Patient Flow Initiative Eliminates Barriers to Discharge
Proactive discharge planning was a key
EXECUTIVE SUMMARY
When Intermountain Medical Center in Murray, UT, reached capacity a few months after opening, a year-long initiative on patient flow determined that part of the holdup was taking care of last-minute details.
- Each unit holds a multidisciplinary care coordination meeting every day to discuss each patient and what they need to go to the next level of care.
- The team sets an anticipated discharge date during the first meeting, giving everyone on the team a target for carrying out their responsibilities.
- The unit charge nurse chairs the meetings and ensures team members carry out their responsibilities for moving the patient toward discharge.
When patient volume at Intermountain Medical Center reached capacity a few months after the hospital opened, the leadership at the 452-bed teaching hospital knew they had to find new ways to transition patients through the hospital.
As a result of a comprehensive year-long project to improve patient flow, the hospital reduced its severity-adjusted average length of stay by 6.78 hours across all service lines and created approximately 21 “virtual” beds, says Lisa Graydon, RN, MBA, chief nursing officer for Intermountain Healthcare’s Central Region.
The patient volume at Intermountain Medical Center reached capacity a few months after the 452-bed teaching hospital opened, Graydon says. The medical center, the flagship hospital of the 22-hospital Intermountain Healthcare system, opened in 2007. The hospital leadership expected the 54-bed ED at the Level 1 trauma center to see about 180 patients in 24 hours, but well over 230 patients were being treated.
Working with a consulting firm, the hospital began an initiative to improve patient flow in 2008. It took about a year for multidisciplinary teams to analyze the hospital processes and come up with improvements, Graydon says.
The effort started with analyzing how patients were transitioned from all points of entry, including the ED, the operating room, and the catheterization lab.
Using data from the hospital’s electronic medical record and the admit, discharge, and transfer system, the team conducted time studies of the hospital’s processes that involved patient throughput. For instance, they measured the time it took from the time the admission orders were issued until patients were in a bed; how long it took to transfer patients from one unit to another; how long it took for housekeeping to turn over rooms; and how much time elapsed from the time the discharge order was written until patients were out the door. “We looked at hundreds of metrics to determine where the bottlenecks occurred, what caused them, and what we needed to improve,” she says.
The analysis showed that one of the barriers occurred when patients were being discharged or transferred to another facility because some of the arrangements didn’t happen until the last minute.
“We found that we weren’t always putting all the pieces together and designating who was responsible for what. The transition time arrived and there were still last-minute details to manage,” Graydon says.
“We knew that planning for the discharge had to begin on day one. If we know where the patients are going from the moment of admission, we can ensure that patients get the right care at the right time in the right place,” she adds.
Members of the patient flow team included hospital leadership, physicians, nurses, case managers, therapists, and representatives from environmental services.
The team collaborated with the discharge planners, case managers, and social workers on their process and opportunities for improvement. One of the first changes was to combine utilization review and discharge planning responsibilities under a unit-based case manager, Graydon says.
The hospital instituted care coordination meetings seven days a week on every inpatient nursing unit. During the short meetings, the entire interdisciplinary team discusses each patient, their anticipated discharge date, and barriers to their discharge or transition to another level of care.
The team talks about what needs to happen before discharge and the appropriate discipline takes responsibility for ensuring it takes place. The unit charge nurse facilitates the meeting and makes sure the discharge needs are met.
“In the past, we were not anticipating the needs until the last minute, but a lot of discharge needs can be taken care of early in the stay. We don’t have to wait until the last minute to arrange oxygen or to make sure the patient will have a ride home,” she says.
The team set a goal of having patients discharged within two hours after the discharge orders are written. At present, 36% of discharge orders are written by 10 a.m. and 50% of those patients are discharged within two hours of the orders being written, Graydon says.
When patients are admitted to the unit, the physician and the rest of the team decide on an anticipated discharge date, which gives them a goal to work toward. The team documents an anticipated discharge date within 24 hours 93% of the time, Graydon says.
At Intermountain Medical Center, case managers are assigned by unit and teams of hospitalists cover the medical floors. The staff on the medical units coordinate with each other on the time of the meetings so hospitalists can attend the meetings when their patients are being discussed.
The care coordination meetings are very specific and focus only on what the team needs to do for patients that day and the next to help them progress toward discharge, Graydon says. For instance, the team might determine the patient needs additional teaching or will need orders for durable medical equipment. “The meetings don’t replace full rounds or care planning rounds. Those take place at another time. They are strictly patient flow meetings,” she adds.
They keep the patient and family informed about the discharge date so they can arrange for transportation and any other support the patient will need at home, or so they can choose a post-acute provider.
The patient flow team found they had to tackle more than one bottleneck to move patients smoothly through the hospital, Graydon says.
For instance, they knew the day before how many people were having planned surgery and could anticipate how many beds they would need, but they didn’t know how many people would be admitted through the ED.
“The care coordination meetings help us plan ahead as much as we can, and the case managers and social workers work on facilitating the discharge plan every day,” she says.
When environmental services was paged as soon as a patient left the room, the staff was able to cut 15 minutes off the turnaround time. “Environmental services set a goal of getting a room turned around in 45 minutes or less, which opened up a significant number of beds,” she says.
When Intermountain Medical Center in Murray, UT, reached capacity a few months after opening, a year-long initiative on patient flow determined that part of the holdup was taking care of last-minute details.
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