Critical Path Network

Patient flow initiative reduces hours on hold, decreases length of stay

Single access point for admissions, bed status reports improve throughput

Since Baptist Memorial Hospital-Memphis began a patient throughput initiative, the patient holding hours in the emergency department and post-anesthesia care unit average less than 30 hours per day despite the fact that 50,000 patients come through the emergency department each year and the hospital has more than 30,000 inpatient visits a year.

The hospital's solutions to the patient throughput include funneling all admissions through its Bed Express system, issuing a bed status report to all hospital departments every four hours, and stationing access case managers in the ED 16 hours a day.

Before the new system, the hospital had a cost center for ED holding hours, says Darla Belt, RN, director of performance review and accreditation.

"The hours on hold have dropped so much that we could delete the cost center," she adds.

The hospital's average length of stay has dropped by one day since the hospital reorganized its case management department in October 2007 and created a resource center that includes the Bed Express and staff to assist the case managers with clerical duties.

"The purpose of the case management department redesign and setting up the resource center was to improve throughput, not just by more rapid exit through the back door but by controlling what comes in the front door," Belt says.

Before beginning the redesign of its processes, the hospital team created a flowchart showing every way patients could access the hospital and identified eight different access points.

"We are a tertiary facility that serves a big area and there are a lot of access points in our hospital. It creates a challenge in coordination of admissions and keeping the patient flow going smoothly," she explains.

Patients access the hospital through direct admissions, obstetrics, the outpatient clinics, transfers from other facilities, the emergency department, through outpatient diagnostics if they end up needing to be admitted, and from the outpatient surgery center. Some patients come for outpatient diagnoses and end up being admitted.

About 35% of admissions come through the ED.

Under the new system, all room assignments come through the Bed Express system, whether it's a new admission or a patient being moved to a different unit within the hospital, says Randy Brightwell, RN, BSE, MA, case manager in the resource center and transfer coordinator.

The Bed Express is staffed around the clock by RNs who review the clinical data and ensure that a bed is available and that all the services the patient needs are available at the hospital, Brightwell says.

The hospital no longer takes direct admissions or transfers through the emergency department. Instead, they all come through the resource center, which clears a path for the appropriate level of care.

The hospital has a global telephone number that physicians and other facilities call to request a bed for a patient being admitted or transferred.

"In the past, when someone called and requested a bed, no one questioned them. Sometimes the patients were out of network or out of the geographic region their insurance specified but we dealt with that after the fact," she says.

All of the admissions are channeled through the resource center and Brightwell, who is backed up by other staff members. A case manager has been trained to assume his duties if Brightwell is on vacation or sick.

In addition, all transfers from other facilities must go through the transfer coordinator.

"Sometimes another hospital will want to transfer a patient to our hospital and his or her physician won't even have been on call that day. In other cases, the doctor is unaware that the patient's benefits don't cover care in our hospital but they do cover care in a competing hospital. The result could be a huge copay for the family. We try to catch all of these on the front end," Belt says.

The resource center is not involved in transfers from another facility's emergency department because of the federal Emergency Medical Treatment and Active Labor Act (EMTALA).

Instead, access case managers cover the ED for 16 hours a day during peak times. They handle precertification issues and work with the physicians to decide if the patient qualifies for the inpatient level of care.

"We have a social worker in the emergency department so if a patient doesn't qualify for the acute care, we can make long-term care referrals or home health consultations right from the emergency department," she says.

Bed Express tracks what beds are available and which have been cleaned and released by housekeeping and issues a bed status report every four hours that is e-mailed to department managers and posted in the physician's lounge and parking lot.

Red status means patients are holding in the ED or post-anesthesia care unit. Yellow means the hospital is getting short of free beds. Green means the patient throughput is going well.

"We know the status of beds in a timely manner. Two years ago, we were in red status for many days. This year, we've had only 26 hours on red status. Most of the time, our status is green," she says.

The hospital's Bed Express personnel keep a running total of what service line beds are available and try to reserve beds for certain patient diagnoses, Belt says.

If a particular kind of bed is getting low, Brightwell issues a page to all case managers, the house supervisor, and whatever unit on which beds are needed asking them to speed up transfers as best they can.

The medical staff coordinator maintains a list of the top 50 admitters and calls them to help triage patients out of the hospital whenever the bed status reaches the yellow level.

When the hospital set up its resource center, the resource center employees collaborated with the architect on the department design and where everything would be located.

For instance, the Bed Express is located across from the transfer coordination and the people who handle precertification, making communication instantaneous.

"Having the employees who were going to work in the department design the space resulted in an efficient operation and improved communications," Belt adds.