says Viccellio, who chaired the American College of Emergency Physicians 2008 Task Force Report — Emergency Department Crowding: High Impact Solutions — to advise Emergency Department staff on prevention of boarding — the primary cause of ED overcrowding.

Health Department Sanctioned

Stony Brook began moving admitted patients out of the ED and onto unit hallways at times of full capacity, after the New York Health Department approved and recommended the practice. "It's been an urban myth for about 20 years that stable admitted patients could not be treated in the medical hallways, even though they were piling up in emergency department hallways," Viccellio says.

Denise King, RN, MSN, CEN, president of the Emergency Nurses Association, says the general hallway fire safety rule is eight feet of wall-to-wall clearance. "People have to recognize that hallways in the ED are not any less crowded than upstairs, but it's safer to put patients on floor hallways than keep them in the ED," she says. "You don't know how sick the next patient will be that comes through the emergency room door."

"Due to both extreme overcrowding and limited ED space, many hospitals have no choice but to use other areas of their physical plant strategically," says Terri Straub, RN, vice president of Quality and Patient Safety for the Greater New York Hospital Association.

"And that's nothing but sensible policy, as long as the patients in question are receiving safe, timely care that's appropriate to their condition," she says.

Full-Capacity Protocol

Stony Brook enacted its full-capacity protocol in 2001. About 15 patients per month are distributed to the unit hallways. Some days, there are no additional patients; other days, there are several. The key, Viccellio notes, is spreading hallway patients throughout the hospital, instead of burdening one department.

When senior leadership activates the full-capacity protocol, the bed utilization coordinator notifies nurse managers that they are receiving additional patients. The patient beds are placed in areas that least obstruct traffic flow, such as stretcher alcoves, and are close to a bathroom. They are given a privacy screen and a wireless or hotel call bell. Staff continuously updates patients on room status. Patients usually are in their own rooms within eight hours, says Carolyn Santora, RN, MS, CMAA-BC, associate director of Patient Safety and Regulatory Affairs at Stony Brook.

"Hallway care is definitely a patient dissatisfier, but the patients overwhelmingly report they'd rather wait for a room upstairs, which is quieter and more private, than in the ED," says Andrea Kabacinski, RN, MS, manager of Stony Brook's Neurology/Acute Stroke Unit.

Only stable patients qualify for the temporary hallway placement. Patients requiring intermediate or intensive care, ventilation, oxygen in an amount greater than four liters, isolation, negative pressure, suctioning, or who have stool incontinence, are not candidates.

Reduced Length of Stay

Benefits of moving patients up to medical floor hallways include shorter length of stay, greater patient satisfaction, improved ED flow, and better discharge times, according to a four-year study of 278,975 Stony Brook ED visits, conducted by lead author Viccellio and published in the October 2008 issue of Annals of Emergency Medicine.

The study showed moving patients to inpatient hallways rather than boarding them in the ED reduced their total hospitalization by 0.8 days. ED door-to-physician time decreased from 90 minutes to 25 minutes.

"Within the first three months of enacting the protocol… on the way up to the medical floor a bed would appear," Viccellio says. "All of a sudden, rooms got cleaned and nurses got doctors to discharge their patients."

Kabacinski agrees. "Before, it was out of sight, out of mind. Now, when overcrowding is in your face and a patient is waiting in your hallway, you work a lot faster to expedite patient discharge and get the patient a room."

Nurses on Board

In the beginning, treating patients in hallways was difficult for the nurses to visualize, Santora says. "After more review and discussion, the concept was easy to grasp — when the Emergency Department is overcrowded and the hospital is full, the safest and most private place is on an Inpatient Unit because patients have access to the appropriate nursing and medical expertise for their condition."

Although they may take on an extra patient or two, the nurses feel it is safer for patients, Santora notes. "The nurses know they have resources on the floor that cannot be provided in the ED, and the nurse-to-patient ratio is much lower."

Viccellio and King estimate about 600 U.S. hospitals care for admitted patients in hallways when hospital beds are full. Viccellio advises hospitals to treat overcrowding as an institutional problem that goes well beyond the ED. "Hospitals need to examine whether their systems are designed for the needs of staff or the needs of patients. If an admission is held up because it's a change of shift, or housekeeping is at lunch, or someone is giving a report, or one unit of the hospital wants a perfect census, then the hospital is focused on the needs of staff and not the patients.

"We've got to get admitted patients out of the Emergency Room so we can do our job — treating emergencies — and the hospitalists and nurses on the medical floors can do theirs," Viccellio continues.

"Admitted patients belong on inpatient units. Period."

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Leslie Flowers is a freelance writer.

To comment, e-mail editorNY@nursingspectrum.com.
Viccellio's research is available at www.hospitalovercrowding.com.

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