Critical Path Network

Hospitalwide throughput initiative lowers diversion by 71%

ED CMs, admissions nurse speed process

Faced with patients waiting for a bed for hours in the emergency department and an increase in time on ED diversion, Southern Ocean County Hospital in Manahawkin, NJ, began a hospital-wide initiative to improve throughput.

The hospital had always had some problems with backup in the ED, but it was getting worse, says Barbara Stanek, RN, BSN, MPA, CNA, director of patient coordination.

In 2005, before the initiative began, the hospital was on diversion for 1,144 hours, or an average of three hours a day, for a revenue loss of $500 per outpatient and $5,000 per inpatient. In 2006, the hospital was on diversion only 329 hours, a 71% decrease with an increase in the volume of patients in the ED.

Revenue loss for 2005 because of backups in the ED was estimated at about $2.2 million, according to Marilyn Butler, RN, MSN, CCM, case management director.

The hospital has 176 inpatient beds and more than 230 physicians, with a primary service area of 110,000 residents, which swells to more than 210,000 during the summer months. In the off season, the hospital averages about 90 ED visits a day. The figure rises to 120 visits a day during the summer months. About 80% of hospital admissions come through the ED.

The hospital has a unit-based case management department with two case managers and one social worker for each 32 beds. The case managers follow all acute patients and assess them within 24 hours, either in the ED or on the unit, and develop a discharge plan within 48 hours of admission.

In addition to the inpatient nursing units and the ED, members of the throughput improvement team include representation from all hospital departments, including case management, housekeeping, laboratory, radiology, dietary, and materials management.

The team started by breaking down the time in the ED into segments — such as registration to admitting order, time caring for patients, and admitting order to inpatient bed — and looking at opportunities for cutting the time.

Creating solutions

That phase resulted in implementing case management in the ED, creating a new position for a clinical admissions liaison nurse, and developing a set of pre-printed bridging orders for basic care to be used for stable patients who need to be admitted.

The overall ED length of stay from the time patients register until they are in an inpatient bed dropped to 6.46 hours in 2006 from 7.5 hours in 2005. The figure dropped to six hours for the first nine months of 2007.

The time that elapsed between the admitting order and the time the patient was in a bed was 3.5 hours in 2005 and dropped to 2.9 hours in 2006. The figure dropped to 2.2 hours for the first nine months of 2007.

The time from the waiting area to a treatment room dropped from 37 minutes to 20 minutes. The time it took for the physician to see the patient was 64 minutes and dropped to 41 minutes. The percentage of people who left without treatment dropped from 2.1% to 1.1%.

One initiative on the front end was to bring patients straight from the ED waiting room to the treatment area where there were open bays and conduct bedside registration.

"We shortened the triage by getting patients into the back as soon as possible when there were beds open," Stanek says.

On the front end, the hospital ED staff are looking at ways to move patients through the ED more quickly. On the back end, the case management department is working to shorten lengths of stay, Butler reports.

CMs in the ED

Two full-time case managers work in the ED on 12-hour shifts.

The ED case managers are responsible for facilitating the patient's hospitalization from pre-admission through discharge from the ED. They manage the care of patients who are treated and released as well as those who are admitted, and monitor inappropriate admissions and admission status.

In addition to working with the ED staff to get the patients moved out, the ED case managers find alternative levels of care, such as rehabilitation centers and skilled nursing homes so that patients who don't meet criteria are not admitted.

The case managers have been trained to evaluate psychiatric patients so patients who are being voluntarily committed can be placed in a psychiatric facility more quickly. Before the case managers were trained, psychiatric patients would stay in the ED for long periods of time until the county mental health representatives arrived to evaluate them.

Clinical admissions liaison nurse

The hospital created the position of clinical admissions liaison nurse to manage all the admissions and transfers coming into the hospital as well as bed placement, and monitors discharges throughout the day on the floors.

"In the past, if the supervisor was busy, there was a delay because the beds became a secondary issue," Stanek says.

The position is staffed by nurses five days a week from 9 a.m. to 9:30 p.m.

"We've worked with the ED staff to identify potential admissions before they are actually admitted. The nurse knows well in advance if someone is going to be admitted and can anticipate what beds will be needed," Stanek says.

For instance, if a patient in the ED has an extensive cardiac history, the nurses can anticipate that he or she will need a telemetry bed.

"The clinical admission liaison nurses work as a team with the ED nurses, physicians, the case managers, and the inpatient units to keep things going," Stanek says.

Now, in some cases, a bed is ready for a patient once the admission order is signed.

As the role expanded, the nurses began monitoring the census in the hospital.

"They observed that problems were arising with direct admits from physician offices. They sent the patients to the admissions department whether or not we had beds or they would send them to the ED even if we did have a bed," Stanek says.

Now the physician offices call the clinical admissions liaison nurse directly and the nurse can speak to the physician to find out the patient status if necessary. If the hospital doesn't have a bed and the patient is stable enough to go home, the nurse suggests that the patient come back later when a bed is available. If the patient is not stable, the patient is referred to the ED for evaluation.

The throughput team works with the housekeeping department so that when a bed is available, the housekeeper calls or pages the admission nurse with the room number.

"It's a manual process. We don't have a bed board but the process works," Stanek says.

The team has a bed meeting every morning to discuss potential discharges.

"We evaluate bed status every eight hours to look at all patients coming into the institution. It's a constant state of flux because patients are admitted and discharged during the day," Stanek says.

The hospital's computerized medical records make it possible for any admissions nurse or supervisor to get the status of a patient in the ED or on the floor.

"They see movement on the floors. The clinical admissions nurses work out of the ED while the supervisors make rounds on the floors and look for potential discharges," Stanek says.

The case management department has worked with the hospitalists to create a set of bridging orders, which cover basic care needed for a patient to be admitted and moved to a bed.

"The order sets are for specific diagnoses when it's better for the patient to get into a bed and the hospitalists can't get down to the ED," Butler says.

About 25% of patients admitted to the hospital are treated by hospitalists.

"As we see more and more people without medical coverage, we have more people who don't have a primary care physician and use the ED for primary care," she says.

The bridging orders are a preprinted set of orders that can be checked off by the ED physician. Patients have waited in the ED for hours until the hospitalist can call in an order.

"We are hoping this will decrease the registration to admission order time. Many times, a patient may be in the ED for several hours until we can get a physician to come in and write an order. We can't assign beds until the order is written," Butler says.

The hospital has created an alert level process that advises staff of the availability of beds. There are four alert levels, 1 through 4, all color-coded on each department's desktop.

Level 1 means that there are sufficient beds to cover the anticipated admissions. Level 4 means that the beds are full and there are not likely to be any free beds for a while. For instance, if the first square is green, it means that the inpatient side has sufficient beds. If the second square is red, that means that the ED is inundated with patients.

"Every department can see immediately where beds are available and where the backups are. To support the throughput process, each department has created interventions that they put in place depending on the latest level. Everybody in the hospital supports throughput," Stanek says.

(For more information, contact Marilyn Butler, RN, MSN, CCM, case management director, Southern Ocean County Hospital, e-mail: