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Team manages bed crunch with systemwide approach
Admission sources analyzed
While many hospitals face the same problem in terms of bed shortages, the solutions to this challenge are as varied as hospitals themselves. Hoag Hospital in Newport Beach, CA, opted to address the problem by forming a Bed Utilization Management (BUM) team that took a systemwide comprehensive approach.
Hoag is a not-for-profit hospital with four centers of excellence including cardiac, OB/GYN, cancer, and orthopedic. "We enjoy a fair amount of success," says Raymond Ricci, MD, emergency department chair at Hoag, noting that the hospital ranks first in Orange County in terms of patient choice and is the market leader in admissions, with 250,000 visits to the hospital and satellites.
"The problem was fairly straightforward," says Ricci. "We had too many patients and not enough beds." In addition, Ricci says the hospital census was increasing by about 6% per year, and the admission rate from the emergency department was increasing at roughly 12% per year. "We also had sicker patients coming to our emergency department," he adds.
In 2001, Hoag had about 70 hours per month of paramedic diversion in the emergency department, compared to 10 or 15 hours a month the year before. That figure represents the number of hours it was closed to paramedics. "This was worrisome," Ricci says. "That was a signal that we were not providing access to the community."
In short, Ricci says Hoag was being bombarded. Patients were coming in from everywhere, including other hospitals, health maintenance organizations, surgery and same-day services, and direct admissions from physicians. "It felt like we were getting hit from all directions," he says.
When hospitals fail to manage patients properly, patients in the emergency care waiting area often leave, Ricci notes. "When we close to paramedics, our patients go to other hospitals," he adds. "That does not make patients happy, and that does not make physicians happy." In addition, surgeries are postponed and the staff are overwhelmed. "They are unhappy and dissatisfied and they want to leave, and that is not a good thing in an era of staffing shortages," he says.
To address this problem, Hoag formed the BUM team with a charter to improve access to the hospital and improve bed utilization and availability. Ricci says the team used a combination of short-term quick fixes that could be implemented immediately and long-term goals and solutions.
According to Ricci, the composition of the team was a key element of its success. It included people from administration, medical staff, the emergency care unit, case management, social services, nursing, admitting, support services, same-day services, and recovery room. "One of the keys to our success is that all these people had a stake in what we were doing," he says.
The BUM team started by analyzing admission sources and space. According to Jackie Jordan, RN, BSN, Hoag’s director of case management, because the overall effort was a complicated process that affected the entire hospital, the BUM team tried to identify certain boundaries. "We tried in a very organized way to look at the process from the time when the physician decides to admit the patient until the time the patient is discharged," she reports.
For example, if a patient is in critical care and must be moved to medical surgery, a bed must be ready, transportation must be available, and the nursing unit must be ready to accept the patient.
Likewise, when a patient is discharged, the physician must make rounds, the discharge order must be written, and a destination must be secured. "Once the patient is discharged, you have to turn the bed around and start the process all over again," she adds.
According to Jordan, the BUM team felt it required some measures of how bad the problem really was. "We didn’t know how many patients were being blocked from admission or how long it took to turn over a bed," she explains. "We needed to spend some time putting metrics to the process."
One of the first things the BUM team did was send a group to Virginia Mason Medical Center, a hospital in Seattle that had undergone a bed shortage situation several years before when a nearby hospital closed. "They were running at 99% capacity every day," says Jordan.
To address the problem, Virginia Mason established an operation center made up of a centralized area with admitting support services and supervisor. "It was very organized," Jordan reports. "It really made you feel like you had a pulse on what was going on in the [hospital]."
Virginia Mason also designated an access nurse to facilitate patient admission, transfer, and discharge. Because the hospital received many surgical admissions from outside the state, it had to stay on top of who was being admitted and discharged, she adds.
In addition, Virginia Mason established weekly meetings with managers, supervisors, and charge nurses from all departments in the hospital to address the bed shortage.
Hoag had its own formidable set of challenges. For example, the hospital experienced up to 150 bed cleanings a day, depending on the number of admissions, discharges, and transfers. In terms of bed utilization efficiency, Jordan says the BUM team came up with several issues that it wanted to focus on.
One key issue was patient flow. "We felt that we needed something to help with patient flow and bed control," says Jordan. That meant establishing an infrastructure that did not then exist, along with a centralized communications system. "We wanted to engage our physicians in helping us with utilization and discharge because they help move the patients," she adds. "We can’t do it without them."
The BUM team initiated a bed-cleaning tour, which meant helping support service staff clean the room, turn the beds over, move the equipment, and report to the nursing station. "We found a lot of opportunity by going out and really learning the process," Jordan says. "Unless you go out there and do it, you really don’t have an appreciation."
Team pinpointed communication problems
The BUM team also sent out surveys to the medical staff, nursing staff, and various other departments. One problem that surfaced was multiple phone calls to find out the bed status. Jordan says that was due largely to the bed board, which was a manual system with magnets. "It is the only place in the house that tells you what the house really looks like, and you have to physically come down and look at it," she explains.
The BUM team also realized it had to establish a communications infrastructure to connect all the departments. In the short term, the team employed some quick fixes, such as revising the bed placement guidelines. "Nursing directors helped prioritize who should get in a bed first in various scenarios," says Jordan. "We also made sure we had daily charge nurse case manager rounds to ensure strong communication about discharge."
The BUM team also developed a patient discharge brochure and advertised an 11:00 a.m. discharge policy along with a lunch-to-go program designed to encourage patients to leave on time.
Hoag also initiated a daily bed status report, which was an e-mail sent to about 50 people at 6:00 a.m. and 6:00 p.m. "In a very quick way, it tells you the unit, the census, available beds, discharges out or transfers, admits, surgeries, any in the emergency room," she explains. "It is a very quick and easy way to get a picture of the house, and it is communicated and updated twice a day."
According to Jordan, one of the challenges was to get everybody to focus on the entire hospital and realize they are part of a bigger picture. She says the BUM team focused on communications to physicians with specifics on how they could help, such as by using urgent care centers instead of the emergency department when appropriate, making early rounds, and initiating early discharge planning.
"You can write discharge orders the day before so if the patient is stable the nurse can discharge them the next day instead of waiting for the doctor to come in to write the order," she says.
The BUM team also made a presentation at the general staff meeting, which about half the 800 physicians attended, and reinforced the 11:00 a.m. discharge with physicians.
In addition, the team added something called the Triad, which was made up of the house supervisor, the admitting supervisor, and the manager of support services. "They came together as a team and really helped troubleshoot at the bed board," she reports. That group met weekly to address issues and work together on a daily basis.
Eventually, the BUM team implemented an automated bed cleaning and tracking system. "We felt we needed centralized viewing of what beds are dirty, what needed to be cleaned, and the status," says Jordan.
According to Jordan, it has been a challenge to employ that system because volunteers, nurses, and support staff all use it. She says there is currently 40% to 50% compliance, but the goal is 80% or 90%. "We are turning beds over faster," she reports. "There are fewer phone calls and there is less frustration."
Hoag then established a utilization medical director who implemented physician profiles, beginning with internal medicine. The risk-adjusted profiles give physicians feedback about high-volume patients, their length of stay, and their charges, Jordan says.
According to Jordan, managing admit-to-observation is an ongoing challenge. Because it often is difficult to get physicians to write admit-to-observations, the utilization medical director sent out a communication on that subject. The BUM team also has an order set including samples of diagnoses that facilitate this process.
Another idea the utilization medical director came up with was a continuing care liaison. Jordan says the manager of social services now is designing a continuing care liaison pilot program. Hoag does not own its own home care, but it made four agencies part of its outpatient development team. "Our goal is to increase the confidence of the physicians in using home care," she explains. In addition to patient surveys, the team surveys physicians about home care utilization.
Fast-track system revised
According to Ricci, because space continued to be a major obstacle, Hoag also revised its emergency care fast-track system. "What we used to do is mix our fast-track patients with medical patients because all the beds were the same," he says. However, the BUM team realized that the fast-track patients’ turnaround time could be reduced to the two- to three-hour range, and if four or five beds were put aside, the hospital could take 30% of its population in the emergency care unit and turn them around in 45 minutes. That boosted capacity in the emergency department, he says.
Hoag also created an emergency care admit nurse position. Since there was no additional space, the hospital brought the nurse to the emergency care unit, and that helped free up the emergency care nurses from doing all the admissions paperwork, he says. It also helped free up the receiving nurse from some of that paperwork. "This was a win-win and increased our virtual capacity in the emergency care unit and up on the floor," says Ricci.
According to Ricci, measurements and goals were critical to the process. "We needed to know where we were [in order] to figure out where we needed to go," he asserts. Ideally, he says, the BUM team wanted to know how it was doing on a moment-to-moment basis.
The outcomes were broken down into categories such as operational emergency care unit capacity, bed tracking, utilization and discharge, and patient satisfaction. Ricci says the BUM team realized the only thing it could control in terms of the number of patients coming to the hospital was elective surgeries. A forecasting model was developed that estimated the number of elective surgeries, and these data were used to help influence hospital administration in this area.
Since the BUM team was established, Ricci says the emergency care unit volume has been trending up, but the transaction time is flat or diminishing. That is considered an important measure of efficiency, and in this case, an improvement, he adds.
According to Ricci, paramedic diversions essentially were eliminated. The BUM team also implemented an Emergency Saturation Triage, known as a "Code EST," that was used to get everybody’s attention regarding bed availability. This is used only when there are patients in the emergency room waiting to be admitted.
Jordan says results were shared with stakeholders to show them how it benefited them. "It was important to have high-level sponsorship," she says. As a result, the CEO was invited to the first meeting, along with the chief of staff. "You could not get more high-level support than that," she asserts. "It really sends a message."