Express unit propels hospital to stellar benchmarking performance
43-minute admission wait for bed is cut to to 1.4 minutes
"Our doctor told us the hospital had a room waiting for us. Instead, we were kept waiting in the emergency room for three to four hours." That response from an irate parent describes the direct admission process at Kosair Children's Hospital in Louisville, KY, before a benchmarking and best practice initiative was implemented. The initiative cut waiting time from hours to minutes in less than a year - and at minimal cost. (See graph comparing peer benchmarking results, p. 76.)
Admission wait time is measured from arrival until the child is in a bed. Before the initiative, 9% of direct admit patients had to wait longer than an hour for a bed and even longer for actual treatment to begin, says Shirley Miller, MSN, RN, executive manager of outpatient services. "Parents came expecting their child would have a bed and treatment started immediately. Yet they would have to wait in the emergency department [ED], where they were uncomfortable not only because of the wait time but the exposure of their child to communicable diseases.
"Now, every direct admit patient has a bed in the Admission Express unit in less than two minutes and in less than two hours has a bed on the med/surg floor," she explains. "During that time, patients have also been registered, assessed by physician and nursing staff, and treatments and interventions have begun." The unit also reduced by 0.5 days the length of stay for four of the top 10 admitting diagnoses.
A team formed in January 1997 to improve the process of direct admissions. Members include the medical directors of the facility and the ED, executive manager of inpatient services, the clinical director of emergency services, the director and assistant director of the pediatric residency program, and the chief pediatric resident. "Because we are a teaching hospital, we knew that having the residents' support was the key to success, so we had to have them represented on the team," Miller says.
Also included were the team leader of the administrative associates and team leader representatives from the ED, medical surgical units, and outpatient medical observations.
The team first outlined the current process on a flowchart. (See "Reasons for Improvement" flowchart, p. 75.) "We realized that families were showing up for direct admissions and didn't know where to go, and we didn't know they were coming," Miller explains. "They were anxious, the child was sick, and we didn't know who they were or why they were there. It just started the whole process off on the wrong foot."
The team also completed a fishbone diagram that analyzed problems noted by the community physicians, staff, ED, and residents as well as the process itself. For example, after the hospital's registration system was decentralized four years ago, physicians had no central contact number. "They didn't know if they should call the admitting resident or the emergency room when they had a direct admit," she says. Physicians also were dissatisfied not only with the length of time it took for patients to get a bed, but with the accompanying delay of treatment.
Paperwork logjams
Staff also were unhappy. "The number of direct admits were increasing," she says. "Even when the patients finally got to the floor, the nurses felt they weren't staffed or stocked to handle this many work-ups." An earlier restructuring of nursing left the facility with fewer RNs and more unlicensed assistive personnel. "These direct admits increased the workload for the RNs because all of them required assessments, and many of them required blood work." The result was that direct admits consumed the attention of at least one nurse, and sometimes two, for extended periods of time, especially in the evening, she says. Or, patients were too unstable to be admitted on the medical/surgical floor and had to be taken to the pediatric intensive care unit.
The team had three goals in improving the process. "One, we wanted the referring physician to make only one phone call. Two, we wanted the patient to be registered and have treatment initiated within one hour. And three, we wanted patients to be appropriate for med/ surg admission."
Next, the team had to decide how to accomplish that. They used an action improvement matrix to determine the relative feasibility of five actions that addressed the root causes. The team gave each action a score for its effectiveness as well as its feasibility. By multiplying the two scores, the team could easily forecast which one was the best possibility.
The team gathered ideas by participating in a benchmarking project on admission wait times in the BENCHmarking Effort for Networking Children's Hospitals. The express unit for admissions was one of the ideas uncovered.
"Kosair really showed the power of benchmarking in this improvement efforts," says Sharon Lau, consultant for the BENCH project in the Los Angeles office of Medical Manage ment Planning. (MMP is based in Bainbridge Island, WA.) "They compared themselves to the best performer, LeBonheur Children's Hospital in Memphis, TN, and then researched those practices that were creating LeBonheur's excellent performance. Then they adapted those practices to their own organization."
Once the admissions express unit was selected as the most viable option, members noted the barriers and aids to each of these areas:
· determining staffing needs;
· determining equipment needs;
· determining cost/charge structure;
· developing policies and procedures;
· developing plan for physicians and resident education;
· determining documentation needs;
· determining process flow;
· hiring and orienting staff.
· determining open date and opening the unit.
"The biggest barrier was that we had no budgeted dollars for either staff, equipment or space," Miller says. "So we had to look at the resources we had available."
The solution was to allocate six beds from the ED's observation area. "In addition to not having to build a unit from scratch or convert beds elsewhere in the hospital, we selected the area because it was being underutilized anyway. We also knew we could share the ED's equipment, such as the PIXIS machine (automated drug dispensing equipment). Also, if a child's condition deteriorates, we can transfer them quickly to the emergency department."
The location also made staffing easier. "When the admission express staff weren't busy, they could assist in the emergency department," she adds. (The two RNs and two administrative associates staffing the unit were reallocated from elsewhere in the hospital.)
The team then sent out letters to community physicians about the new process. "We also sent Rolodex cards containing the new easy-to-remember number: 629-Go In," she says. (See flowchart of the new process, below right.)
Members also offered inservices and information to residents and obtained their commitment to arriving at the unit within 20 minutes after receiving a page. "Because the residents were included in the decision-making process, their response has been tremendous. We are meeting the 20 minute goal on 80% of our patients."
Still, the team hasn't quite met its goal of one hour for the complete direct admit cycle time. "This was based on Le Bonheur's service, and that may not have been a realistic benchmark for us," Miller says. For example, the rare instance in which a consultant assesses the patient in the unit or a patient requires transfer to the intensive care unit skews the cycle time.
In January 1998, the team developed standing orders for clinical dehydration, fever in infants less than 2 months of age, Tylenol, Ibuprofen, and oxygen administration as well as pyloric stenosis. "We hope this will help improve cycle times," she says.
"Still we know that the hour and 45 minute cycle time far exceeds our previous time for total direct admission," says Joy Davis, RN, MS, benchmarking coordinator. "For example, instead of waiting 43 minutes for a bed, most families now wait only one minute and 40 seconds. And there's not a parent out there who complains about that."
For more information, contact Shirley Miller, Alliant Health System, P.O. Box 35070, Louisville, KY 40232-5070. Telephone: (502) 629-7319.
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