Stop inappropriate admissions to improve your hospital's patient flow

Emergency department case managers are a key

With today's shrinking health care dollars and pressure from payers to move patients through the continuum faster than ever, hospitals need to focus on improving patient flow. That's where case managers come in.

"By stopping inappropriate admissions, the case manager really facilitates patient flow. In addition to opening a bed for another patient who needs it, the case manager is preventing utilization of resources for a patient who doesn't need it and optimizing patient safety by not exposing patients to potential infections," says Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System and health care consultant and partner in Case Management Concepts LLC.

Increasing efficiency

Numerous studies have shown that once a hospital reaches a 90% occupancy rate, internal resources tend to slow down, she adds.

"Staff and services don't increase because of higher capacity. When a hospital reaches a high occupancy rate, it still has the same number of stress test machines and the same number of physical therapists. Patients tend to wait longer for services, and the length of stay can go up accordingly," Cesta says.

If case managers can help keep inappropriate patients out of beds, the hospital services will be more efficient and quality of care will increase, she adds.

A multitude of issues affect patient flow, adds Brenda Keeling, RN, CPHQ, CPUR, president and owner of Patient Response, a Milburn, OK, health care consulting firm.

Patients come into the hospital at numerous entry points — the ED, cardiac catheterization, the post-anesthesia care unit, the outpatient unit, and as direct admissions from physician offices, she says.

The traditional practice of having case managers see patients within 24 hours of admission doesn't work well in today's health care environment, Keeling points out.

"Case managers need to review the cases before any admission is accepted to determine that the admission is appropriate and meets medical necessity, and if it doesn't, to query the physician at that time and not three days later," Keeling says.

Although people think that discharge planning should be the main focus of case managers when it comes to improving patient flow, discharge planning actually is the tail end of the process, Cesta adds.

"Case management is a combination of utilization management, care coordination, and discharge planning, all wrapped into one. If case managers are doing all their other tasks well, discharge planning will fall in line with the other processes," she says.

Hospitals need case managers on the front end to make sure things go faster on the back end, and that means that emergency department case management is an essential part of the patient flow process, Cesta says.

"Case managers in the emergency department can keep inappropriate patients out of acute care beds and make sure that the charts of patients who meet criteria are documented properly," she adds.

She recommends having case managers in the emergency department who review the medical record after the emergency department physician has issued the order to admit but before the chart is processed.

"Maybe the patient is clinically ill but the documentation doesn't support it, or maybe the patient can go home with home care or is appropriate for admission to a lower level of care," she says.

Suggestions on implementing CMs in the ED

Cesta suggests having RN case managers cover the emergency department for a minimum of 12 hours a day, with additional coverage by social workers. It takes 2.5 FTEs for case management coverage, 12 hours a day, seven days a week, she says.

"Case managers and social workers in the emergency department should work together in a way that is similar to the inpatient case management model," she says.

Nurse case managers should work closely with the social workers to ensure that all patients' needs are met and all the issues are resolved, she says.

The nurse case managers should cover clinical throughput and utilization and potential discharges, while the social workers concentrate on psychosocial issues that may have caused the patient to come to the emergency department or prevent the patient from being safely discharged.

Plan emergency department case management coverage around high-traffic times, typically from 10 a.m. to 10 p.m. or 11 a.m. to 11 p.m., with the social workers coming in earlier in the morning, she says.

"Ambulances come in whenever there is an emergency, and there is no pattern. The way to determine the best hours for coverage is to look at when patients either walk in or come from the physicians' office. Patients don't typically walk into an emergency department in the middle of the night," she says.

The walk-ins are likely to be the softest admissions and the patients who would greatly benefit from not being admitted to the hospital and, therefore, should get the most attention from case managers, she says.

Watch for patterns

Look for patterns around the diagnoses of patients whose stay is denied.

"It's not always the short-stay patients whose stay is denied. Once they get admitted, patients who do not meet admission criteria may stay for several days," she says.

Many times, it's the soft-admission diagnoses that are denied, Cesta says. Typical diagnoses include chest pain, dehydration, mild head trauma, and syncope.

Aggregate data to determine if there is a particular physician or a particular diagnosis that most frequently is involved in denials and focus on those, she adds.

"One person can't follow every case in a busy emergency department. Case managers need to prioritize which cases to review," she says.

When patients get to the floor, case managers should be coordinating care for the patients so each day is optimized.

"Typically, the role of the case manager is to ensure that patients are getting services in a timely fashion and that they continue to meet criteria for the acute level of care," Cesta says.

An active physician advisor can be a tremendous help with moving patients through the continuum and getting them discharged in a timely manner, Keeling says.

"In most hospitals, case managers can justify having a full-time physician advisor if they show documented evidence from a financial aspect that they are needed," she says

Patients should be discharged from the hospital when they are clinically ready, no matter what time of day it is, Cesta says.

"The plan to discharge all patients by 11 a.m. has never worked. Nobody has been able to do it consistently. All patients aren't ready to march out the door at the same time," she adds.

If all patients leave at the same time, it will affect the admitting process, as the admissions office struggles to fill the beds with patients who have been waiting. This, in turn, affects ancillary services because there is an influx of people needing services, she adds.

"Batching all the work — discharges and admissions — is anti-patient flow. Spreading the discharges spreads the resources associated with admitting," she says.

Patient flow is stymied when hospitals don't anticipate discharges, Cesta says.

"Hospitals don't do well at planning discharges in advance. They often wait until the doctor comes in and issues the discharge order. If you anticipate the discharge the day before, it improves patient flow considerably," she says.

For instance, if a case manager orders transportation to transfer a patient to a skilled nursing facility the day before, the ambulance is likely to arrive within a 15-minute window. If he or she waits until the day of the admission, wait time may be four hours or more.

"If a patient is likely to be discharged tomorrow, the family should be told today so they can prepare," Cesta says.

Using the IM

Use the issuance of the Important Message from Medicare to trigger your advance discharge planning, Cesta says.

When you issue the Important Message, activate the discharge plan. Notify the family, ensure that the patient has the prescriptions he or she needs, and arrange for home health or transportation.

"This strategy works much better than last-minute reactions," she says.

Discharge lounges for patients who are ready for discharge but whose families can't pick them up until later work well at some hospitals. They require additional resources, including a nurse to provide medications and food services.

Hospitals are going to have to move to providing services seven days a week to achieve optimum patient flow, Cesta says.

"Patients who come in on Friday are typically going to be there until Monday, and all that expensive equipment is going to languish. Then, when the hospital ancillary departments ramp up on Monday, there is a backlog of people who were waiting for tests and procedures all weekend," she adds.

(For more information, contact Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System, e-mail:; Brenda Keeling, RN, CPHQ, CPUR, president and owner, Patient Response, e-mail: