Critial Path Network
Team improves throughput, avoids ED diversions
Initiative includes reducing wait for beds
When Sarasota (FL) Memorial Hospital began experiencing a big spike in emergency department diversion, the hospital created a multidisciplinary committee to determine why the diversion was occurring.
The hospital had experienced several diversions in the past until 2004 when the hospital was on diversion 26 times between June and November.
"It wasn't even our peak season. The staffing looked good. The length of stay was good, but we were not able to get the patient flow we needed so our emergency department wasn't backed up," says Judy Milne, RN, MSN, CPHQ, executive director for quality and patient safety.
The mission of the team was to eliminate diversions and to reduce the number of patients waiting for a bed for more than two hours. At that time, 42% of patients were waiting more than two hours to occupy a bed.
At Sarasota Memorial, case managers are responsible for assessing for medical necessity and discharge planning, coordinating with nursing to get the patients ready for discharge as early in the day as possible.
"This initiative reinforced the importance of the case managers' role to screen the patients to avoid inappropriate admissions and to optimize our bed use by getting patients to the right place. We put an emphasis on unnecessary days and try to avoid those by staying on top of the discharge plan," she says.
The team looked for the biggest delays in finding inpatient beds and determined that more surgical patients were waiting longer for beds than patients who were medical admissions or who came through the emergency department.
Statistics showed that 39% of all delays of more than two hours occurred on the surgical nursing units.
One of the hospital's inpatient nursing units was a mixed unit that also included recovery beds for short-stay surgical patients, most of whom were in the hospital for gynecological procedures but who couldn't go to the Phase 2 recovery unit because they needed a bed, not a recliner.
When a nurse has patients who are staying only a few hours on the unit and those who have stays of a day or longer, the workflow is affected, Milne says.
"The longer length of stays of many patients on the unit made it hard for the nurses to focus on the rapid throughput of the short-stay patients," she says.
The team created an outpatient post-surgery recovery area with 14 to 16 beds available Monday morning to Saturday morning for short-stay surgical patients who aren't appropriate for the Phase 2 recovery unit.
"It worked beautifully and seems to have minimized the diversion issue," Milne says.
The team studied the pattern of patient arrivals and departures and determined that the hospital often was above capacity in the middle of the day.
"The pattern of arrival was not matching the patterns of discharge. The peak time is around noon to 4 p.m. or 5 p.m.," she says.
Direct admissions typically peak in the late morning after physician office hours and after 5 p.m. to 6 p.m. The emergency department admissions are steady during most of the day but get heavier in the latter part of the day and into the evening and night.
"We start looking for beds for our surgical patients at 10 a.m. or 11 a.m., but most patients aren't being discharged that soon. We did a lot of work around patient placement processes to free up more beds earlier in the day," she says.
The hospital began posting the percentage of patients waiting more than two hours for a bed, broken down by nursing unit. The team looked at roadblocks to bed turnover, including how quickly housekeeping got to the rooms and patient transportation issues.
The team focused on the ancillary departments, such as radiology, laboratory, housekeeping, and transportation, to determine where some of the roadblocks were occurring and what they needed to do to facilitate patient throughput.
"We also looked at the nursing units to determine how quickly they could discharge patients and make beds available," she says.
When the project began, nurses who were discharging patients had to enter the information twice, once in the electronic medical record and once in the admission/discharge/transfer software, which alerts the bed board team in the case management department that a patient is pending discharge or transfer.
If the nurse forgot to input the information into the admission/discharge/transfer software, the bed board staff didn't know what was taking place.
The team worked with the hospital's electronic medical record software vendor so that the nurse could enter the patient disposition in the software and it would send a message to the bed board staff.
"We eliminated a step so that the nurses didn't have to go into another software program. They could automatically notify the bed board through the electronic medical record. We now get pending transfers and discharges in real time, and it helps us anticipate beds and place patients in a more timely fashion," she says.
The case managers on the unit are in constant contact with patient placement about the status on discharging patients.
"All these tiny details make patient throughput click. It all fits together," she says.
The team's next step is to focus on scheduled discharges and to anticipate the peak times for arrivals and departures.
"Our goal is to get more patients discharged earlier in the day in order to increase capacity," she says.
When Sarasota (FL) Memorial Hospital began experiencing a big spike in emergency department diversion, the hospital created a multidisciplinary committee to determine why the diversion was occurring.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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