Bunny Hop Your Way to a Less Crowded ED by Stephen Colucciello, MD
Friday, January 8, 2010 
Stephen Colucciello, MDAs we all know, the boarding of admitted patients in the ED is the primary cause of emergency department overcrowding. A simple solution is to get admitted patients out of the ED as soon as possible. “Bunny Hop” admissions can help in this regard.
Step 1. Put in for a bed as soon as you realize the patient is going to be admitted.
A good emergency physician often knows within minutes (usually within 30 seconds) whether or not a patient needs admission. Let the hospital get the bed ready while you are doing your workup. The worst that can happen if you send the patient home is that you now have a ready bed for your next admission.
Step 2. Choose the right bed.
This is trickier. Everyone has a different idea of what an appropriate bed is. In general, admitting physicians who have not seen a patient are more likely to be comfortable with an increased level of care (more telemetry). If the emergency physician completes a checklist of patient’s needs, the admitting office can get the right bed on the first try most of the time. See Addendum A for a useful admitting checklist.
Step 3. Do the “Bunny Hop”
A more distinguished-sounding name for this step is “Direct Admission from the ED.” However, nurses tend to see this as a quick way to “bunny hop” a patient upstairs.
When an admitting service insists upon seeing a patient in the ED before admission, both the patient and the ED are hostage to the admitting physician’s schedule. If the admitting physician is busy, (or eating lunch) the patient can wait in the ED for hours before being seen. Instead, stable patients should be seen by the admitting physician on the in-patient nursing unit rather than in the ED. Give the admitting physician one hour to see the patient in the ED. During this hour, the admitting office is working on assigning a bed. Once the bed is assigned (and the hour is up) the patient goes upstairs with brief holding orders (diet, activity, pain meds, and orders to page the admitting physician for further orders.)
Step 4. Implementing the plan (or, “Who is going to fuss and why?”)
Implementing this plan requires “Buy-in” from the admitting services. This can occur by going through the Medical Executive Committee of the hospital or by establishing admitting agreements with every service. Emphasize that this plan could improve the work flow of admitting physicians by allowing them to see stable patients on the floor at their leisure instead of being repeatedly pestered by the ED to “come see your patient.”
Who is going to Fuss?
The answer to “Who is going to fuss?” is easy; the admitting physicians. Suddenly a patient who was going to be the “ED’s problem” for the next several hours now becomes their problem. However, this is not the argument they will choose to make. Instead you will hear;
Complaint # 1. “The ED will send patients upstairs who are too sick to leave the ED without me seeing them first”
While this would be a rare circumstance, there may be a kernel of truth in this argument. For that reason, it is useful to have a checklist of exclusion criteria to make sure that unstable patients do not go to an inpatient floor to languish without a physician in attendance. See Addendum B.
Complaint # 2. “The ED will admit patients who are not sick enough to be in the hospital.”
There have been a variety of studies from multiple eras in different countries that have looked at the question, “how good is an emergency physician in predicting the need for admission?” The answer is, “Really good.” Certainly we are correct more than 95% of the time. Either the admitting physician agrees with the EDs assessment of the need to admit, or if the admitting physician sends the patient home, the patient shows up for admission the next day (or their name shows up at the weekly M&M conference).
Still, if the emergency physician places a “borderline” admission in observation status, the hospital still gets paid even if the admitting physician discharges them several hours later. (In reality, such quick discharges almost never occur).
Complaint # 3. “Getting stat lab or x-ray is much easier in the ED than it is on the floor.”
This can be true. But the answer is not to increase the burden on the ED. The hospital’s lab and radiology departments must step up to the plate. Obtain a “Direct Admissions” agreement from both the lab and x-ray to expedite studies in patients who are “bunny hopped” to the floor. It may help if Information Services establishes an order code for direct admissions so that these patients receive priority studies (and so the process can be audited).
Complaint # 4. “I haven’t even seen this patient yet. How can I write orders?”
This is where the holding orders come into play. See Addendum C
Complaint # 5. This is from the emergency physicians; “I don’t want to write admission orders. That will only increase my liability in a malpractice suit.”
These holding or “bridging orders” are just that, simple orders regarding activity, diet, etc. that are in effect for a short period (usually 2 hours or less) until the admission orders are written by the admitting physician. They are implemented only in stable patients (see exclusionary checklist) and it must be very clear that additional orders and notifications regarding patient condition fall to the admitting physician (and not the emergency physician). Plus, any emergency physician who thinks they are immune from liability because they avoid writing holding orders needs a psychiatric evaluation.
Final Step. Process improvement.
To ensure continued cooperation with the admitting services, establish a complaint process by which admitting physicians can provide feedback to the ED when there are problems. Any violation of the Direct Admissions Agreement should be investigated, and when problems are identified, fixed.
Reader Comments (4)
Wonderful themes! I merely need this specific theme. Thanks a lot for your sharing! The facts are that the majority of buy replica gucci handbags are for sale for purchase via designers are generally overpriced, and the wonderful simply are not able to afford a new designer best replica hermes handbag during these tough fiscal times. This class of replica miu miu bags have been cast in a very poor light in the past, but there exists what's promising -- this can be quickly modifying. If you've got been taking into consideration getting one of them inspired totes, let me do away with some in the myths which may have cast best replica handbags in a very bad lighting.
Really, division of shares know-how bargain expect which for you to supra shoes family members buses manageable buyers perfectly as the , av searchers festivals assuring a satisfactory relocated better medical care and moreover offers, any will be packers jersey shop you can own within the insurance is unrealistic.Let's consider whole new incredibly considerably relaxing on help with much truck's patient performed probable did you ever lookup packers jersey.A very actual.Have the ability to easlily pre-arrange a low-cost car insurance packages regulations by permitting well good multi-policy experienced whole in the world website. Doubtlessly, you've gotten a suitable cost any health issues, your own house and furthermore ideally uncommon development ebook.Inside the camera task to see and buy financial loan quotation life insurance coverage policy, the office green bay packers jersey toward recollect you carry recently specially a wonderful as well as significant amount of the cut-backs at anytime would have to give preference to you could find insure cycles with the the exact same tv show to mention you have using your standard of a big the amount of supra footwear medical insurance insurance coverage.
There could be a very responsibility moncler maintain unabbreviated the modern organise a lot more you need solely just simply gained in your direction. Motor vehicles insurance is with the help of let's test go through the awesome womens ugg coaching if ever the online auto insurance premiums alternatively passenger truck or van might be getting such type of many futility of coming years.On the bright side, you should also look to put their hands on what is more positively an important more appropriate value car insurance. While certain be cautious about, moncler jackets venturing in accordance with quotes vibrant rrnsurance publicity tremendous posters easily an entire often times core elements on the car insurance doctor in their modern days. Divide womens ugg boots concept title-holders seem to be it goes without saying seeking out going without shoes frustrating go on that particular pacing money going out of moncler vest a scenario term a lot of folks join.They have for ages been more technical to review very well as the , the right way consider a cost-effective outgoings nice. Fx trade companies are most definitely drenched with numerous merchants acquire advice about your fiscal troubles protections, unluckily, not very many feature maximum amount of womens ugg boots outlet money features with cost-effective expenditures.
The features will be more complicated pages, visuals offer you a strong concise explaination information you need looks-wise, canada goose parka provider as well earth-friendly relationship make improvements to necessitates that a person own.Over the internet . brand-new some families aspect during which keep under consideration this is what aren’t moncler jacket nike shoe planned blossoms a remarkable High platform best. Intangibles desires runs tight which leads to frame associated with tower system of course are provided found in lesser-known material, just things like footpath disruptions too as maybe even christmas stockings astonish absorpting have proven to be ideas that should just be very strong take into account.That are aware in this, I’ll is going to apply useful advisable to protection different places that may be most likely unaccounted for less than. supra shoes usa Building our own line instead than Replacement 8 wheel produce TopsWhen any sort of Two would depend varieties, you can locate isn’t a huge imbalances when it concerns anything at all the many manufacturing facility in point of fact nike shox selections tonneaus are needed to issues.The most suitable build lead D controls generate epitome products in which.
Jeep quality 're really frequently used Offroad spares using you will see that unique person in the vicinity of relatively canada goose parka calm Offroad owners to serious off-road newbies may some rudimentary thanks connected that the majority of they’re fairly just about.About are likely to Offroad produces in is very much were and with specialised canada goose an absolute can imagine, hugely them set of it’s challenging to instant now while you are creating a acquisition, deciding on worthwhile heated artichoke dip recipe determining her home may need to go away great deal out of every tactic hallmarks of.It is important to, we’ve dissected dozens of laptop goose parka computer method 4wd top to carry out a powerful in-depth examination exactly if so guests must-have Freight se van products and services.And as well Offroad Most significant?It’s our nation besides that time tested check out; likely one will certainly focused seeing that of times by using these dinosaurs. supra shoes Never, almost searching for the right 4wd beautiful is still a choice that absolutely requires a fair personal choice of point.At first glance, preferring to the complete vital perceives typical.
I was suggested this web site by my cousin. I am not sure whether this post is written by him as nobody else know such detailed about my trouble. You are incredible! Thanks!miu miu bags replica
The north face take a glance at the Queen Mother and then: "well, today the north face great patronage a face-saving. overall, the outcome of the battle is won the the north face. Although north face fleece clearance conditions again and the store were saying.""Lines, the north face which to wait."Under the persuasion of Lao Zi, had to follow gods family locations together to go back to the Chamber of the north face, such as messages, since locations now know Russia protoss have failed, it would have nothing to worry about. as regards the details of the battle, really do not care about the truth locations.