Patient flow initiatives slash average LOS
Rates cut from 7.5 hours to just more than 5
Three years ago, the average length of stay (LOS) for admitted ED patients was about 7.5 hours at the 17th Street campus of New Hanover Regional Medical Center in Wilmington, NC. Today, it is down to just more than five hours.
This improvement was achieved through a combination of initiatives, including the creation of a rapid admit unit and the addition of a computerized bed tracking system, says Nancy Wooline, director of emergency and psychiatric services for the New Hanover Regional Medical Center network, which includes the 17th Street campus and Cape Fear Hospital.
"About three years ago, we looked around our network and realized we were super-saturated and that the old tools we had in place for moving patients through the continuum of care were no longer effective," she recalls. 'We felt we had done all that we could do off the back end, so we looked to shorten LOS." At that time, she notes, the network was seeing a combined total of 68,000 ED patients a year. Today, it is up to about 100,000.
By creating the rapid admit unit, the ED was "decompressed," explains David Doolittle, MBA, RN, manager of the unit. "We take some patients out of ED, which allows the ED staff to see more patients," he notes. The unit itself resembles a mini-ED, with small stalls, trauma beds, and easy access for the ED staff, who are about 75-100 feet away.
The unit is used, for example, when an ED physician determines a patient should be admitted to the tower (as an inpatient), but a bed isn't ready. "In the old days, that patient would have been locked up in [an ED] bed," Doolittle says. "Now, we can pull them into the nine-bed unit and do all the admission work: paperwork, start IVs, drawing labs, getting the first antibiotics on board, and so forth."
This process takes 48 minutes, he says; meanwhile, the patient's bed is being cleaned and the room is prepared. "The key thing is that we have opened up a bed in the ED to allow an additional patient to come in," notes Doolittle, adding that the unit sees about 75%-80% of all patients not admitted to the intensive care unit.
The unit itself is typically staffed with three nurses; three patient care technicians (PCTs), who are hybrids between unit clerks and nursing assistants; and one unit clerk. They have been cross-trained in phlebotomy, electrocardiograms (EKGs), transport, and other similar functions, Doolittle says.
There were no new full-time equivalents (FTEs) added to the nursing staff at the medical center, says Wooline. "We used parts of the FTEs from inside nursing and moved them to this unit," she says. "For example, we had some floating admission nurses."
A collateral benefit of the rapid admit unit is that it has been "a great morale booster" for the inpatient nursing staff, Wooline says. "When they receive a patient from the rapid admit unit, they receive what for them is really a transfer," she explains. "There are not long hours of extensive assessments, for example."
The bed tracking system is a natural complement to the rapid admit unit, says David Long, MHA, business manager for nursing administration. "There is a great deal of collaboration between David [Doolittle] and myself," he notes.
As soon as a bed is requested from the ED, that individual is entered in the "patient wait queue," so Long knows there is a patient in need of bed. "With that information going into a queue, you know what time the patient arrived," he explains.
The patient placement facilitators examine the system by using Series software from San Francisco-based McKesson Corp., and look to see where available beds are in the tower on the inpatient floors and in rapid the admit unit. All of that information is displayed graphically for them, Long notes. "With a couple of flat-panel monitors, you can have a dual display, look at different icons, and see if a bed is empty, vacant, filled, being cleaned, and so forth," he says.
This process is further facilitated by bedside admission, initiated about a year ago by moving registration staff out of the lobby. All of these factors greatly increase the speed at which a bed assignment can be made, says Long. "With more automation, David and I can look at the system and see, for example, that as soon as a patient presented to the admit area we could just send them to the rapid admit unit," he explains. As the admission orders come together, they are processed at the bedside, Long says. "It's really a collaborative effort to minimize wait time," he adds.
Sources
For more information on bed management strategies, contact:
- David Doolittle, MBA, RN, Rapid Admit Unit Manager; David Long, MHA, Business Manager for Nursing Administration; Nancy Wooline, Director of Emergency and Psychiatric Services, New Hanover Regional Medical Center, 2131 S. 17th St., Wilmington, NC 28401. Phone: (910) 815-5188.
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