Behind the Creation of the Emergency Department Acute Care Unit

Jill Ehrendreich RN, MSN, CMSRN; Chase Lodico, MBA, RN, CEN; Jenna Maloney, RN, MSN, CNL

The unit on 9 Kellogg accepts both adults needing observation and inpatients from the Emergency Department (ED). Renovations planned for 9 Kellogg in the late spring and early summer of 2022 resulted in the closing of a 23-bed unit for six to eight weeks, decreasing the overall number of adult medicine beds while increasing the boarding time for ED patients. A rise in patient boarding time could add stress to an already short-staffed ED, increase the risk of the hospital going on bypass, decrease patient satisfaction, cause delays in care and, overall, have a negative impact on patient throughput.

The primary goal in creating the ED Acute Care Unit (ACU) was to decrease the volume of patients in the ED, promote patient safety and support the ED nursing staff. A nurse-led interdisciplinary team of ED nurses and physicians, nurses from the 5 Kellogg and 9 Kellogg units, case managers, hospitalists and personnel from patient placement created a five-bed acute care unit within the ED called the ED-ACU. By partnering with RUSH hospitalists, medicine nurses could provide greater detail about the progression of care for observation patients admitted from the ED to the ED-ACU. Moving observation patients out of the ED and into the ED-ACU beds allowed the ED staff to expedite the movement of patients from the waiting room into ED beds for care. The move also created more bed space for patients awaiting admission.

The nurse-led interdisciplinary team devised a process for patients to be identified and admitted to the ED-ACU, receive care, and be discharged or, if needed, upgraded and admitted to an inpatient unit. Building a separate unit in Electronic Medical Records improved patient safety by helping to distinguish ACU patients from other ED patients. It also enabled the team to track safety events separately and quickly identify process issues and educational needs.

The team’s efforts led to the development of criteria for the types of patients to be admitted to the ED-ACU and for better identifying them. Managing the flow of patients from the ED to the ED-ACU required the creation of algorithms to ensure all involved were clear on the process. An interdisciplinary team of nurses, unit leaders and operational stakeholders produced the algorithms and protocols for the ACU, focusing on daily operations.

Due to these collaborative efforts, the allocation of the necessary resources, the delineation of clear processes, communication with key stakeholders and frequent interdisciplinary meetings, the ED-ACU successfully operated from May 22 to June 30, 2022. During this six-week period, more than 100 patients were admitted to the ED-ACU area. The patient criteria, the efforts by the utilization review nurses and the input of ED and medicine physicians contributed to a lower rate of upgrades and resulted in a decrease in bed usage in the inpatient units. The number of daily boarded patient hours decreased from 49.4 before the pilot to 39.4 during the ACU pilot. Staff in both the ED and ED-ACU said they felt more supported by leadership to troubleshoot challenges and that the process algorithms provided clear workflows for patient care. Furthermore, the unit succeeded in decreasing the workload of the ED staff while maintaining safe patient care and expediting patient throughput.