With diversions, ED is just a symptom of inefficiency
Check bed life cycle, physician says
Although the emergency department (ED) is a popular scapegoat when it comes time to assign blame for hospital diversions, it is just the symptom of an inefficient hospital, says John Whitcomb, MD, medical director of emergency services for St. Luke’s Medical Center in Milwaukee.
That inefficiency is defined by several clinical processes, "all of which are slow," adds Whitcomb, who helped spur development of a cutting-edge bed management system at Aurora Health Care. "They all happen at the same time in the middle of the day, and they all have in common one person occupying two beds or a bed with nobody in it."
Those problematic processes, he says, include the following:
• Discharge from the hospital.
From the time the physician writes the discharge order until the bed is reoccupied, Whitcomb says, is in the range of six to eight hours. He says the patient is there for the first two or three hours, and then there are multiple handoffs — to nursing, to pharmacy, to transport the patient. Each one is just 15 minutes, but when there are 10 of them, suddenly that’s six hours.
• Transfers between units in the hospital.
When a patient is transferred from the intensive care unit (ICU) to the nursing floor, he or she is in one bed and waiting for the other, he notes. The other bed has to be cleaned, and the order has to be given and coordinated with pharmacy. Then the patient, along with personal effects, has to be moved, and the family directed to a different waiting room. Again, according to Whitcomb, it’s about a six-hour process.
• Procedures in the operating room (OR).
While an elderly or frail patient is in the OR for a five-hour procedure, "his slippers and robe are in the original room," Whitcomb points out. "He may go back there, or he may go to a room in the ICU, which is on hold because the patient is so frail." Both beds are held in reserve until the outcome is clear.
• Outpatient procedures.
There’s a similar process with outpatient procedures, whereby physicians hold open the option of admitting a patient to the hospital, just in case there are complications or unforeseen outcomes. "In the meantime, there are all these other procedures where a bed is put in reserve, and all of those procedures peak in the middle of the day," he says.
That means that in the middle of the day, he explains, any hospital with an occupancy rate of more than 80% thinks it’s at 120%. "It’s because [clinicians] have saved a bed, just in case.’ It’s that just in case’ stuff that’s causing the problem."
At noon, Whitcomb says, hospital personnel likely are to get so panicked by these numbers that they send business elsewhere, only to find there are 20 available beds at 8 p.m.
"That’s because they didn’t know how many beds they had, really," he says. It doesn’t help that various physicians are calling the units directly to make private deals to get their patients admitted, Whitcomb says.
"It’s a confusing process," he says. "You can’t keep track and you don’t have control of how long it takes for one empty bed to get reoccupied. So how can you make a science of that?"
To correct what Whitcomb calls "the life cycle of a bed," there is certain hard information that can be measured, he says. Terms that need to be clearly defined, include the following:
• Available bed.
"This is not a licensed bed, not a budgeted bed, and not a bed with sheets on it," he says. "It’s a staffed bed. Access people need to recognize that the hospital they’re working with is not the same every day. Every day it’s a little different. Patients are complicated. Some patients have one nurse, and in another place, one nurse is caring for five patients."
• Open bed.
An open bed, Whitcomb says, is a bed for which a discharge order has been written. When the order’s written, the clock begins ticking, he adds. "When is the secretary going to report it? When is the patient going to be moved out? When is it going to be cleaned? When is a new patient assigned to it? When is a report given from the incoming patient? When is the patient actually in the bed?"
If it generally takes six hours after the order is written for a bed to be open, Whitcomb notes, what would be the benefit if that time were cut in half? "If you can add three hours of occupancy, and the average hospital stay is five days, you gain 3%," he says. "With a 500-bed hospital, you’ve gained three empty beds. Once the situation is defined, you can put a tool together to manage it, and you can act prospectively. Then you can make what you do match the hospital’s mission."
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