Ever since the first waves of COVID-19 ended in late 2021, Yale New Haven Hospital has set and broken records for patient volume a number of times. Emergency Department (ED) staff have been hit particularly hard, but Jan. 2 was extreme, even for them.
That day, the York Street Campus Adult Emergeancy Department, Saint Raphael Campus ED and Shoreline Medical Center ED combined were at 280 percent capacity. More than 144 patients were boarding – waiting in the ED for beds to open on inpatient units. For some patients, that wait was one to two days because with 1,447 patients, the hospital was 98 percent occupied.
“It was the worst day of hospital overload since we started tracking data” in 2014, said Arjun Venkatesh, MD, chief of Emergency Medicine at YNHH and chair of the Department of Emergency Medicine at Yale School of Medicine.
ED staff needed immediate help, and they got it, from employees and departments throughout the hospital. YNHH activated its emergency operations plan for surge, which is managed by the Hospital Incident Command Structure (HICS). The hospital implemented measures to safely discharge as many patients as possible to open beds for boarding patients. The ED and other departments implemented strategies – some existing and some new – to ease ED overcrowding and maximize staffing. Some of these strategies remain in effect.
“These efforts helped attenuate some of the most extreme danger in the ED,” Dr. Venkatesh said. “We were able to reduce some of the ED overcrowding that day without a single safety incident.”
In response to boarding and overcrowding during surges, Lisa Maciejak, RN, patient services manager, YSC Adult ED, and her assistant patient services managers help care for patients. Maciejak also reassigns staff to focus on certain types of patients, including those requiring a higher level of care.
One strategy she and her physician partner developed to address capacity constraints focuses on maintaining staff-to-patient ratios and strategically placing patients throughout the ED based on their acuity. This strategy includes evaluating patients who require a different level of physician and nursing resources to manage their care on the department’s C-side when the A-side is overstretched.
Moving less-critical patients to another area also opens A-side beds.
In the future, some of these less-critical patients will be treated in the 35-bed ED Annex building, scheduled to reopen in the spring.
In the past, the ED’s D area was used for patients who would be treated in and released from the ED. It is now used primarily for boarding patients.
“Some of our boarding patients are here for days,” said Beth Liebhardt, RN, nursing executive director, Emergency Services. “We strive to maintain privacy and quiet, but this is far from ideal. We have to do what’s best for patients.”
That can mean moving patients to other units. Most post-surgery patients are discharged from the Post Anesthesia Care Unit or moved to inpatient beds by early evening. Those PACU beds have been used overnight for boarding patients.
Medicine (EP 5-5) is among some inpatient units that have cared for ED boarding patients during recent surges. EP 5-5 staff set up a bed in a corner near the unit desk with curtained dividers around it, which patients occupy until a room is ready. The bed has easy access to a bathroom; the lights in the area are dimmed; and staff try to keep noise to a minimum.
“The patients and family members obviously don’t like not having a room, but we do our best to make them comfortable,” said Anne Marie Walsh, RN.
“We acknowledge to our patients and family members that it’s not a perfect solution, but we let them know they are part of our unit, and they’re receiving the same level of care they would receive if they were in a room,” said Debora Lindewall-Matto, RN, patient services manager. “The nursing staff really try to go above and beyond for these patients.”\
Procedures for Environmental Services (EVS) and Patient Transport also changed during the Jan. 2 surge to help ease ED overcrowding. Normally, after an inpatient is discharged, Patient Transport will receive a “go on gold” notification. That means they can bring the new patient to the unit while the room is being cleaned or after it’s done.
On Jan. 2, the order changed to “go on brown.” That meant patients were brought to the inpatient units before their rooms were ready. Some patients might have had a temporary wait in the inpatient unit, but they were out of the overcrowded ED and closer to the primary care team sooner.
During any surge, EVS staff will clean more rooms than normal, and while they work efficiently, they must still follow the nine required cleaning steps.
“We do not take shortcuts on the cleaning,” said Stephen Branch, EVS manager.
It takes about 30 minutes to clean a room, but unit staff can help shorten that by removing the bed linens after a patient is discharged and putting items in their proper places in the room before the EVS associate arrives, he said.
“I want to thank all of our Nursing partners and staff on the units who help us,” Branch said. “I am especially grateful to our EVS staff for their hard work every day, and particularly during these difficult surges.”
Yale New Haven Health leaders recognize the toll surges and overcrowding takes on patients, visitors and staff. The health system continues to develop measures such as the Capacity Coordination Center, Hospital at Home program, ED Annex and Discharge Lounges to better manage patient flow.
“The patient volume and overcrowding the hospital has experienced these past couple years have been extraordinarily difficult for our staff,” said Michael Holmes, executive vice president and chief operating officer, YNHH. “We are incredibly grateful for our employees’ and physicians’ creativity and flexibility in finding ways to deal with these surges, and for their dedication to caring for our patients under the most challenging circumstances.”
