Critical Path Network
The secret to improved throughput? Communicate
Duke increases capacity
Increased communication among the multidisciplinary patient care team has increased patient throughput at Duke University Hospital, a 924-bed acute care facility in Durham, NC.
"Our hospital has functioned at capacity Monday through Friday and many weekend days for more than two years. In order to continue to serve patients in our community, we needed to be as efficient as possible. We knew that we had to increase bed capacity in order to accommodate new patients," says Mary O'Brien, RN, MBA, director of patient resource management.
With the help of a consulting firm, Compirion Healthcare Solutions, the Duke health care team looked at ways to improve communication.
Among its initiatives was development of a daily discharge huddle among members of the interdisciplinary treatment team, setting a goal of 11 a.m. for 20% of discharges and focusing on patients likely to be ready at that time, and increased communication between the nursing day shifts and night shifts.
At Duke, like many hospitals, the health care team tended to operate independently within the specific duties of each specific team, O'Brien says.
"The nurses, the case managers, the physical and occupational therapists, and other disciplines all functioned in silos, and communication was always an issue," she says.
O'Brien's vision was to create a venue in which key stakeholders in the patient care process attend a brief daily meeting to focus on the next day's activities.
Duke University Hospital's case management department has a service line-based model. Each floor of the hospital has two immediate care units and one intensive care unit.
Daily discharge huddle assembled
One method of increasing communication was the institution of a daily discharge huddle, a team meeting that is different from rounding, and the daily report on each unit.
The hospital piloted the discharge huddle on one floor and has rolled the process out throughout the entire hospital.
The discharge huddle typically includes a physician representative, the charge nurse, the patient resource manager, and any other pertinent member of the treatment team, such as physical therapists or physician extenders.
During the meeting, the team discusses the patients who are pending for discharge the next day.
"The meeting is very well scripted. The physicians present the patients who are pending for discharge the next day, and the team discusses what has to happen for the patient to be discharged," O'Brien says.
The team uses the 80% rule. If there is an 80% probability that the patient will be discharged the next day, he or she is placed on the pending list.
"The staff concentrate on the other 20% that are the requisites for discharge, such as obtaining lab values, getting the patient to ambulate, pulling the Foley catheter, or putting in a PIC line," O'Brien says.
The charge nurses and the care team discuss what each patient needs for discharge, and they come out of the huddle knowing what they need to achieve the next day in order to get the patient discharged, she adds.
The patient resource managers enter the information from the discharge huddle into the hospital's electronic case management software so outcomes can be reported on the hospital level.
"We want to make sure that we are being accurate in determining which patients are pending discharge. If a unit has 10 patients pending discharge, we want to make sure that those same 10 patients are the ones who left," O'Brien says.
The hospital has a target of discharging 20% of patients pending discharge by 11 a.m. and 50% by 1 p.m.
"When discharges are delayed, it causes problems for the emergency department and the post-anesthesia care unit. We need to get the first surgical patients to the floor so we can start the next cases. We need to make sure that as the emergency department starts to fill during the busy hours, we have capacity in the beds upstairs," O'Brien explains.
When the process started on July 1, 2008, only 11% of patients were discharged by 11 a.m. By the end of May 2009, the figure had jumped to 18%.
"In order to have 20% of patients discharged by 11 a.m. hospitalwide, it has to break down at the unit level. We worked with each unit to help them understand our goal," O'Brien says.
The nursing leadership works with the unit staff to focus on the patients who are most likely to be discharged.
For instance, if there are five patients pending for discharge, the team identifies the three they can guarantee they can get out by 11 a.m and focuses their efforts on them.
The increased communication has been helpful in the bed flow meetings during which all units report which discharges are anticipated.
"Having accurate information on pending discharges allows for more effective planning since the hospital often is at capacity all day," she says.
The proactive approach to discharge continues during the night shift.
For instance, if a patient has transportation in place and the only thing needed for discharge is to have a lab report, the case managers alert the nighttime nursing staff to make sure the lab is drawn.
"Typically, not much goes on during the night in hospitals. We have increased communication during the shift change huddles so that the daytime information is shared with the nighttime charge nurse. This way, the night staff take a proactive approach to make sure the patient is ready for discharge the next day," she says.
The staff also alert the resident physicians so they can prepare the discharge instruction sheets and get the prescriptions written overnight.
"It's all about proactive communication. The information shared between teams was fragmented when we started. By improving communication, we have improved the patient flow process," O'Brien says.
Increased communication among the multidisciplinary patient care team has increased patient throughput at Duke University Hospital, a 924-bed acute care facility in Durham, NC.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content