Critical Path Network

Poster alerts patients to their discharge responsibilities

Markers allow family members, nurses to write questions and answers

Patients at Seton Medical Center are made aware of their proposed discharge date early in the stay through a laminated poster with a Wizard of Oz theme titled "The Road Home."

The 11x17-inch poster, written in English and Spanish, prompts patients to ask questions ahead of time instead of waiting until the day of discharge.

"We provide dry-erase markers that allow family members and patients to jot down questions and communicate back and forth with the nurses and case managers, and to get their questions answered in a timely manner so they'll be prepared for discharge," says Patricia Ramming, RN, network director of patient logistics at Seton Healthcare Network in Austin, TX.

The poster includes questions patients may want to ask about discharge, such as details about diet, post-discharge activities, and medications they will have to take. It includes other questions such as, "Are you going to have problems getting your prescription filled?" and "Do you have transportation home?"

Using the poster to get patients ready for discharge is one of a series of throughput initiatives that are part of a partnership among case management, the clinical staff, admitting, and the housekeeping department.

For instance, the case management team compares the hospital's length of stay, weighted for acuity, to other hospitals and targets Seton for the top 10%.

In 2004, faced with an increasing number of patients on hold overnight in the emergency department, Seton Medical Center created a throughput department that operates 24 hours, seven days a week. Department staff include house supervisors, express admissions nurses, and nonclinical bed board staff. The hold time in the emergency department dropped dramatically after the department was created.

"We are continually looking at ways to be more efficient on the discharge end. We typically run at 85% capacity and are looking at ways to get more beds utilized without increasing our capacity," Ramming says.

Among the initiatives are a daily bed briefing to discuss bed and staffing issues for the day; a discharge team that brainstorms about patients with complex discharge needs; and a networkwide bed board that tracks capacity throughout the entire hospital system.

Representatives from all areas of the hospital, including charge nurses from every floor, managers and directors of every department, case management, and human resources, attend the morning bed briefing.

The multidisciplinary team also includes representatives from plant operations in case there are mechanical issues; central supply, which provides all patient care equipment; and environmental services so they know what to expect and can staff as needed for the projected volume for the day. The house supervisor leads the meeting.

"We share the plan for the day, looking at all discharges and arrivals and identifying areas where there might be bottlenecks. We work as a team to expedite the admissions and discharges we know about in the morning," Ramming says.

The team comes up with a plan to ensure that admissions and discharges flow smoothly throughout the day. For instance, if the ICU is at capacity, and there are patients scheduled for surgery who will need to be in the ICU, the ICU team facilitates moving patients out if they can be transferred safely to another unit.

"The ancillary departments are part of the multidisciplinary team and we problem-solve together on ways to expedite the tests and procedures patients need before discharge. For instance, we have teamed with the laboratory to develop a bright-pink sticker that shows we need these labs run first," she says.

Dealing with complex discharge needs

A discharge team meets weekly to discuss discharge options of patients with complex discharge needs. The team includes case management, nursing, admitting, and sometimes social work, depending on the needs of the patient.

The team discusses any obstacles to discharge, including financial constraints if the patient is stable enough to move to another level of care.

"We determine if we need to get financial clearance with a post-discharge provider. If the patient has Medicaid pending, we have contracts with post-acute providers so that Seton provides the financial support to the patient; then once Medicaid is approved, the facility reimburses us," Ramming says.

The team conducts a cost-benefit analysis to determine if it's cheaper to pay for a lower level of care instead of keeping the patient in acute care.

"This arrangement helps decrease length of stay and frees up the bed for patients whose care is covered by a payer," she says.

Each hospital site has a patient flow committee, a multidisciplinary team that meets once a month to examine any type of discharge problems that come up regularly. The system is expanding the initiative to the network level with a network committee that will share successful initiatives with peers in other Seton hospitals.

Bedside discharge

The hospital has eliminated one step in the discharge process, sending financial counselors to patient rooms to go over billing issues and collect copayments rather than having them stop by the admissions office on their way out of the hospital.

When the patient tracking system indicates that a discharge is pending, the financial counselor clears it with the nursing staff and goes to the patient's room. The initiative is called courtesy discharge rounds and was started at one site and has been rolled out across Seton's campuses.

"It's more private to have a discussion in the room and the patients are more relaxed. This has eliminated having several patients waiting at the admissions office at one time," she says.

The hospital's electronic bed board gives the staff real-time information on what beds are ready for patients, which ones are being cleaned, which are blocked, and pending discharges and admissions. It allows the admissions staff to determine when beds will be needed on which unit and set priorities for the housekeeping staff.

The board includes information about scheduled admissions for the next five days, giving staff the opportunity to make sure paperwork is in order before the patient arrives.

"The admissions case manager can see when a bed request comes in and can proactively make sure the documentation is in place so that the patient meets InterQual criteria," she says.

Physician offices can make one call to find out capacity in any Seton hospital.

"We have systems in place to give an upcoming admission visibility. Admissions can complete the insurance verification; the case manager can review the doctor's orders ahead of time and make sure the patient meets InterQual criteria," she says.

The system helps with forecasting and scheduling of patients. For instance, Seton does not have an outpatient infusion center and anyone who is receiving a blood or chemotherapy infusion must be in an inpatient bed. If someone is coming in for a blood transfusion or chemotherapy and one campus is at capacity, the bed board staff can divert the patient to a facility that can serve them immediately rather than having them wait.

When a physician calls the central phone number to admit a patient to a particular hospital, staff can see instantly if the hospital is full.

"If Seton Medical Center is full, they can tell the doctor that there is a potential discharge in four hours or they can admit the patient directly to Seton Northwest," she says.

The bed board gives the staff the ability to visualize the emergency department's volume at all hospitals within the system.

"If we're getting a transfer request for a tertiary care center, we can focus that request to the emergency department that can handle the patient," she says.

The Seton network has a zero-diversion agreement with the local emergency medical systems. The EMS system can communicate through the Seton system and find out which hospitals have capacity in the emergency department and bed availability.

"Our network includes a Level II trauma center, a children's center, a cardiac and heart transplant center, and other tertiary care centers. Whenever possible, we can triage patients to the most available facility for stabilization and transfer them to other facilities where they can get the care they need," she says.

Other initiatives include:

  • Creating the position of an express admissions nurse who floats through the hospital and helps whenever needed, getting the paperwork started, conducting a history and physical, drawing blood, or taking care of other admission needs for the patient.
  • Expanding the patient tracking system so that the admissions staff can see projected discharges in a timely manner and work up front to collaborate with case management and nursing staff to identify where and when beds will be available.
  • They are piloting a new case management structure on some floors. "Instead of case managers being located geographically in the unit, we are focusing more on the patient illness and scope of services," she says.

For instance, the same case manager follows a pulmonary patient from the ICU to the floor, instead of handing it off to another case manager when the patient is transferred to a different unit.

"We have reestablished the relationship that the case management team has with the utilization review team. The utilization review team works in partnership with the case managers proactively for the patient instead of getting involved on the back end," she says.

(For more information, contact Patricia Ramming, RN, network director of patient logistics, Seton Healthcare Network, e-mail: