Observation status has been under the radar for a while, and with the two-midnight rule in full force, getting patients to the right place on a ward or discharged appropriately has taken on new urgency. Excela Health in Greensburg, PA, took observation wait times of as long as 30 hours and cut them by a third on average, saving the system a million dollars in the first year alone.
"We were losing money, spending more the longer they stayed," says Eric Kreinbrook, RN, MSN, currently the patient information manager, but then the clinical nurse coordinator for the observation unit. "We had 44% of our times in the unit greater than 23 hours, and 23% were greater than 36 at one of the hospitals." That hospital was Latrobe, the site of what would become a big and ultimately successful experiment.
The quality improvement team decided to tackle the problem by bringing together every single person who touched the patient to meet with nursing, administration, and the chief medical officer. The team included housekeeping, emergency department staff, radiology — anyone who ever came into contact with an observation patient attended meetings at one point or another, says Kreinbrook. Eventually, a core group of main stakeholders formed around the key issues, but people were brought in as needed to talk about issues as they arose.
"We figured out pretty quickly that the biggest problem was that no one had ownership of observation status. Nurses paid attention to patients who were the sickest. So we created a stand-alone observation unit at Latrobe Hospital, where nurses were trained specifically for observations patients. Those patients were their patients," he says.
The unit is an open unit, meaning anyone in the hospital can admit to the observation unit, while many facilities have a closed unit, to which only ED physicians can admit.
The new unit was originally housed within the ED itself, but because both that department and the obs unit had a greater need of beds than the two units had in the single space, they opted to move out of the ED and house the obs unit elsewhere in the hospital.
It took two months to plan the observation unit opening, and it went pretty smoothly, although Kreinbrook says having an open unit is stressful: It can be hard to track down physicians. "If there is a 16-hour discharge goal, then for patients who are over 18 hours, we call the physician and ask for the discharge plan. But when there are so many physicians in the mix, it can be harder to get ahold of the right one."
At 18 hours, every patient has a time out. There is a tracking form for each patient clipboard, with the discharge goal, stress test results, and 18-hour proactive discharge steps. At the time out, if there is no discharge plan on the clipboard, the physician is contacted, and if the doctor is unavailable, that is escalated to the assistant or chief medical officer. "We also set it up with cardiology that they have an hour to call in results to us after stress tests."
For any testing, observation is third in line, after emergent and stat testing. A HIPAA-compliant white board that includes the patient room number, nurse, testing, patient initials and the discharge goal is visible to everyone. This helps keep everyone on track, Kreinbrook says. "We also have the physicians put the discharges in a planned state, stating that if the testing comes back negative, the patient will be discharged to follow up with his or her primary care physician. All of that is done up front."
There is dedicated case management, so that the patient is put in the right unit from the start. Patients are not put in the observation unit unless that’s where they should be, nor are they admitted unless they should be. "We have a 13% conversion rate, which has been very consistent, and that’s because our patients are in the right place from the start," he says.
The observation training of nurses was a key factor in the success, he says. "There is a difference we could see when people were off or we had nurses fill in from other units. They didn’t explain to the patient what observation was for, that the goal is to get you home in less than a day. That mindset of not giving you everything that inpatients get because you are not an inpatient, that we want you to go to sleep, and then have a stress test first thing in the morning and then go home — they didn’t get that."
Physicians who have patients over 23 hours in observation get letters from the chief medical officer asking them to explain why. They also have a letter put in their recredentialing file. If there was a full admission recommended and they put the patient in observation, they also have a letter put in their file. On the flip side, Kreinbrook says physicians are rewarded for doing a good job with praise and recognition.
The hospital isn’t a good place to be, he says. "[Patients] are exposed to germs, they spend time in bed and lose strength. Being out of the hospital fast is healthier for them. We want to get them back to their life."
More of the patient base was younger than one might think — ruling out acute things — and Kreinbrook says helping give those patients quick peace of mind, rather than having them linger for hours wondering, is good in too many ways to count: patient health, provider morale, wasted resources saved, mom’s not worrying. The list goes on.
"I think this is essential," he says of the observation unit changes they made. "If you come to that unit, you are on the clock. We even had different color chart packs for them. We were green. If you see the green chart in radiology, you knew, it was on the clock. This patient skipped the line. If you were housekeeping, you knew, if the bed was empty, you cleaned it."
There are weekly meetings on Fridays where every case over 23 hours was reviewed, then eventually, any case over 20 hours.
At the meetings, when the longer cases were discussed, the core team members tracked problems for trends, and if a particular department was an issue, that department was called, and problems were solved. "Minor failures are all okay. We ask how we can make something better. We reach for the greater goal."
For more information on this topic, contact Eric Kreinbrook, RN, BSN, Patient Information Manager, Excela Health, Greensburg, PA. [email protected].
