Reports say diversion on the rise: Use technology to overhaul patient flow
Make smart use of cutting-edge tracking systems
Diversion rates. Patient and staff satisfaction. Patient safety. What do these three things have in common? They all hinge on the efficiency of your ED’s patient flow. Research shows that diversion and overcrowding are an increasing problem for many EDs. A recent report from Rep. Henry Waxman (D-CA) identified 22 states where hospital officials have stated they cannot safely accept ambulances, causing delays in patient care.1 Another report from the Washington State Hospital Association and the Association of Washington Public Hospital Districts, both in Seattle, revealed that more than half of the state’s EDs went on divert status during the past year.2
To boost efficiency in the face of these ominous statistics, progressive ED managers are making smart use of cutting-edge technology, which gives you up-to-the-minute information about your ED. "That can result in real-time interventions taking place," emphasizes Linda Kosnik, RN, MSN, CS, chief nursing officer at Overlook Hospital in Summit, NJ. "This avoids system stress and, ultimately, overload."
With increased volume and less reimbursement, your ED must run as efficiently as possible, urges Larry A. Nathanson, MD, an attending ED physician at Beth Israel Deaconess Medical Center in Boston. "By using the right technology, you can keep tabs on your patients and identify bottlenecks in the system," he says.
Delays in admission and X-ray cycle times result in increases in ED occupancy, says James Espinosa, MD, FACEP, FAAFP, medical director and chairman of the ED at Overlook Hospital. "The goal is to prevent [when possible], identify, and mitigate such a scenario," he explains. Although Espinosa acknowledges that the ED alone can’t solve the patient flow problem, he estimates that your admission cycle times can be reduced by 15%-20% with specific interventions. "If even a limited number of beds are continuously freed up in the right place, at the right time, that might be all you need to stay one step ahead of the crunch," he says.
Here are some effective ways to use technology for better patient flow in the ED:
• Identify delays for "hold" patients with a computer tracking system. When patients are being held in the ED, it reduces your capacity, stresses Espinosa. "An ED with 25 beds holding five patients is now a 20-bed department," he says. Patient safety issues are also a concern, Espinosa adds. "When patients who would be best served by the expertise of a specialty bed area are held in the ED, there is potential for errors that can lead to something more significant," he says. "This can also be a cause of dissatisfaction for ED staff, who may feel pulled from other tasks to care for these patients."
The ED has set a goal of fewer than 60 minutes, from the time the decision is made to admit a patient to transferring that patient to a bed. "We are currently at 76 minutes, and we are still improving the process," reports Kosnik. A patient tracking system is used to identify delays and take action as soon as they occur. On a single computer screen, staff can see the status of the following eight steps in the admitting and treatment process, updated every 15 minutes:
- arrivals;
- occupancy;
- arrival to bed (goal = 15 minutes);
- bed to treatment by nurse (goal = 15 minutes);
- bed to treatment by physician (goal = 15 minutes);
- arrival to physician (goal = 20 minutes);
- X-ray cycle time (goal = 30 minutes);
- admission cycle time (goal = 60 minutes).
If a goal isn’t met, a specific intervention kicks in, says Kosnik. "For example, if three 15-minute bars are over the limit for X-ray cycle times, the radiology tech calls another tech over to the ED or sends patients over to the main X-ray department," she explains. Progress quickly can disappear without continuous monitoring, warns Kosnik. "You need to review, provide feedback, adjust the process, and repeat, repeat, repeat," she says. "Unwatched, the new system will return to the old system."
• Implement an "ED dashboard" system. Before staff at Beth Israel Deaconess Medical Center moved to a new ED, the previous ED had two centrally located "whiteboards" that could be seen throughout most of the department, says Nathanson. The new ED is larger and has seven zones, he says. "It is very difficult to view the lay of the land’ from any one position," adds Nathanson. To address this, he developed an electronic tracking system known as the "ED dashboard," which is visible on a 4-foot screen in a centrally located area and on several other computers throughout the department. At a glance, staff now can view key information, including the number of patients in the waiting room, their status, bed availability, test results, and current volume. (To see sample screen from the "ED dashboard," click here.)
"Just from this summary screen, the providers and administrators have all the information they need at their fingertips to get the pulse of the department and to drive patient flow," says Nathanson. The hospital’s own secure medical-record system, CareWeb (developed by the hospital’s chief information officer), provides the lab, radiology, and electrocardiogram results, he adds.
Here are key benefits of the system, according to Nathanson:
- Nurses can more efficiently triage patients to less busy zones.
- Administrators can monitor patient flow from their offices.
- All providers instantly can see a color-coded summary as to whether their patients’ labs and X-rays are ordered or complete, if an inpatient bed has been assigned or if a patient has a prior electrocardiogram in the system.
Registration clerks, who have mobile wireless laptops, have a color-coded message telling them what beds need registration and with what priority. When a patient is moved out of a bed, the screen shows "requires cleaning" for the support staff.
Although the system was custom written by Nathanson to interface with the hospital’s clinical system (developed internally), it possibly could be used at other EDs, he says. "The interface might be a challenge, depending on what systems you are running," he notes. Most of the major expenses of the system, such as computers in the ED and the hospital mainframe, already exist, says Nathanson. He estimates that the current system costs approximately $100,000, including staff for development, implementation and training, and hardware, including a 42-inch plasma monitor. "A more expensive system may be more cost-effective than cheaper software that does not support patient flow and pulls providers from the bedside," he argues.
Nathanson notes that an effective system does not operate in isolation. "The closer the integration with registration, lab, radiology, cardiology, and the inpatient bed-board, the more effective the system will be," he says. The system often saves 30 minutes or more during an eight-hour shift, because staff don’t have to continually check the computer for information about lab tests or wait to be informed about results, says Nathanson. "At times it has even saved a few hours in a single visit, since at a single glance, a provider could see that a test was not ordered correctly or the blood hadn’t made it to the lab," he adds.
References
1. Minority Staff Special Investigations Division, U.S. House of Representatives. National Preparedness: Ambulance Diversions Impede Access to Emergency Rooms. Washington, DC: Committee on Government Reform; 2001.
2. The Washington State Hospital Association and the Association of Washington Public Hospital Districts. Who Will Care For You? Washington Hospitals Face a Personnel Crisis. Washington DC: Washington State Hospital Association; 2001.
Sources
For more information about using technology to improve patient flow, contact:
• James Espinosa, MD, FACEP, FAAFP, Medical Director, Emergency Department, Overlook Hospital, 99 Beauvoir Ave., Summit, NJ 07902. Telephone: (908) 522-5310. Fax: (856) 767-0430. E-mail: [email protected].
• Linda Kosnik, RN, MSN, CS, Chief Nursing Officer, Emergency Department, Overlook Hospital, 99 Beauvoir Ave., Summit, NJ 07902. Telephone: (908) 522-2095. Fax: (908) 522-5897. E-mail: [email protected].
• Larry A. Nathanson, MD, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02115. Telephone: (617) 632-0130. Fax: (815) 361-0899. E-mail: [email protected].
Resources
A report titled National Preparedness: Ambulance diversions impede access to emergency rooms was released on Oct. 16, 2001, by Rep. Henry Waxman (D-CA). The report can be downloaded at no charge at: www.house.gov/reform/min/maj/maj_terrorism_diversions.htm.
A report released Oct. 9, 2001, by the Washington State Hospital Association and the Association of Washington Public Hospital Districts details growing shortages of nurses and presents solutions. The 79-page report can be downloaded free of charge at www.wsha.org. (Click on "Publications" and then "Who Will Care for You? WA Hospitals Face a Personnel Crisis.")
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