By Toni Cesta, PhD, RN, FAAN

Introduction

As of this writing, there are reports about hospitals across the country that have reached or exceeded capacity. These hospitals have only one or two available critical care beds, and some have no open medical or surgical beds. Running at 100% capacity seems to be a new phenomenon for these hospitals. They are struggling to figure out how to accommodate ever greater influxes of patients that do not jibe with their discharges. It is clear the hospitals are overwhelmed with COVID-19 cases, and they are coming at rates that are outside the bounds of anyone’s experience. But as I listen, I have to wonder. Where is case management? Are these administrators using case management to its fullest? Is there a capacity management plan?

Capacity Management: Do Not Wait for a Crisis

I have worked at New York City hospitals that ran at 100% capacity most days of the week, every week. You may wonder if this was because they were not run well, or maybe case management was not up to snuff. In my estimation, neither of these were true. The fact was these hospitals were in densely populated areas serving millions of people, so overcapacity was a daily issue. Some days were worse than others. But the trick was to treat capacity management as a routine problem to be addressed every day, like any other daily problem. The capacity management lesson from the COVID-19 crisis is that the organization should create a plan and review it every day. The hospital should know whether they are running green, yellow, or red every day. Each color code, particularly yellow or red, should trigger a set of interventions to return the hospital to green.

Understanding capacity management can help in other ways. It can indicate if the hospital is overbedded, where a product line may need to be adjusted or enhanced, and how efficiently the emergency department (ED) is operating. Most importantly, it can indicate what activities case management will need to perform to open more beds.

When a hospital operates at greater than 80% capacity, the entire system slows down. More patients waiting for tests, treatments, or procedures means longer wait times and longer lengths of stay. The overall length of stay starts to creep up, and everything slows down. Fewer discharges mean more patients waiting in the ED. It might even mean patients going elsewhere for treatment. Fewer discharges mean fewer medical/surgical beds, fewer critical care beds, and more PACU holds. You can see how this reversed process creates all sorts of problems.

The idea is to never be overcapacity. Easier said than done, right? It all goes back to those capacity management guidelines. Keeping an eye on capacity every day is the only way to keep occupancy under 80% or 90%.

As you can see, capacity creates more capacity. Administrators have to prevent it from happening in the first place. A few words about the guidelines: First, these are only examples. When developing a similar tool, you can use this one as a starting point. The idea is to individualize them to your hospital.

Guidelines for Bed Capacity

Criteria for Determining Zone and Communication Plan

Determination of zone will be made by a joint decision among the “Core Team” members

Green Zone

Yellow Zone

Red Zone

Definition includes any combination of the following:

  • Pending discharges within normal range;
  • No diversion status.

Definition includes any combination of the following:

  • Pending discharges below normal levels and less than scheduled admissions;
  • ICU Holds > 3;
  • PACU Holds > 3;
  • ED Holds > 3;
  • On diversion.

Definition includes any combination of the following:

  • Pending discharges below normal levels and less than scheduled admissions;
  • ICU holds > 5;
  • PACU Holds > 5;
  • ED Holds > 5;
  • On diversion.

Implementation Steps for Each Zone

Green Zone

Yellow Zone

Red Zone

Actions:

  • Conduct bed huddle meeting 8:50 a.m. and 1 p.m.
  • Case management to work with nursing leadership, social workers, and physicians to expedite discharges.
  • Prioritize imaging and lab tests for patients who are admitted and discharged. (CM)
  • Floor nurses must take call/fax report as soon as the bed is ready. Patient is sent immediately.
  • Housekeeping supervisor prioritize rooms to be cleaned.
  • ED case manager assesses potential discharges, telemetry requests, expedites testing, expedites discharges.

Actions:

  • Provide bed status update at least every four hours in the huddle as needed.
  • Consider opening hall beds as overflow areas. (CT)
  • Case managers initiate rapid discharge process. (CM)
  • Provide transportation for discharged patients who need it. (CM/SW)
  • Request physician to conduct expedited reading of diagnostic tests (i.e., stress tests, CT scans, MRI, etc.). (CM)
  • BC and housekeeping supervisor prioritize rooms to be cleaned.

Actions:

Continue actions initiated during the Yellow Zone

  • Conduct a continuous re-evaluation of zone status. (AD)
  • Consider the need to go on diversion. (AD)
  • Consider opening additional overflow units/beds PACU recovery/ambulatory surgery recovery. (AD)
  • Request physicians to reassess patients for potential of discharge (physicians should be notified of need to do this by 3:00 p.m.). (CM)
  • Notify NH/Rehab of need to discharge patients in the evening. (CM)
  • Limit transfers from other facilities. (CM)
  • Evaluate the possibility of cancellation of surgeries scheduled elective procedures and transfers. Assess elective volume of cases for next three days. (CT))
  • Delay or divert direct admissions. (AD)

Administration (AD), Case Management (CM), Medical Director (MD), Nurse Executive (NE)

SOURCE: Institute for Healthcare Improvement

As you review the grid, bear some things in mind. The job titles might need to be adjusted for your hospital. The benchmarks for moving from one color to the next most certainly will have to be adjusted for your hospital.

Developing a Capacity Grid

Case management should manage capacity each day. When the hospital is green, leaders can predict discharges and admissions will balance out, there are no holds anywhere, and the hospital is not on diversion.

There are two types of diversion. The first occurs when critical care patients are diverted from the hospital due to a lack of beds. Under these conditions, emergency services will take those patients to another hospital. The other form of diversion is general. In this case, all patients through the emergency system are taken to other hospitals. Diversion is a means of last resort and should never be used unless absolutely necessary from a safety perspective. During the pandemic, it is likely all other hospitals in a region are experiencing the same capacity issues.

There are a few metrics one can predetermine to indicate when the crisis hits. The types of crises can range from storms, hurricanes, and floods, to mass casualties from a shooting, or other viruses or illnesses. Therefore, developing these tools is important in the long run and can apply to any similar emergency where capacity is an issue.

Keep these issues in mind when developing a grid:

• List key team members. These are people who will be called to action when the grid turns yellow.

• What metrics flip the facility to yellow, and then to red, including:

- Pending discharges;

- Pending admissions;

- Holds in the ED;

- Holds in critical care;

- Holds in the PACU.

• Other geographical areas that can be flexed to accommodate additional patients;

• How to staff those areas.

The case management department should be front and center during a crisis and become the “feet on the ground” for managing capacity. In this way, clinicians can focus on caring for patients and facilitating their throughput from a clinical point of view.

The department needs to take an all-hands-on-deck approach when the hospital is in yellow or red. A proactive approach on yellow days may prevent the hospital from entering the red zone. If the facility reaches the red zone, you might have to escalate the approach.

The work of the department can be prioritized by:

  • Patient flow;
  • Discharge planning;
  • Utilization review/management.

Remember that none of these approaches are set in stone. It may be necessary to reprioritize the work on an hour-by-hour or day-by-day basis. Be sure discharge planning and utilization review are closely aligned if different staff members perform these roles. Transitions should take place as soon as patients are clinically ready. Never forget the non-COVID-19 patients. They need care, too.

Methods of Patient Flow

During times of high capacity, the primary goal is to keep the patients moving. Specifically, continue to hold daily interdisciplinary care rounds with the team, but in an abbreviated form, focusing on delays, discharges, and throughput.

Talking points for rounds:

  • The inpatient plan of care;
  • Expected outcomes of care;
  • Barriers to care or throughput;
  • Avoidable delays;
  • The discharge plan;
  • Barriers to discharge.

Keep a discharge list that is updated hourly, and provide the list to the supervisor or director via email. If there will be a discharge for the following day, order transportation the day before the discharge so patients can vacate their bed as early as possible. Alert family of the discharge as well. Determine if the family will be ready to receive the patient at home, and that all necessary patient and family education has been completed.

Facilitate tests, treatments, and procedures, but question any that may be performed on an outpatient basis. Conduct clinical reviews as needed with an understanding that this may not be the main priority. Discharge planning and transitional planning may usurp those clinical reviews.

Be sure to identify any barriers to throughput or discharge, and discuss them with ancillary departments, the supervisor, or other clinical team members, during or after rounds. Each delay adds time to the patient’s length of stay.

Capacity Management

Each morning, the case management department should review how many patients are in the ED. Review the ED volume against expected discharges to determine where capacity issues may lie. Understand where bottlenecks might occur based on the anticipated bed needs. Use the capacity management grid to identify potential problem areas. Build these trigger points into the patient flow software, if available.

Discharge planning also is critical to staying out of the yellow or red zones. Whenever possible, anticipate tomorrow’s discharges. Prepare for their early departure, including good communication with the patient and family. The director should flex staffing according to problem areas, or areas of bottlenecks or shortages of specific beds. Understanding these needs requires constant communication with the ED case manager. Understand that patient assignments may not be consistent each day as problem areas come up that need to be addressed.

During these times, consider abbreviated discharge planning assessments. Be cautious as not to miss information needed for a safe discharge plan. Give the patient their second Important Message from Medicare (IM) as soon as you know they are within two days of discharge. Address discharge delays immediately and seek help if you cannot resolve the problem on your own. Consider identifying a location in the hospital where discharged patients can stay until their family picks them up. This frees up the bed for another admission or transfer.

COVID-19 Discharge Planning Waivers

If you are in a surge hospital during the pandemic, the following are waived:

  • Choice list;
  • Three-day skilled nursing rule;
  • EMTALA;
  • The requirement to work with patients and families in selecting a post-acute provider based on quality data.

Swing rehab or other specialty beds for COVID-19 or other overflow patients.

Utilization Management

Consider clinical reviews the lowest priority. Be sure to actively manage the routes of entry to the hospital, especially the ED. Check that the patients’ levels of care are correct so as not to overuse inpatient beds. Move patients to lower levels of care as soon as they are clinically ready. These are the touchpoints where the roles of utilization management and discharge planning must be tightly linked if the roles are separated in the department.

COVID-19 Utilization Review Waivers

If you are in a surge hospital during the pandemic, the following are waived:

  • You do not have to create a utilization review plan to evaluate the medical necessity of admissions, duration of stays, or appropriateness of services provided.
  • Hospitals do not have to maintain a utilization review committee.

CMS states these waivers allow case management staff to focus on other roles and functions.

The ED in Yellow and Red Zones

Case management should have a strong presence in the ED. Use aggressive discharge planning tactics. Watch for unnecessary admissions. These might be patients who could go home with the assistance of home care. The same might be true for potential observation patients. Work closely with home care agencies to facilitate these types of determinations. Consider asking one or more agencies to staff a home care intake person in the ED during these times.

Other COVID-19 Challenges

The chief financial officer will need to understand that the “discharged not finally billed” list will lengthen. Case management leaders need to prioritize roles in the department. For example, the appeals coordinator might need to take a caseload or expedite discharges. The Medicare Outpatient Observation Notice and the IM can be explained by phone, and the forms can be delivered by bedside caregivers.

Communicate with payers. Understand their post-acute plans during the pandemic. Ask the physician advisor speak with their medical director to understand inpatient vs. outpatient needs. They may consider a patient who is monitored in isolation an observation patient. If this happens, direct them to the guidelines explaining these should be inpatients. For example, the Milliman Care Guidelines explain this in detail.

Remember: The Two-Midnight Rule has not been waived.

These are difficult and challenging times. Work with senior leaders to better ensure they use the valuable resources case management offers to the greatest extent possible. Remember that reducing overcapacity involves more than just discharge planning.