Short Stay Rooms and Long Stay Patients by Stephen Colucciello, M.D.

Stephen Colucciello, M.D. Have you ever thought about the different types of patients we see in the ED and the rooms we put them in? In this blog, I won’t group patients by diagnosis or chief complaint but instead by their length of stay in a particular room.

The easiest group to manage is the “Short Timers”. These patients are usually coded as triage Code 5 in the ESI scheme. They breeze in and breeze out; often through a Fast Track Area. No x-rays, no labs, no IVs. Just examine the patient; maybe remove some sutures or look in the ears, and then discharge to home.

I am not talking about these patients.

Strangely enough, the second easiest group to manage (from a room perspective) is the “Sick as Stink” patients (Hey, I’ve practiced in the South for the last 27 years). These patients are usually Code 1 or 2 in the five-tiered system. While the medical issues may be complex, room use is not. These patients come into a room, often by medic, get procedures, get lines, get fluids, get tests, get meds, get consults; etcetera etcetera…. The point is, they come into a room and stay in that room (except to go to CT) until they go upstairs for admission.

I am not talking about these patients either.

I want to talk about a typical Triage Code 3 or 4 patient who comes into a room and is ultimately discharged. Their “Long Stay” room use looks like this;

• Wait for doctor
• History and Physical
• Wait for nurse
• Blood work/Therapies
• Wait for x-ray
• Diagnostic Imaging
• Wait for results
• Wait a little longer for results
• Still Waiting
• Eat some fries
• MD discharge counseling
• Wait for nurse
• Complain on cell phone to 15 friends and family about ED stay
• DC
• Angrily throw DC papers on floor while cursing “this $%#@ing ED”

Waiting For Short Stay Test Results And Labs Needs To Be Done In The Waiting Room, NOT The Exam Room

Most of the time spent in the room is hardly “Quality Time”; in fact, perhaps 80% of the time the patient spends in the “Long Stay” room is spent watching TV or worse, watching the clock. If you were to track the average number of patients that pass through a room filled only with Triage Code 3 patients who are ultimately discharged you might do the following calculation: 24 hrs/day x 60 min/hour divided by 200 min/pt and wind up with only 7 patients per day moving through that room.

What if we moved the “Wait” to the “Waiting Room” and out of the “Exam / Treatment Room? The “Short Stay” Examination and Treatment room becomes high-value real estate. Patients basically never wait in these rooms because the rooms are used just for examination and treatment; once that is completed “it’s out of the pool and into the waiting room”. Now the room usage looks different.

• History and Physical
• Blood work/Therapies
• To Waiting Room
  • Diagnostic Imaging
• Back to Waiting Room
• Discharge Room
  • MD discharge counseling
  • DC by nurse (or MD)

In the “Short Stay Room”, more than 80% of the time spent in the room is actually used to get something done; less than 20% of the time is spent waiting. Now the calculation is: 24 hrs/day x 60 min/hour divided by 20 min/pt and wind up with 72 patients per day moving though that room; a TENFOLD increase in room usage!!

There are some important caveats to using Short Stay Rooms:

• Keep track of patients in waiting rooms!!!
  • Out Of Sight = Out Of Mind
  • Use the tracking board
• Need alerts when lab and x-rays back
  • Computer? Tech?
• Need discharge room
  • Counsel patients
  • Privacy Issues …“about that drip you have”

Choose the right patient for Short Stay Rooms; they should be sick enough to need testing but not sick enough to stay flat in bed. Who can’t use a Short Stay Room and then go to a Waiting Room?

• Unstable VS
• Needs Monitor
• Can’t sit up
• Altered Mental Status, Intoxicated, Suicidal
• Gets lots of IV narcotics
• Really old, really sick, or lots of worried family

Who is gonna fuss if you start designating certain rooms as “Short Stay Rooms”? Your whole staff; nurses, techs, and doctors. In fact, everybody but the patient and the administrators is going to be unhappy at first. Because it is much easier to leave a patient sitting in a treatment room waiting, than to turn that room over quickly and see another patient (or another 3 patients) instead. More patients mean more work and by keeping patients waiting unseen in the waiting room the pressure is off (until the LOS and patient satisfaction scores come in). To make Short Stay Rooms work you will need buy-in from the ED staff.

The easiest way to use Short Stay Rooms is to put them in Triage. If there are no empty beds in the Treatment Areas (see “Pull to Full” Blog from last month) patients go directly into a Short Stay Room in the Triage Area. The physician or mid-level provider does an exam, orders tests and/or meds; then the patient leaves the Triage Short Stay Room for a sub-waiting room to await test results or x-rays. They can later go to a treatment room and see a new doctor who will review the test results and discharge the patient. If no treatment rooms are available, the patient can go back to the Triage Short Stay Room for discharge counseling by the Triage MD.

If your ED is beyond its capacity and your waiting rooms are filled with patients who have not yet been seen; consider a 35 million dollar renovation. Otherwise use the “Short Stay Room” Strategy for free. If you choose the second option, please send the 35 million to “Colucciello” at EM-Blog.

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