Hospital enhances patient placement with switch in bed control oversight

Preadmit tracking, electronic bed board system are key

Improvements in communication and placement strategies gained by moving bed management oversight from the admitting department to nursing are facilitating patient throughput at Wake Forest University Baptist Medical Center, says Jonathan Morris, RN, bed management coordinator for the Winston-Salem, NC, facility.

A new preadmit tracking and electronic bed board system has greatly enhanced the process, adds Morris, who was hired as a "bed czar" in May 2003, in part to bring that system into being. (See screen page.) The gradual implementation of the system, completed in November 2005, has enabled the medical center to consistently meet its goal of assigning a "clean, ready bed" to 96% of unscheduled patients in less than two hours, he notes. (See graphs below.)

"When we started collecting that data — how long it took from a request to the point we were able to assign a clean bed — [that percentage] was in the mid to upper 80s," Morris says. The improvement happened even before full implementation was achieved in November, he says, because his staff began using the new computer program "a few steps at a time" in December 2004 while still handling bed requests over the telephone.

"We did a pilot using the post-anesthesia care unit [PACU] and two nursing units — one medical and one surgical," Morris explains. "We used that pilot to look at each step in the process — "right click here, left click there" — so we would know how to take the request from the PACU and the best way to funnel it to the receiving unit."

While using the new computerized system "to the [highest] degree possible, we were still taking requests by phone," he adds. "As we turned around and called the units, we were also pretending we were doing [the same steps] in the system, so we could look at any glitches."

The idea, Morris says, was for his staff to fine tune the process before beginning to train other nursing personnel. "We looked at, 'Who will do what? What will my staff do? Do we have the information we need without talking to someone? Is there a step we missed or is this an interface issue?' We did that for a couple of months before bringing up [other units]."

Before he assumed the bed coordinator role and the tracking system was implemented, Morris says, "bed control for this 821-bed inpatient facility was strictly pieces of paper." A month after he came on board, an admissions nurse who reported to him was hired, he adds, and a little more than a year later, in July 2004, bed control officially was moved out of admitting and into nursing.

The location of the bed management area — next to admitting — stayed the same, "but the reporting structure and focus has changed," Morris notes. The idea behind the switch, he says, was that a nurse would be more adept at the process, from the perspective of triage and level of care.

Changes in status to a higher or lower level of care — both at the beginning and during an inpatient stay — happen more quickly and easily because of the increased clinical focus, Morris says. "Before, we might have beds in some locations that would not be used because it was ingrained in the workflow of the [previous bed control employees] that this was a hands-off area."

In some instances, however, it is appropriate to use oncology or cardiac beds for patients coming from the ED, he says, and employees with a clinical focus are more comfortable making those exceptions.

"With oncology [bed occupancy], there typically are peaks and valleys," Morris notes. "A lot are scheduled, and you can almost predict [the number of beds] you will need."

Bed management staff with clinical training also are aware of any medical implications — the kinds of non-oncology patients who are appropriate to place on an oncology unit, for example.

"Prior to me and some other clinicians coming in, the thought process wasn't there. It was, 'I can't go into that unit — I have to make the patient wait.' They were pretty much black and white, and health care [decisions are] so gray. You have to think."

While the majority of his staff are still non-clinical, Morris adds, "we've worked hard on educating them, explaining the thought process behind why we do what we do. There is a lot of open dialogue."

Bed management staff are now better able to communicate with the hospital's nursing units, he says, and, if necessary, obtain reports from outside facilities to better enable patient placement, although that function is typically handled by nursing.

Another benefit of the increased clinical focus, Morris says, is that nurses are able to "proactively communicate with physicians as to why we're doing what we're doing, to alleviate any backlash from the medical staff."

In the past, physicians often suspected that their patients couldn't get to a unit because nurses were "hiding" beds until the next shift, he adds. "It's practically impossible now to hide a bed with the systems we have in place, because they're all connected."

As for feedback from physicians on the improved process, he ascribes to the no-news-is-good-news theory, Morris adds. "To me, a positive [reaction] from a physician is not hearing a negative. When I first took this role, there were a number of complaints — not only to nursing administration but to hospital administration — about patients being scattered on different units and about bed crunch issues. There has been a decrease in that."

General medicine practitioners, in particular, he says, had complained about their patients being spread out on multiple units, while cardiologists contended that there were "too many non-cardiac patients using [cardiac beds] for telemetry."

In response to those concerns, the department developed algorithms to establish "cluster units" — grouping surgical units and medical units based on medical specialty, Morris says. "There were slight algorithms in place before, but they were not as intense."

To further address the situation, the hospital has added more telemetry beds on the medical units, he says. Not having to move a patient to another bed at the same level of care to free up a telemetry bed — for another patient who may be waiting in the ED — saves valuable time and improves patient flow, Morris notes.

Real-time viewing

With the preadmit tracking system and electronic bed board, he says, staff are "able to visualize every single unit and every bed in real time — whether it's clean, dirty, occupied — and it's all done through interface activity with our main frame."

That "biggest improvement" has resulted in many other improvements, Morris notes, including the ability to "time stamp" to determine where backups are occurring and to do process-time analysis with the ED and the neonatal intensive care unit [NICU] to determine "how we're doing from a patient flow and patient throughput standpoint."

The sequence of events, he explains, is as follows: "We electronically page the nursing unit and funnel a request, and they have a 10-minute time frame to assign a bed. When they assign the bed, the requesting unit or area will be notified by electronic page that the bed has been found, and will see in real time if the bed is clean or dirty, waiting to be cleaned."

The process has "truly eliminated all of the telephone tag and the 'he said, she said'" conversations about assigning blame, Morris says. "This puts everybody on a whole new honor system."

The bed management department has four other registered nurses in addition to Morris, he says, as well as 13 clerical employees, some full time and some part time. "We operate 24-7 — we don't close down and let the ED take over [after hours]."

There was also 24-7 coverage when the function was overseen by the admitting department, Morris notes, but while day shift employees were designated for bed management, after-hours staff performed other admitting functions in addition to bed control.

When the switch was made, he adds, the number of full-time-equivalents (FTEs) that had been allocated to the admitting department for bed control were shifted to his department. Another 1.7 FTEs were added, Morris notes, to make up for the after-hours employees, who remained in admitting.

There was some resistance to giving up control of the function from admitting employees who had worked in bed management for many years — for a manager to whom they were very devoted, says Keith Weatherman, CAM, MHA, associate director for patient financial services. "Traditionally, bed control has been a part of admitting, and it was hard for them to give that up. We had a lot of meetings and got their buy-in."

During the same period, the admitting department was in the process of assuming responsibility for three outpatient clinics, he notes, which opened up new job possibilities for those employees.

With some of the experienced bed management employees moving into clinic positions, Weatherman adds, it became even more important for the admitting manager to work closely with new bed management staff during the transition.

"The nursing staff that came on board had to learn the admission/transfer/discharge [ADT] system, how to do transfers and assign beds in the computer, and perform some census [functions] at night," he say. "It was not a clean break. [Admitting personnel] were involved in the process from the time it began in July 2004 until November 2004."

In addition to the benefit of enhanced clinical communications, Weatherman points out, the change in bed management oversight is appropriate because of changes over the years in the way hospitals do business.

"At one time, bed management needed to be in patient access because there were rate differences for private rooms," he says. "Years ago, Medicare reimbursement was for a semi-private rate. [Finance staff] might have to collect the difference from a patient who wanted a private room or, if the person was put in a private room because a [semi-private room] was not available, they would have to do a write-off. Now, with a predominant room rate and reimbursement according to diagnosis-related groups, it's a whole different ballgame."

Some hospitals have moved not only bed management but the entire access department under nursing, Weatherman notes, which he believes "hurts on the finance side. It doesn't have to be all or nothing."

A side benefit of the Wake Forest reorganization for him personally has been the removal of bed control-related issues from his department's jurisdiction, he says. "Before, there were phone calls that I — and even the director and CFO — would get that were about bed control questions. Now we can concentrate on patient access, patient finance, AR [accounts receivable] issues."

Transport tracking is another feature of the bed management software suite, which is a product of Pittsburgh-based Teletracking Technologies, he notes. This tracking device for medical center transporters — who wheel patients down to the discharge area, for example, or to radiology for a scan — interfaces with the bed tracking and preadmit tracking/electronic bed board functions, Morris says.

"[Transporters] get a page from the response center giving them a number to call," he explains. "They dial in and get a computerized message saying, for example, 'Room so and so needs discharge with a cart.'" The system, Morris adds, automatically locates the closest idle transporter.

The transporter accepts the job by dialing into the system, he says, which logs in the transporter and tracks his or her time and productivity.

When the transporter is ready to leave the unit with the patient, he uses the house telephone or the phone in the patient's room to call in and report that he is in progress, Morris says. "If it's a discharge, the system flags that bed as dirty, and we automatically see it. Before, we were solely dependent on nursing to send down the information to us."

In the past, it was not uncommon to get notice of a discharge "two or three hours after a patient had left the building," he notes. "When the shift ended, [unit nurses] would put in all of the discharges, and the next shift would get hit [with handling them].

To ensure that the system continues to run smoothly, he follows up regularly with unit managers and directors, Morris says, to make sure that unit secretaries and staff are actually putting the pending and confirmed discharges into the system.

"It's a wonderful system, but it is a computer," he points out. "It's only as good as its users."

(Editor's note: Jonathan Morris can be reached at jomorris@wfubmc.edu. Keith Weatherman can be reached at kweather@wfubmc.edu.)