From the Guidelines
Implementing a "pull to full" strategy in the emergency department is crucial when wait times exceed 2-3 hours or waiting room capacity reaches 80-90%, as it prioritizes initial assessment and treatment over ideal space conditions, ultimately reducing morbidity and mortality by providing timely care. This approach involves bringing patients from the waiting room into the ED, even when no standard treatment spaces are available, and designating hallway spaces with privacy screens to maintain patient dignity. According to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1, ensuring scene safety and checking for response are critical initial steps in emergency care, which can be facilitated by a "pull to full" strategy.
To execute this strategy effectively, it is essential to:
- Ensure adequate staffing ratios to provide quality care in non-traditional spaces
- Establish clear protocols for which patients can be safely placed in non-traditional spaces, considering their medical condition and potential for deterioration
- Maintain regular reassessments of these patients to adjust their care as needed
- Prioritize patients who require immediate attention, such as those with cardiac arrest, using guidelines like those outlined in the American Heart Association's recommendations for initiation of resuscitation 1
The "pull to full" approach can improve patient flow, reduce left-without-being-seen rates, and improve time-to-provider metrics, ultimately enhancing the quality of life for patients by providing timely and effective care. However, this strategy should be considered a temporary solution during high-volume periods rather than standard practice, as it can strain staff and potentially compromise privacy and comfort. By prioritizing patient care and safety, emergency departments can reduce morbidity and mortality, even in situations where ideal space conditions are not available.
From the Research
Pull to Full Emergency Department
There are no research papers directly related to "pull to full emergency department" in the provided studies. However, the studies discuss various aspects of emergency medical care, including the use of automated external defibrillators (AEDs) and cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrests.
- The studies suggest that early defibrillation and CPR can significantly improve survival rates following out-of-hospital cardiac arrest 2, 3.
- The use of AEDs requires developing and implementing a program at sites where the cardiac arrest rate is high, with trained first responders and a plan for transferring patients to an advanced care facility 3.
- The effectiveness of AED programs can be improved by training community volunteers to initiate CPR and by optimizing the response time of emergency medical services 3, 4.
- The literature also discusses the role of epinephrine in cardiac arrest, with some studies suggesting that it may improve return of spontaneous circulation but not necessarily survival to discharge or neurologic outcome 5.
- A recent study compared the circulation-airway-breathing (CAB) and airway-breathing-circulation (ABC) approaches for resuscitation of patients following traumatic injury, suggesting that the CAB approach may be beneficial for hypotensive trauma patients with active hemorrhage 6.
Key Points
- Early defibrillation and CPR are crucial for improving survival rates in out-of-hospital cardiac arrests.
- AED programs require trained first responders and a plan for transferring patients to an advanced care facility.
- Community volunteer training and optimized emergency medical services response times can improve AED program effectiveness.
- Epinephrine may improve return of spontaneous circulation but not necessarily survival to discharge or neurologic outcome.
- The CAB approach may be beneficial for hypotensive trauma patients with active hemorrhage.