Discharge Planning Advisor

Letting go of the that’s not how we do it here’ mindset

System takes flexible approach to enhance flow

When it comes to discharge planning and other health care challenges, "don’t be afraid to rock the boat," advises Jonathan Morris, RN, bed management coordinator at Wake Forest University (WFU) Baptist Medical Center in Winston-Salem, NC.

"Part of the problem at many hospitals is they get locked into that’s not how we do it here,’" adds Morris, whose background is in nursing and case management. Resist falling into that routine, he says, by asking, "Is there a better way? Is there something else we can do?"

When it comes to patient throughput and bed management solutions, Morris notes, that might mean letting go of the "discharge at 11" mindset, for example, or being flexible about using specialty beds for general medicine patients when appropriate.

"We try to look at evidence-based research practice," he says, "and we’re constantly looking at other facilities to see what initiatives they’ve put into place."

Surveyors with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognized WFU Baptist Medical Center for its own patient flow and bed management initiatives, Morris says, suggesting on a recent visit that the facility submit the program for a JCAHO award that honors best practices in different areas of health care.

Those patient throughput initiatives have included, among other things, a new pre-admit tracking and electronic bed board system, a change in bed management oversight, and the creation of an emergency department (ED) holding unit that has been successful in reducing the percentage of patients who leave without being seen (LWOS).

The 10-bed holding unit was initiated at the end of 2003, Morris explains, to improve ED throughput by accommodating patients who are still being screened for various conditions or who are waiting for inpatient beds.

The unit is designed for patients awaiting a clinical decision or "rule out," he says. "We don’t put higher-level-of-care patients in there.

"It’s hard to say what helped the most, between [the holding unit] and coming on the pre-admit tracking board, but [the ED] is now below the national average for percentage of patients who leave without being seen, Morris says. Formerly between 4% and 6%, he adds, the hospital’s LWOS rate now is 2% or below.

Gradual implementation

The gradual implementation of the pre-admit tracking and electronic bed board system, completed last November, 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, notes Morris, who was hired as a "bed czar" in May 2003, in part to bring that system into being.

"When we started collecting that data — how long it took from request to the point we were able to assign a clean bed — [that percentage] was in the mid-to-upper 80s," he says. The improvement happened even before full implementation was achieved in November 2005, Morris 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," he 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.

Bed management

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, he says. "Before, we might have beds in some locations that would not be used because it was ingrained in the work flow 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 nononcology patients who are appropriate to place on an oncology unit, for example.

Increased clinical focus

"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," Morris says.

While the majority of his staff still are nonclinical, he 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 now are better able to communicate with the hospital’s nursing units, he says, and, if necessary, obtain reports from outside facilities to better facilitate patient placement, although that function typically is 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 noncardiac 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."

Other improvements

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.

With the pre-admit 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 mainframe."

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 RNs 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]."

Transport tracking

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.

Transport tracking is another feature of the bed management software "suite," 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, Morris says, which logs in the transporter and tracks his or her time and productivity.

Following up

When the transporter is ready to leave the unit with the patient, he or she 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," Morris 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."

[Jonathan Morris, RN, can be reached at jomorris@wfubmc.edu.]