1. Creating a Rapid Admit Unit
to Prevent Overcrowding
and Provide Safe Passage
for Patients
Marie Hankinson, PhDc, RN

2. Objectives
I. Define Emergency Department Overcrowding
II. When to Create a Rapid Admit Unit
III. Describe the Benefits of Creating a Rapid
Admit Unit
IV. Describe Metrics to Measure Your
Program Success

3. Definition of ED Overcrowding
“A situation in which the
identified need for emergency
services outstrips available
resources in the ED”
ACEP Crowding Resources Task Force, 2002. Retrieved
from http://www.acep.org/workarea/downloadasset.aspx?id
=8872

4. Common Strategies to Decompress
the Emergency Department
• Code Purple
• Fast Track
• Hallway Beds
• Pull till Full
• Advanced
Nursing
Interventions
• Rapid Medical
Evaluation
(RME)
• Bedside
Registration

5. Front End Flow Tactics
RME- Clinician in Triage
• Midlevel Provider in
Triage
• MD in Triage
• Intake Team
Fast Track Low Acuity
• Super- Track ( ESI 5’s
+ Simple 4’s)
• Fast- Track ( ESI 5’s,
4’s & simple 3’s)

6. Boarding Patients
ED patients who need to be admitted are
“boarded” until inpatient beds become
available. The practice of “boarding” patients
creates safety and negative consequences
such as increasing LWBS, patient
walkouts, adverse events, errors, mortality
rates and diversion of ambulances.

7. Causes of ED Overcrowding
In 2006, the Institute Of Medicine (IOM)
described emergency care in America at the
“breaking point”.
The most common documented factor for
ED Overcrowding is scarcity of beds for
patients admitted through the ED.
Studies consistently tell us that inpatient
occupancy is positively associated with
patient waiting in the ED.

8. Key Drivers of ED Overcrowding
• Lack of staffed inpatient beds
• Lack of ICU and Critical Care beds
• Shortage of hospital or ED Staff
• Shortage of specialist physicians willing to take
ED call
• Inability to cover specific specialties and
having to transfer patients to other facilities.

9. Behavorial Health Patients
• 5-8% of ED volume
• Shortages of Mental Health Care
Bad news is that we have a lack of studies
that can explain the impact on ED
Overcrowding!

10. ED Overcrowding
Reduces
• Health Care Quality
• Patient Safety
• Patient Mortality
• Failure to receive
antibiotics and
analgesic medications
• Adverse events such as
hospital acquired
pneumonia and
pulmonary embolisms.
Research
• Use existing capacity
more efficiently.
• Improve internal
processes.
• Resources
Joint Commission
IHI
RWJF Urgent Matters
ACEP

11. When is a Rapid Admit Unit
Needed?
• ED is overcrowded
• Boarding patients
• Long waits for inpatient beds
• Patient satisfaction decreases
• LWBS numbers increase
• Staff satisfaction decreases

12. How to Sell The Idea
• Holdover hours
• Capacity/Code Purple status
• LWBS
• Satisfaction
• Identify and optimize/profitize an area with
low utilization

13. What is and isn’t a Rapid
Admit Unit?
• Not an Observation Unit.
• Clearly delineates responsibility
for patient care between the
emergency department
physicians and admitting
physician.

14. What is Needed to Create a
Rapid Admit Unit?
• Support from administrative team
• Support from Medical Staff
• Physical space outside the ED
• Determine number of beds
• Staffing
• Skill mix
• Orientation

15. Involve Other Departments
• Finance
• How will you charge these patients?
• Dietary
• Pharmacy
• Environmental
• Security
• Volunteers
• Hospital operators
• Admitting
• #1 department to involve: IT

16. Supplies & Equipment
• Patient care supplies
• Copier
• Fax
• Pyxis® automated medication
dispensing system
• Patient monitors
• Thermometers
• Crash cart
• Computers
• Phones

17. Inclusion/Exclusion Criteria
Types of patients
• Medical/ telemetry
• Direct admits
• ICU patients
• Isolation
• Geriatric Patients
• Pediatric Patients
• Hours of service

18. Standards of Care
• Admission procedures
• Transfer / Discharge procedures
• Documentation guidelines
• Customer Service Guidelines

19. Quality Monitors
• Types of patients
• Levels of service
• Satisfaction ( both inpatient and
emergency)
• Incident reports
• Staff feedback
• LWBS
• Door to Doc Time

20. Cost
• Staff
• Reimbursement

21. Measuring Success
• Decrease ED wait times
• Decrease LWBS
• Improve Patient Satisfaction
• Improve Staff Satisfaction
• Reduce Medical Errors
• Improve Quality and Safety

22. 2011 ED Patients Triaged, Not Seen
25
35
21
36
39
27
28
35
38 38
21
8
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Numberofpatients
GOOD

23. 2011 Total ED VISITS
4140
3943
4493
3916
3875 3787 3785 3723 3657
3776
4071
4226
3693 3620
3921
3485 3415
3104
3259 3192 3112
3334 3332
3582
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Numberofpatients
GOOD
TOTAL TARGET

24. Metrics to Measure Success
• Reduction of patient boarding in the ED
• Decrease the Time to Admit Orders
• Improve Patient Satisfaction
• Improve Staff Satisfaction
• Reduction of LWBS

25. Elements of Performance (EP)
Publication of the Joint Commission in
December 2012.
• Standards LD.04.03.11 and PC.01.01.01
are revised standards that address an
increased focus on the importance of
patient flow in hospitals.
• Go into effect January 1, 2013, with two
exceptions: LD.04.03.11, EP’s 6 and 9 will
be effective January 1, 2014.

26. LD.04.03.11
The hospital manages the flow of patients
throughout the hospital.
• EP 1. The hospital has the processes to support
the flow of patients throughout the hospital.
• EP 2. The hospital plans for the care of admitted
patients who are in temporary bed locations, such
as the post anesthesia care unit or emergency
department.
• EP 3. The hospital plans for the care of patients
placed in overflow locations.
• EP 4. Criteria guide decisions to initiate
ambulance diversion.

27. LD.04.03.11 continued
EP 5. The hospital measures and sets goals for the components
of the patient flow process including:
• The available supply of beds
• The throughput of areas where patients receive
care, treatment and services ( such as inpatient
units, laboratory, operating rooms, telemetry, radiology and
PACU).
• The safety of areas where patients receive care, treatment
and services.
• The effeciency of the nonclinical services that support patient
care and treatment ( such as housekeeping and
transportation).
• Access to support services ( such as case management and
social work).

28. LD.04.03.11 continued.
Effective January 1, 2014
• EP 6. The hospital measures and sets
goals for mitigating and managing the
boarding of patients who come through the
emergency department.
– it is recommended that boarding timeframes
not exceed 4 hours in the interest of patient safety
and quality of care.

29. Conclusion – putting it all together!
• Create your project team.
• Assess and map your current process.
• Define your guiding principles:
“design a rapid admit unit.”
• Develop initial draft and solicit feedback
from staff members.
• Implement and Evaluate the plan.
• Sustain and Continue to Improve!

30. Next Steps
• Evaluate other processes. Involve other
departments Such as Admitting, Customer
Service, Inpatient Nursing Units.
• Sustain the Gains! Share data immediately
and regularly.
• Continue to assess the process. Measure
different aspects of this process to
eliminate boarding times.

31. Thank you

32. References
• Amarasingham, R., Swanson, T. S., Treichler, D. B., Amarasingham, S. N., & Reed, W. G. (2010). A rapid
admission protocol to reduce emergency department boarding times. Quality and Safety in Health
Care, 19, 200-204. doi:10.1136/qshc.2008.031641
• Burley, G., Bendyk, H., & Whelchel, C. (2007). Managing the storm: an emergency department capacity
strategy. Journal for Healthcare Quality, 29, 19-28. doi: 10.1111/j.1945-1474.2007.tb00171.x
• DeLia, D., & Cantor, J. C. (2009, July 17). Emergency department utilization and capacity (Research
Synthesis Report. No. 17). Princeton, NJ: Robert Wood Johnson Foundation. Retrieved from
http://www.rwjf.org/pr/product.jsp?id=45929
• Liew, D., Liew, D., & Kennedy, M. P. (2003). Emergency department length of stay independently predicts
excess inpatient length of stay. Medical Journal of Australia, 179, 524- 526. Retrieved from
http://www.mja.com.au
• Liu, S. W., Thomas, S. H., Gordon, J. A., & Weissman, J. (2005). Frequency of adverse events and errors
among patients boarding in the emergency department. Academic Emergency Medicine, 12(Suppl. 1),49-
50. doi:10.1111/j.1553-2712.2005.tb03828.x
• Richardson, D. B. (2006). Increase in patient mortality at 10 days associated with emergency department
overcrowding. Medical Journal of Australia, 184, 213-216. Retrieved from http://www.mja.com.au
• Viccellio, P. (n.d.). Our environment: The silent issue (PowerPoint presentation). Retrieved January
22, 2013, from http://www.hospitalovercrowding.com
• Weiss, S. J., Ernst, A. A., Derlet, R., King, R., Bair, A., & Nick, T. G. (2005). Relationship between the
National ED Overcrowding Scale and the number of patients who leave without being seen in an
academic emergency department. American Journal of Emergency Medicine, 23, 288-294. doi:10.1016/
j.ajem.2005.02.034

33. Contact Information
Marie.Hankinson@
yahoo.com