Care starts on arrival with centralized admissions area at Elmhurst Memorial

Assessment, initial testing done before patient goes to nursing unit

A centralized admissions area (CAA) at Elmhurst (IL) Memorial Healthcare handles much of the workups and assessments that unit nurses typically do, minimizing treatment delays and enhancing patient throughput.

Patients who go through the CAA arrive on the nursing unit having received a complete evaluation, with lab work and tests done and antibiotics and pain medication ordered, says Matthew J. Lambert III, MD, MBA, FACS, FACHE, senior vice president, clinical operations.

The CAA is one of several Elmhurst Memorial initiatives prompted by a hospital-wide operations improvement program that began several years ago, adds Lambert, who oversees the program along with the chief financial officer and director of process redesign.

"We spent about a year in the non-clinical areas and the last two-and-a-half years in clinical areas," he says. "We identified a lot of problems with interdepartmental communication. Every department was doing an excellent job, but they were not cognizant of, or sensitive to, the demands they were putting on other departments. They were optimizing their own particular enterprise."

As is true of many hospitals, Lambert says, "there were areas where patients that needed to be admitted to the hospital were sort of stuck."

More than 50% of admissions come through the emergency department, where patients are often hung up waiting for beds, he says. While Elmhurst Memorial is an older hospital with capacity constraints, Lambert notes, conversations with nurses indicated there was another reason for the long wait.

"We found out that there was a reluctance to accept new admissions related to the amount of work involved," he says, "so there was a lack of cooperation [from nurses], a passive-aggressive attitude."

As the operations improvement team investigated further, Lambert continues, they realized that just streamlining the ED process would not solve the problem. "Patients would just wait longer — getting to the floor faster did not mean getting care faster."

"We also found that admissions and discharges peaked at the same time — between noon and 3 p.m. — as physicians come in later in the morning to discharge patients," he adds. "We realized we had to fix everything, not just one thing."

The CAA originally was designed to address direct admissions, Lambert says. "Patients directly admitted from the physician's office or by phone would wind up on the unit without orders because the physician hadn't sent them. They would be languishing up there and [hospital staff] couldn't get hold of the physician."

Even if the orders came, nurses would be busy with something else, he says, "so the patient would be in bed, but nothing was happening. They might not get a meal, or they might not get pain medication for several hours."

To accommodate the five-bed CAA, Lambert says, the hospital designated a space formerly used by physicians to see patients for exams or minor procedures on an outpatient basis.

"We staffed it with a couple of RNs and a couple of technicians," he notes. "We insist that orders come with the patient, and if they don't come, [an access nurse] calls the physician's office and asks [staff] to fax them over."

Patients go through the registration process, which is done at bedside, and the initial orders are completed in the CAA, Lambert says. "We try to get as much done as possible before the patient goes up to the unit."

There are five private treatment rooms in the CAA, he notes, where family members can sit with patients while the initial orders are completed. Patients typically spend about three hours in the CAA, Lambert adds, and once the X-rays, blood work, or other procedures are finished, they go to the nursing unit.

"For the nurses on the floor, [the CAA] has eliminated what, with the documentation that is required, could be a two-hour process," he says.

The CAA's hours of operation initially coincided with physician office hours, but have now been expanded to seven days a week, Lambert says, and the CAA is now picking up a lot of overflow from the ED. "About half the patients [the CAA is] seeing are direct admits, and half are from the ED."

The maximum number of patients seen in the CAA on a given day is in the mid-20s, he adds, which is about half the daily admissions.

The CAA has been a key factor in improving the flow into the hospital, Lambert says. "In the past, it was not unusual for a patient to wait several hours for antibiotics. Now that wait is down to less than an hour."

Two years ago, patients admitted from the ED spent an average of 348 minutes, or 5.8 hours, waiting there before admission, he says. As of June, that wait had been reduced to 234 minutes, or 3.9 hours.

Patient reaction to the CAA has been mixed, Lambert notes. "From those coming from the physician's office, it's positive, but ED patients have a little trouble understanding why they are being moved from one area to another. Some patients assume once they leave the ED they're going to the floor, and that doesn't always happen."

Some patient education is required, he says. "We explain to them that before they go to the room we're going to finish the rest of their testing and procedures, so they won't have to come down again [right away]."

Getting a bed was 'like pulling teeth'

Historically, it was "like pulling teeth to get a reservation" when a registrar called to find a bed for a patient, with unit nurses always saying beds were not ready, notes Cindi Ruffner, manager, registration and scheduling.

Now access nurses — who have been in place about five years, three years before the CAA was established — take reservations from physicians and arrange for bed placement, among other functions, Ruffner says.

Their role, according to Sue Prestipino, RN, one of two access nurses, was created from a quality and financial perspective, to make sure patients are placed appropriately according to clinical needs.

The nurses, who report to the quality resource management department, look at whether the patient is under the correct admission status and at the right hospital according to payer guidelines, she says. The main focus, however, is on quality, Prestipino adds. "We were trying to organize the process so that once people arrive, we can expedite them through the system in a timely manner."

The access process

From the access nurse's perspective, she says, the process works as follows: "The physician will call with an admission request. We screen for medical necessity and appropriate placement, and set up an appointment for the patient to come over. We are able to discuss the clinical course, which helps us place them."

Orders are either given verbally by the physician, faxed over, or arrive with the patient, she adds.

For the past year, Prestipino notes, access nurses have handled bed control for the entire hospital, so they take care of that piece as well. "It's a good fit," she says. "Before that, a clerical staff did bed control and [patients] just came when the physician sent them."

The access nurses work with a computerized bed board, Prestipino adds. "We know when there is a discharge, so we know when there is room for them."

"We make the reservation for admission, secure the orders, and when the patient arrives, one of the access nurses meets them in the lobby," she continues.

That step is both a customer service gesture and an opportunity to assess whether or not the patient is able to go through the regular admission process or needs additional help, Prestipino says. "People like to know they're expected."

Then the access nurse takes the patient to the CAA, she adds, noting that all the areas involved — admissions, the access nurse office, and the CAA — are close to each other and to the main entrance of the hospital.

At that point, the CAA staff takes over, doing the assessment, computer work, and any orders that need to be done immediately, Prestipino says. "The goal is to get them in and out in two hours," she notes. "Patients in the CAA have priority in our testing areas."

Access nurses perform a similar function with patients who are being admitted from the ED — reviewing the case and working to find the most appropriate placement, Prestipino says.

If there is an opening in the CAA, she explains, the patient is taken there to complete the process, which is not as lengthy because of the testing that has already been done in the ED. If the CAA is full, Prestipino adds, the patient will go directly to the nursing unit.

"The idea is to maintain a smooth patient flow, and [to avoid] having a lull in care," she says. "The patient is always being treated, always being worked on."

In addition to the CAA being "a big satisfier for nursing staff," it has helped promote good relations with physicians, Prestipino says. "There is also more personal contact with patients, who are reassured that when they come in, somebody knows who they are, why they're there, and we guarantee their safety."

Elmhurst Memorial runs a very high census, as do most of its neighboring hospitals, she notes. One of the indicators of the organization's success with operations improvement, Prestipino suggests, is that the facility has never had to go on hospital-wide bypass. "We feel we're able to manage patient flow because of these processes."

[Editor's note: Matthew Lambert can be reached at Mlamber@emhc.org.]