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Managing patient throughput can be one of the biggest challenges for nursing units, with patients often remaining in the ED because there are not enough beds available on the unit, or there are not enough nurses to care for all of the patients. But some facilities are finding a solution with the use of Admission, Discharge, Transfer (ADT) nurses.
ADT nurses can be effective when nursing units do not have sufficient ability to flex their staffing models as patient throughout volumes and needs change throughout the day, explains Denise Perry, MHA, RN, CENP, senior consultant with Novia Strategies in Poway, CA. Patient throughput can be affected significantly by the time it takes to conduct the admissions process on a nursing unit and the time it takes to discharge the patient and free up the bed for a new admission, she says.
This delay affects the rest of the hospital when discharge is delayed and patients are held in the ED or surgical unit while waiting for an inpatient bed, she notes, or patients may be waiting at a clinic or elsewhere in the community for a bed to open up. Getting patients moving through nursing units can clear the logjam so that the benefit is felt throughout the hospital, Perry says.
Hospitals apply various interventions to improve throughput, but Perry says the use of ADT nurses has proven to be one of the most effective. The role of an ADT nurse typically encompasses a broad range of patients, including those who are transferred in from and out to another unit, which is a slightly different workflow process than hospital admission and discharge, she notes. Nursing units usually are affected more by one type of admission and discharge than the other, so ADT nurses focus on the one that has the greatest impact on patient throughput, she says.
“It’s important to analyze your data to determine the peak times, the time of day, or day of the week that will most benefit from having an ADT nurse in that role, handling those patients independent of nurses on that unit who have another patient assignment,” Perry says.
ADT nurses have become more popular recently as hospitals look for more effective solutions to patient throughput issues rather than just adding more nurses to a unit, she says.
The real problem is not always the actual performance by nurses of the admission and discharge processes, Perry notes. A number of factors, such as the timeliness of admitting physician orders to how long it takes environmental services to clean a room and get it ready for the next patient, can drive a logjam, she says.
ADT nurses can be part of a more targeted approach once you understand the issues contributing to patient throughput delays, Perry says.
“People are realizing that just throwing more nursing hours at a problem isn’t always the best solution and doesn’t make the problem go away,” Perry says. “Hospital administrators are realizing that they need more clarity about exactly what is needed. ADTs can be part of the solution while also looking for strategies to address other components of the hospital throughput problem.”
There are a few models to choose from when employing ADT nurses. One is a unit-based ADT nurse, which works well for a unit that has a high volume of patients needing this attention on most days, Perry says. That is often the case with post-surgical units and with short-stay units, where patients are more likely to stay for one to three days rather than a lengthy period, she says.
“I’ve worked with large units of 40-plus beds where they may experience 15 to 20 total admissions and discharges in one 24-hour period,” Perry says. “That’s a lot of bed turnover and activity going on in that unit. The ADT nurse can be particularly useful in helping to get those admitted patients settled, or the discharge patients organized and out the door.”
Some organizations also find that ADT nurses can be particularly effective in the ED, Perry says. A hospital with a large proportion of admissions through the ED — that can be up to 60% of their admissions — will find it beneficial to place ADT nurses in the ED to conduct the admission process with the patient before even being transferred to a nursing unit, she says.
That can give the ADT nurse a head start on all the paperwork and documentation that can slow down admission and discharge, Perry explains. The patient typically will have a full set of admission orders from the physician, but then there also must be a comprehensive nursing admission history that includes details on medications, home environment, fall risk, skin breakdown risk assessment, and other factors.
“It’s time-consuming, taking 35 to 40 minutes for an average patient and sometimes much longer in some more complex cases,” Perry says. “When these documentation and history tasks take place in the ED before the patient gets to the nursing floor, there is no delay on the nursing floor between the time the unit accepts that patient and the time it is ready to accept the next one. It smooths that process because the patient is ready to admit immediately, rather than taking that 35 to 40 minutes every time a patient arrives at the nursing unit.”
Another way using ADTs is effective is when the admissions and discharge workload is not weighted heavily in a particularly unit or in the ED, but rather is spread through units and may include a large proportion of admissions from other facilities. In that case, a centralized ADT system in which roving ADT nurses are deployed from the float pool team is used, Perry explains.
“They’re deployed to the units as needed, when that unit is being hit hard and needs to improve the efficiency of their admissions and discharge. They become sort of like first responder nurses on a pager, floating around the hospital to assist with ADT activities where they are actually occurring at that moment,” she says. “This works well when there is no consistent peak volume in the ED, surgery, or outside transfers in, but there is a need throughout the facility overall. These ADT nurses can be just as effective, and their value justified to administration, just as much as when they’re dedicated to a particular unit.”
That approach is a turnaround from when ADT nurses first came to the attention of hospital administrators and every unit manager thought that an ADT nurse would solve all their throughput problems, Perry says. Many hospitals tried putting an ADT nurse on the units they assumed were the busiest and experienced the most delays, but that perception was not always correct and the ADT resources were underutilized.
Rely on the data to show you where ADTs will be most effective, Perry says.
That means the first step to employing ADTs is researching hospital data to identify where the admissions and discharge logjams occur — whether it is primarily in one unit or more generally spread throughout the facility.
“Which departments are holding patients more frequently than others? Is the emergency department pretty much able to get their patients into beds as needed, but the surgery recovery room can’t?” Perry says. “Or is surgery recovery always able to get beds, but transfers from other facilities or the community experience long delays? Anecdotal evidence like complaints by staff might lead you in the right direction, but you’re only going to get a reliable answer by studying the data.”
Perry advises analyzing admission and discharge data by patient care unit, hour of the day, and day of the week. That should create trend lines that identify the highest areas of need, which will suggest the best ADT model for your situation.
The answer could be a combination of the models, Perry notes. It may be most effective, for instance, to have a dedicated ADT nurse in the ED and one or more floater ADTs for other patient units, she says. The use of ADTs should be tailored to your own institution’s needs, but it must be based on analytics and not an informal impression of where the problem lies — and just on whatever unit leader is complaining the loudest, Perry says.
The role of the ADT nurse must be clear not only to the nurse, but to everyone else on the units where he or she will work, Perry says. When assigning an “extra” nurse to a unit, and especially when the nurse can be summoned as needed from a float pool, it is easy for others on the unit to treat that person as an extra hand who can be tasked with whatever needs to be done at the moment, Perry explains.
“After you assign a nurse to a unit, that role may morph into more a blanket resource nurse position in which the person does help with admissions and discharge, but also relieves nurses for breaks and lunch time, pass medications, assist with infusions,” Perry says. “When that happens, either the ADTs are not accomplishing what you sent them there to do, or, in fact, that unit doesn’t need a full-time ADT in the first place.”
Watering down the ADT’s role could greatly undermine the effectiveness of an ADT program, she says. The hospital should include an education component when introducing ADTs to the facility or a particular unit, heading off potential conflict and watering down of the ADTs’ effectiveness by explaining their roles to everyone involved, Perry says.
The volume and effectiveness of ADTs also should be monitored carefully, she says. Maintain data on the number of ADT admissions and discharges per unit and compare that to the trends in ED holds or patients waiting for transfer.
“Outcomes data will tell you the effectiveness of the ADT program and whether you might need to shift ADTs from one unit to another, or possibly switch a centralized ADT program with a float pool,” Perry says. “A variety of factors can affect where the logjam occurs, and that is not necessarily going to remain the same over time. Monitoring the outcomes data may show you that, at some point, things have changed and your original determination of where and how to deploy ADTs needs to be reassessed.”
The proper use of ADTs can produce cost savings for the hospital in addition to improving patient care, Perry says. Patient volume can influence staffing levels, and slow admission and discharge at any point in the process can lead administrators to apply more resources to that particular unit. But adding more employees to the unit is costly and is not always the most effective solution, Perry says.
“If you look at the microsystems and not just the hospital as a whole, you might see that if you tease out these ADT activities then the patient volume and throughput is manageable for the existing staff without increasing the total number of staff assigned to that floor for every shift,” she says. “There is an opportunity for cost control and labor hour control by identifying those workflow and patient activities that can be better assigned to a specialist rather than increasing the total hours on the floor as a whole.”
The financial impact of improving patient throughput can be profound, Perry says.
“If I have a 20-bed emergency room and I have six patients who are holding in beds, then I really only have a 14-bed emergency room. That’s going to affect your bottom line in that department,” Perry says. “On the other end, if I have delays in discharging patients, then I’m going to have organizational costs from extended care that can be captured and used to demonstrate how the savings offset the costs of the ADT nurse hours.”
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Dana Spector, Nurse Planner Fameka Leonard, AHC Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.