Critical Path Network

Bed capacity project reduces discharge, ED delays

Hospitals take multidisciplinary approach

As a result of a joint initiative to improve bed capacity, Fort Sanders Regional Hospital and Parkwest Hospital in Tennessee reduced discharge delays, increased discharges between 11 a.m. and 2 p.m. by 8%, and consequently reduced the amount of time patients in the emergency department wait for inpatient beds from 70 minutes to less than 30 minutes.

Fort Sanders Regional Hospital, a 556-bed hospital in downtown Knoxville, and Parkwest Hospital, a 310-bed hospital on the west side of the city, were experiencing increasingly long waits for beds in the emergency department and for patients being directly admitted, says Sheryl Hiers, RN, MPH, CCM, manager of quality and clinical effectiveness at Parkwest Hospital. Both hospitals are part of the Covenant Health System.

The problem was exacerbated, particularly for Fort Sanders Regional, when a downtown hospital closed, says Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for Covenant Health System.

"During our busiest times, patients sometimes had to wait eight to 12 hours or had to stay in the emergency department overnight because there was no bed available. We knew that we needed to improve our patient flow process so we could accommodate more patients," Hiers says.

Representatives from both hospitals developed a multidisciplinary team to review, assess, and implement changes in the bed flow process.

"We knew that good patient throughput involves more than just case managers. It starts in the emergency department with the physicians and nurses and includes people throughout the entire hospital. Case managers focus on getting patients in the right bed and discharge planning, but they can't do it alone. It takes a multidisciplinary approach," she says.

Members of the team included house supervisors, the bed board staff, the admitting case manager, the manager of case management, charge nurses (called "shift leaders") from all areas of the hospitals, nurse managers, nurse educators, unit case managers and social workers, the emergency department case manager, and representatives from transportation and environmental services.

"Bed flow involves more than just discharging patients. It involves people throughout the hospital. Our purpose was to set up communication between all the people who are involved and develop ways to make the process work better," she says.

For instance, people in housekeeping have to understand why it's important to get the room cleaned in a timely manner. Nurses have to understand why it's important for them to take patients as soon as a bed is available if necessary, rather than waiting until after shift change, Fugate adds.

The team began by defining the role of everyone who could affect patient flow and educating them on why their role is important.

"We asked them for their perception of their role and what they considered timely, then discussed the impact that a delay could have," Hiers says.

The team compiled data on when the most admissions occurred, waits for inpatient beds for direct-admit patients, and wait time in the emergency department.

They outlined the jobs of all team members and discussed ways patient flow could be affected if someone doesn't do his or her job in a timely manner.

"People in hospitals tend to work in silos, and nobody understands how one little action can delay patient flow. Getting everybody in a room to talk about it helped everyone understand what needs to be done. Once everybody understood their role, patient flow began to improve," she says.

For instance, housekeeping didn't understand that taking their time to clean a room backed up the emergency department or that they needed to prioritize which rooms needed to be cleaned, she says.

For example, if there are several patients in the catheterization lab waiting for beds, housekeeping should clean the rooms on the cardiac floor first.

As a result of the meetings, housekeeping and transportation changed their hours of operation to accommodate the need for beds during peak times.

Representatives from other departments made similar changes to help move patients through the continuum in a timely manner.

"It makes it easier if everyone is on the same page," Hiers says.

Mark Maples, chief technologist at Covenant Health, worked with the team to develop an electronic discharge flow board with icons that show all the milestones that must occur before a patient is discharged.

Milestones include "complete medication reconciliation," "complete core measures," "obtain signed Medicare letter from patient," "complete patient education," and "confirm transport has been notified." Other icons indicate when the room is empty, when it is being cleaned, and when it is ready for a new patient.

The flow boards are large and posted all over the hospital.

All of the rooms on all the units are shown on the flow board. When the treatment team indicates that a patient may be able to be discharged the next day, the case manager, nurse, or unit secretary enters it on the discharge flow board, and the "intent to discharge" icon appears on the flow board in the slot for that patient room.

The flow board includes time frames for each task to be complete. When "intent to discharge" is place on the flow board, the clock starts ticking and the nursing staff know that they need to get the discharge order signed as soon as possible.

When the physician signs the discharge order, the "discharge flow" process begins and the clock starts on the time frames for medication reconciliation, discharge instruction to patients, and other milestones.

If a time frame is missed, the icon turns red, alerting the staff that the person responsible should make this task a priority.

The team set a goal of working together so 40% of patients could be discharged from Parkwest by 11 a.m. and from Fort Sanders Regional by 2 p.m.

Staff assess the patient census throughout the day, holding regular huddles to assess patient flow issues. The team created a chart showing when the huddles occur, the location, the attendees, and the goals.

"Unless everybody on the team focuses on patient flow, bottlenecks are likely to occur," Hiers says.

The huddles start at 4 a.m. when the house supervisor, shift leaders, and bed control office staff reassess staffing needs, looking at anticipated surgeries and patients who are scheduled for the cardiac catheterization laboratory, potential patient admissions from the emergency department, and patients whose discharges are anticipated by the case manager and the nursing unit.

At about 8:30, the same group assembles and is joined by the case management manager, a surgery staff representative, and a heart catheterization lab representative to determine staffing and bed capacity needs for the day and to look at anticipated discharges for the day and at patients with special needs, such as those with sitters and restraints.

"They look at how many discharges were written at 7 a.m. when the hospitalists arrive and what patients the surgical staff anticipate will need to be admitted," Hiers says.

At 9 a.m., the nursing units hold a census meeting attended by the nurse manager, case manager, social worker, and nurse educator. They discuss and assess bed needs, anticipate discharges, anticipated admissions, and review data needed for core measures, and patients who should receive Important Message from Medicare letters.

All social workers and case managers in the department meet as a group at 11 a.m. and discuss the bed needs for the day, the anticipated discharges, and what needs to happen to facilitate the discharges. They identify the outliers and barriers to discharge and identify patients appropriate for palliative care or transfers to hospice.

The bed control team meets again at 4 p.m. to reassess bed capacity and staffing needs for the night shift.

If the bed control team sees an unexpected increase in the number of patients who need a bed at any time during the day, they call a huddle to look at ways to accommodate the need for bed.

Representatives at the individual hospitals meet once a month to look at patient flow from a bigger perspective, Hiers says.

At both hospitals, case managers begin discharge planning on admission, using the anticipated length of stay for that DRG.

The case managers have a goal of seeing patients within 24 hours of admission and alerting them of the anticipated discharge times, Fugate says.

When a discharge is anticipated, medication reconciliation is done the night before by the pharmacy staff so physicians, nursing staff, and case managers are not delayed the next day in coordinating the patient's discharge, she says.

Throughout the stay, case managers make sure the patients and family members understand the discharge day and time.

"At Fort Sanders Regional, the case managers have an innovative way of getting the patients and family members on board for the earlier discharges. They explain that the early discharge time gives the patients or family members time to go the pharmacy and get their discharge medications and that the nurse or case manager on the unit will still be there if they have questions after they get home," she says.

Both hospitals offer the family alternatives for getting the patient transportation home, such as providing cab vouchers or bus tickets if the discharge time isn't convenient.

[For more information, contact: Sheryl Hiers, RN, MPH, CCM, manager of quality and clinical effectiveness at Parkwest Hospital, e-mail: shiers@covhlth.com.]