Full Capacity Protocol: Boarding in Inpatient Unit Surge Spaces

Authors:

Andy H. Lee, MD, MBA; Samita M. Heslin, MD, MBA, MPH, MA, MS; and Peter Viccellio, MD, on behalf of the SAEM ED Admin and Clinical Operations Committee.

Overview

Full capacity protocol (FCP) is a hospital-wide intervention activated as a hospital approaches maximum occupancy. It aims to relieve emergency department (ED) crowding by transferring admitted patients boarding in the ED to temporary care spaces in inpatient units, which may include inpatient hallways, conference rooms, supply rooms, etc., until another bed in the unit becomes available.¹ The goal of this strategy is to share the burden of inpatient boarders safely and equitably throughout the hospital while also freeing up ED staff, resources, and space to enable the delivery of quality care to new emergency patients.

Hospitals that have implemented FCP have demonstrated significant improvements in operational metrics important to ED and hospital management. These include lower ED wait times and left-without-being-seen (LWBS) rates, reduced patient mortality, increased patient satisfaction, and higher operating revenues.² Surveys of patients who experienced both ED hallway and inpatient hallway boarding showed a strong preference for inpatient hallway boarding in terms of safety, comfort, and privacy.³ Moreover, unlike internal ED initiatives, the wider scale of this intervention has the advantage of a larger and more sustainable impact. To date, hospitals have reported few or no safety events that could be attributable to FCP.

There is a significant variation in how different hospitals have implemented FCP. While all implementations require a system-wide approach and involvement of ED, inpatient, and nursing leadership, hospitals choose their own site-specific capacity criteria to activate and deactivate FCP. They also develop standardized protocols to coordinate a unified response from clinical and patient flow/bed control teams and ensure clear communication with front-line healthcare workers.^1,4-6 Most hospitals also predesignate in advance the number and nature of potential auxiliary care spaces in inpatient units (including hallway spots, conference rooms, and supply rooms) and may centralize the day-to-day operation of the FCP to existing bed control or command center teams.⁷ Hospitals should also leverage their electronic health record (EHR) systems to facilitate communication and track operational and safety metrics.

Interested Parties

Key stakeholders to involve in FCP implementation include senior hospital leadership in charge of clinical operations, quality, and safety; departmental and unit-level physician and nursing leadership and staff; admitting office/bed control teams; frontline staff; IT for modifying the EHR; and compliance and building safety to meet regulations (i.e. fire marshal guidelines). Sponsorship from hospital leaders is necessary to align mission goals and allocate staff, resources, and funding.

Collaboration with department and unit-level physicians and nursing leadership is critical and is perhaps the most common barrier. This is because FCP implementation requires care delivery to occur in atypical auxiliary spaces that hospital units separate from the ED may not be comfortable with.^2,7 Additional challenges may arise if departments and units traditionally operate in a siloed approaches to patient care. Finally, the involvement of frontline staff is critical to ensure safe transfers of care and to help manage patient expectations.