Throughput measures decrease LOS in ED

CMs take proactive approach to discharges

Despite an increasing number of visits to the emergency department, Nyack (NY) Hospital has been able to meet its standard of 30-minute service 95% of the time and decreased its discharge length of stay in the ED by 35%.

The hospital, part of the New York Presbyterian Healthcare System Inc., received the Compass Award from Press Ganey for its achievements in increasing clinical, operational, and patient satisfaction in the ED.

Although case managers do not routinely cover the ED and are called in for interventions as needed, the department takes a proactive approach to patient throughput, working to free up patient beds and eliminate backups in the ED, says Jennifer Howard, RN, BSN, MHA, CCM, supervisor for clinical resource management at the 375-bed hospital.

"It's not just the emergency room staff who are responsible for our success; it's addressing issues on the back end that makes is possible to move patients through on the front end, and that's where the case managers come in. Our case managers take a big role in addressing all the little roadblocks that delay the patient discharge," she explains.

Department organization

The case management department includes seven full-time RNs and four full-time social workers who work Monday through Friday, along with three part-time RNs. The department employs per diem case managers who work when needed during the week and cover the facility on Saturdays.

The case managers are assigned by unit, according to their expertise and experience. For instance, the two RNs who are case managers on the cardiac unit and cardiac care unit have extensive experience in cardiac care. The nurse and the social worker who staff the oncology unit both have backgrounds in oncology care.

They take a proactive approach to moving patients through the continuum as quickly and safely as possible.

For instance, the case managers in the joint center start the discharge process for total hip replacement and total knee replacement patients when they come in for preoperative testing.

The nurse case manager and social worker meet the patients and educate them on what to expect while they are in the hospital and what they will need to do after discharge.

By seeing the patients before surgery, they are better able to anticipate their discharge needs.

"They give each patient a list of facilities that their insurance company approves for rehabilitation after the procedure. We do everything we can to get the discharge planning process in place before the patient comes in," Howard says.

The hospital's average length of stay for patients who are receiving total knee replacement is two days. Hip replacement patients stay an average of three days.

"The case managers follow them closely to monitor their progress and make sure they are ready for discharge. We try to move patients safely along the continuum of care as quickly as we can," she says.

The case managers carry a caseload of 15-25 patients and review each chart every day.

The case managers round on a daily basis with the treatment team on their unit, assessing every patient as a potential discharge and anticipating what they will need for discharge.

"My department works closely with the nursing manager and supervisors on the unit to make sure that patients get the care they need and are discharged in a timely manner," Howard says.

Howard serves on the bed rounds team along with the chief medical officer, the director of nursing or the chief nursing officer, the ED manager and assistant manager or the medical director of the ED, the admitting manager, the bed control manager, and the housekeeping manager.

The team meets at least once each day to look at hospital capacity, admissions, anticipated discharges, other potential discharges, and how patient flow needs to occur, Howard says. On days when there are capacity issues, the team meets for a second time.

"We look at what beds are available, what surgical patients will need beds, how many patients there are in the emergency department, and what discharges are anticipated. We look at what patients we can safely discharge and which ones we can't," she says.

For instance, the team determines which patients could be transferred from the telemetry unit, the surgical ICU, or medical ICU to free up those beds for patients coming out of surgery or through the ED. They look at what beds are available and clean for those patients and those that might be free later in the day.

"We rely heavily on nurses on the unit to let us know if they've moved patients onto the unit," Howard says.

When the ED department is experiencing a high volume, it issues a "Code 30" alert through overhead pages that signal the rest of the hospital and alert the staff to take proactive steps to discharge patients and free up beds.

"When the case managers know there is a Code 30 in effect, we know we should start looking for beds. The case managers are very attuned to patient flow. They start going through their lists of patients to see who can be discharged that day," she says.

Faced with patient complaints about unacceptable times in the ED, the hospital used Lean Six Sigma techniques to redefine patient flow. The biggest change they came up with was to eliminate the old triage process and to move bed control to the ED.

Now, when patients come into the ED, they are met by a "meeter-greeter" who shows the patient to a cubicle with a bed and calls in the triage nurse. Triage and registration both occur in the cubicle, Howard says.

During peak hours, the ED is staffed by three triage nurses, she adds.

Patients are then placed in a bed in the appropriate treatment area, such as the cardiac area, the trauma area, or the general treatment area. The hospital has created an ED Express Care section for people with minor problems, such as sprains or lacerations that need stitches. The area is staffed by a nurse.

The ED staff call in the case managers to coordinate placement for patients who do not meet inpatient admission criteria but who cannot be discharged home.

Many of the interventions are for patients who need a psychiatric admission rather than an admission to the acute care hospital.

Case managers also are called in to manage the care for Medicare patients who don't meet inpatient criteria but who need custodial care. They work to get them admitted to the local long-term acute care hospital.