For ED bottlenecks, look at your OR scheduling
Elective scheduling in OR drives bed capacity
"Nobody really looks at the operating room when they're talking about ED overcrowding. But that elective schedule is what drives the peaks and valleys on the inpatient side," says Susan Madden, MS, Press Ganey's VP for analytics.
She takes orthopedics as an example. If all of your total-joint surgeons want to work on Tuesdays and Wednesdays, "that loads up the orthopedic floor with two- to three-day lengths of stay. So when that hip fracture patient comes into the ED, there's no orthopedic bed to put that patient in."
In looking at your wait times, she says, you should:
- focus on the operating room, as well as separating scheduled vs. unscheduled volume "so that you have separate capacity within the operating room to do both of those, and so they're not competing for the same resources"
- smooth out your elective admissions "primarily through the OR by using simulation modeling to even out the schedule." That way there is some predictability in admitting and discharging patients throughout the week to downstream units, preventing those dreaded peaks and valleys.
"What that does," Madden says, "is open up capacity on the inpatient side of the hospital so you don't have to board patients in the ED anymore. And all of that reduces wait times in the ED and the OR."
Take a step back and look at capacity across the hospital, instead of thinking in silos when talking about wait times. Hospital wait time is not just an ED problem; it's a symptom, says Christy Dempsey, RN, MBA, CNOR, senior vice president for clinical operations at Press Ganey.
What data should you look at?
To ease bottlenecks, Dempsey suggests first identifying where your peaks and valleys are on the inpatient side. "You can look at the variability of the admitted patients out of the ED day to day and the admitting patients out of the OR everyday." Likely what you'll find, she says, "is that the variability on those elective, totally schedulable operating room admissions are as variable or more variable than the ones coming out of the ED."
On the OR side, Madden says look at your volume of add-on cases and their pattern of arrival. You then can prepare and plan for — "rather than really slotting those cases in to wherever you have a hole in the OR schedule" — what you need to do for those cases separately and prevent clashes with your elective schedule. And look also at the volume and arrival patterns of emergency or urgent cases. Collect data such as when those urgent cases are arriving in the ED and when surgeons are calling the OR to book that case. "Some of those," Madden says, "are common pieces of data that are collected by hospitals, and some require new systems to collect those."
You have to look at cause and effect. To smooth peaks and valleys in the inpatient census, and in the OR, you have to look at where the patient is going, his or her destination unit, and lengths of stay, Dempsey says. "So that, again, you're predictably admitting and discharging all week long to those downstream units."
Also examine the utilization of the OR. For example, if general surgeons and urologists share an inpatient floor, Dempsey suggests avoiding scheduling them on the same day. Then, too, a like number of patients is being sent to downstream units throughout the week. Depending on lengths of stay, she suggests scheduling general surgeons maybe on Monday and Tuesday, with urologists scheduled for Thursdays and Fridays.
How simulation modeling can help
The easiest way to do that, she says, is with simulation modeling, which "lets you play with multiple scenarios until you find the one that's right for your organization." Simulation modeling makes the process faster and a little less intensive, but she points out you can still do it if you don't have access to simulation technology.
The most important thing is to eliminate peaks and valleys in the elective OR schedule and in so doing look also at all of your downstream units. "Most of the time, OR people don't do that," Dempsey says. "They come up with a schedule that works for the operating room. And we have to get rid of those silos so we're not thinking in terms of just the ED, or just the OR, but we're looking at organizational patient flow."
Using block scheduling
Dempsey says some hospitals allocate blocks of time for either a specific surgeon or service. For example, Dr. Smith has Tuesdays from 8 a.m. to noon every week. Most surgeons, she says, want their most intensive cases scheduled during the week — the assumption there being that they want to have the weekend free for recreation. "But the fact is," Dempsey says, "when you ask surgeons and you really boil it down, the reason they don't want their patients there over the weekend is because they feel like the ancillary support is not the same on the weekends as it is during the week."
Let's say a total joint patient comes in on Friday. Well, physical therapy then has to be available on the weekend. Dempsey says there has to be a commitment from the hospital to provide ancillary resources on the weekends if surgeons are willing to smooth their elective cases.
Madden says one approach is to isolate your elective case schedule to adjust the block schedule so that certain kinds of surgeries are spread across the week depending on which nursing units those patients would eventually go to.
Ultimately, by using both block scheduling and simulation modeling, you can "tweak your schedule and tweak your volumes and see what the impact is going to be" on the census of nursing units and the hospital overall.
Engaging staff
Dempsey says you want physicians at the table as well as surgeons, anesthesiologists, hospital leadership, vice presidents, and directors of the OR, the PACU, and some of the downstream unit nursing staff.
She says she's had good results working, in particular, with physicians. "[T]he reason is physicians are basically scientists. So if you give them good data and you let them be part of the decision-making based on those data, you're going to get physicians at every meeting.
"What physicians don't like to do," she says, "is come to meetings where no decisions ever get made, where nothing is based on data but it's based on anecdote, and no progress is made.... But you give them credible data, let them help make the decisions based on those data, and make progress at every meeting — they'll be there."
"Nobody really looks at the operating room when they're talking about ED overcrowding. But that elective schedule is what drives the peaks and valleys on the inpatient side," says Susan Madden, MS, Press Ganey's VP for analytics.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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