Tracking delays cuts LOS, improves patient flow

More discharges take place in the morning

A process that tracks delays in service at Calvert Memorial Hospital in Prince Frederick, MD, has improved patient flow by ensuring that tests and procedures occur in a timely manner.

"We've seen some drop-off in length of stay, in terms of hours since we began the process. Our length of stay has always been relatively low, running between 3.4 and 3.5 days. What I have seen since we started this initiative is that our systems are running better. We are identifying breaks in the system and working on ways to improve them," says Jennifer Stinson, RN, BSN, CCM, director of case management.

Since the initiative began in mid-2005, the hospital has increased the percentage of patients discharged in the mornings from 15% to 35%.

"To me, the fact that the initiative shows an increase in discharges earlier in the day means that our systems are working better," Stinson says.

Case managers have the primary responsibility for collecting and reporting delays of service.

"The case management team reviews every patient every day. This puts them in a position to see that everything that needs to be done is done and allows them to identify system failures in the hospital," Stinson says.

The hospital's case managers fill out delay-in-service forms, which they turn in to the risk management office. The risk management office forwards the delay in service forms to the responsible department, which has 48 hours to respond. The risk manager enters the reports and the responses of the department heads into the computer.

"We send them to nursing, laboratory, case management, the medical staff. Any time there has been a break in a patient receiving service in a timely manner, we note it and forward it on for a response," Stinson says.

The case managers have copies of the delay in service forms with them at all times. In addition, there is a supply on all nursing units and any staff member can fill it out and send it to the case management department.

"It's a user-friendly form that takes only a minute. The staff fill out what department may be responsible for the delay and writes a note and that's it," Stinson says.

Risk management tracks the incidents and analyzes them to look for trends, printing out trend reports every month.

"The initiative allows department managers to keep trending down and keep drilling down to get to the problem. It won't go away on its own but will keep showing up month after month," she says.

Each department head gets a copy of the individual forms and data showing trends.

"Some departments have never had a trend. We're a small hospital. A trend could be just five incidents," she says.

Some departments have had only one incident of a delay occur and it's never happened again because the department head took care of it with education. For instance, if there is a delay in a case management task that continues over a month, Stinson looks at the incident as an opportunity for education for the entire case management staff.

"The delay in service initiative is not used to telling departments that they have to do things a different way. It's to show us what is broken, and sometimes we don't know exactly what is broken until we look at the trends," she says.

Staffing increases

Department heads have been able to use the delay in service trends as a way to justify an increase in staff.

"A lot of the time, we knew there was a problem but were having a hard time getting the data to demonstrate that there is a problem and exactly what the problem is," she says.

When trends are identified, a multidisciplinary team examines the trends and looks for ways to reverse them.

The department heads have 48 hours to respond to the delay in service reports.

For instance, when the initiative began, the case managers became aware that blood draws that were ordered for the morning were often getting done later in the day and the results were not back in time for the patient to be discharged that day.

At Calvert Memorial Hospital, the nursing staff works two shifts — 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.

The blood draws are the responsibility of the nurses on the morning shift. If they couldn't complete the blood draws, they left the task for the day shift nurses, who often were involved in other matters early in the morning. When the physicians came on the floor in the mornings, looking for lab results, they found that the results were not available because the blood draws hadn't been done.

Now when the morning shift nurses cannot complete a blood draw, they put the orders in a telephone caddy, which is picked up by the lab transporter, who also is a phlebotomist.

The phlebotomist does the lab draws that haven't been done, ensuring that the lab can get the results back in a timely manner.

"It works great. We no longer have delays for that reason. The labs are drawn, the doctor is notified early in the morning, and discharge is not being delayed because we are waiting on lab results," Stinson says.

Within 30 days of identifying the trend in delayed blood draws, the team had come up with the idea of having the phlebotomist perform whatever draws had not been done.

"We saw the trends and broke it down to where the problem was, then fixed it," she says.

Another initiative involved making sure that the Foley catheters are removed as quickly as possible following orthopedic surgery.

"We were finding out that on the day the patients were ready for discharge, the catheters were still in. Instead of discharging them on the morning of Day 2 or 3, we had to pull the Foley and keep the patients until they could void. Instead of a 10 a.m. discharge, the patients might stay until 3 p.m. or 4 p.m.," Stinson says.

The team revised the order sets for orthopedic patients, adding the order to remove the Foley catheter at the same time the nurses disconnect the PCA pump for pain control and discontinue IV fluids. The risk management department tracks the trends for the system.

Changing the order sets to include removing the Foley catheters took around two months because the physician staff had to be involved.

"In the meantime, we made everyone aware of it and alerted them to get the Foleys out in a timely manner," Stinson says.

The case managers began looking at the order sets first thing in the morning to make sure everything was being completed.

The hospital has 13 case managers who are assigned by physician. The average caseload is 12 to 15 patients at a time.

The case managers are responsible for utilization review, discharge planning, clinical documentation improvement, teaching, monitoring core measures, and other quality initiatives. The staff works six days a week and is on call on Sunday.

(For more information, contact: Jennifer Stinson, RN, BSN, CCM, jstinson@cmhlink.org.)