2021 Annual Conference

CNS Improving Outcomes

Emergency Department (ED) overcrowding is a systemic problem in the U.S., leading to delays in care and increased morbidity & mortality. The National Emergency Department Overcrowding Score (NEDOCS) is a validated scoring tool to accurately assess the severity of ED overcrowding through objective measures of ED and inpatient bed status, current ED patient volume, and current ED length of stay. Early recognition of worsening ED overcrowding may be used to proactively manage ED throughput by reducing delays in inpatient admissions and diagnostic studies, and identifying a need for additional ED staff. In conjunction with the NEDOCS calculation, a collaborative decision support tool to improve communication of the ED-to-inpatient admission process may be effective at reducing ED overcrowding and improving patient throughput.

A decision-support matrix, based on an objective measure of ED overcrowding, was implemented to reduce inpatient admission times, reduce delay in ancillary support for ED patients, and direct recall of additional ED staff. The ED Charge Nurse conducted a NEDOCS calculation every two hours to determine crowding status. Upon escalation of ED overcrowding, the in-house nursing supervisor would actively manage inpatient bed status to minimize admission waiting times. Additionally, ancillary support services would be asked to expedite diagnostic studies, and on-call ED staff would be recalled if it were determined that staffing shortage was impacting patient flow. To improve staffing, critical care nurses cross-trained to the ED and would augment the ED staffing when available, thus reducing the need to activate the on-call nurse. Pre and post comparison of NEDOCS scores, patient volume, and ED time to admission were evaluated.

Throughout this 18-week period, the average NEDOCS value per week remained constant, despite the fact that the average patient volume at the time of the NEDOCS calculation increased by 36.3%. Additionally, the median time from decision-to-admit to patient disposition decreased by 48 minutes. Furthermore, the increased collaboration between the ED charge nurses, the nursing supervisor, and the critical care nurses resulted in a more supportive working relationship.

The ability to identify and quantify overcrowding is an important aspect of managing the flow of patients in the ED. Reducing overcrowding in the ED requires a collaborative approach in order to be effective. Reducing overcrowding in the ED results in the ability to provide more timely care to patients with urgent or emergent needs.