Avoid patient bottlenecks with these helpful hints

Consistent controls can reduce gridlock

It often takes a crisis to make things work. Getting patients transferred out of the intensive care unit on a smooth timetable is every manager’s wish, but more often it’s a quagmire. Patient gridlock in critical care units is getting worse, says Linda Kosnik, RN, MSN, chief nursing officer at 450-bed Overlook Hospital in Summit, NJ.

Patients can await transfer to a step-down floor for up to 10 hours while other cases are held up in trauma or the emergency department pending admission. The bottleneck slows down everyone and everything, says Kosnik.

Yet, when a crisis occurs, such as a natural disaster, it’s surprising how efficiently the system can work, adds Nancy Levy, RN, MPA, Overlook’s unit manager for adult critical care. Suddenly, patients are transferred promptly, there are ample open beds downstream, and capacity in the ICU seems to emerge from nowhere. Why can’t things work that way under normal circumstances?

Patient gridlock is people-created problem

They can, according to a study of ICU operations conducted by the Institute for Health Care Improvement. Like most operational problems, patient gridlock in the ICU is a people-created situation, according to the group. The Boston nonprofit investigates ways to implement effective strategies in health care.

Overlook participated in the Institute’s groundbreaking study of adult ICUs along with more than a dozen other acute-care hospitals. After analyzing the patient gridlock problem, the organization presented a set of operational improvements, which it called "process changes."

Hospitals that have implemented those changes tend to experience fewer gridlock problems, according to Levy. Two of the study participants, including Overlook, suggest the following:

• Prepare patient transfer orders well in advance. Most ICUs find this process difficult. But the reason has to do with inconsistent oversight. The unit charge nurse has to be well informed and effective in keeping track daily, even hourly, of a patient’s readiness for transfer. "She has to stay on top of things," Levy says.

Having the orders done during the previous evening or night is a good idea, says Levy. This means planning 24 hours in advance with the patient’s attending physician. Nurses usually have only one opportunity to discuss the pending transfer with the attending physician, and that time is during early morning rounds. Most delays, as every nurse knows, occur when the attending physician fails or is too busy to review the notes and give a signed approval to move the patient out of the ICU. Many of these suggestion are included in a 1998 Institute report on process change.1

• Consider retaining intensivists. Hospitals with full-time intensivists on each shift have solved this problem. The intensivist can review the notes during the night and sign the orders, Levy says. By morning, the patient can be cleared for transfer.

The advance work also will give the charge nurse ample time to coordinate a bed availability with the step-down floor, Kosnik adds. But to make this work, nurses within the ICU and on the receiving floor have to be willing to work in sync, she says.

If the hospital won’t retain an intensivist, empower residents and nurses working as a team to make the diagnostic assessment ahead of obtaining the necessary transfer approvals. This can shorten the time involved by the attending physician in reading the patient notes and filling out the transfer documents. The purpose would be to speed up the approval process not to give residents and nurses transfer authority, Levy states.

• Establish an open ICU. An open unit policy can make admissions and discharges simpler. The patient’s own physician can be responsible for the patients discharge plan, says Michael C. Witte, DO, medical director of the ICU at Mercy Hospital Medical Center in Des Moines, IA.

Some critical care specialists have touted multidisciplinary assessment teams as effective. During morning rounds, the team can collectively identify patients early who may be ready for transfer that afternoon or the following morning, Witte says. "The literature shows that they can be effective in getting appropriate patients out sooner and lowering lengths of stay as well," he adds.

• Use point-of-service (POS) testing. Hospitals are improving their record on testing by moving more technology to the bedside. The institute found POS testing can significantly reduce delays and bottlenecks. Overlook administrators have supplemented these changes by giving critical care official priority in all patient testing, moving the pharmacy closer to the ICU, and emphasizing collaboration between ICU personnel and others such as lab staff and respiratory therapists.

• Transfer patients before, not during or after, shift changes. The reason should be obvious, says Levy. There is too much confusion during shift change. Delays on one shift may cause further delays on the next, Levy adds. Some nurses say that an oncoming shift is better staffed or better able to implement transfers "because it’s quieter," Kosnik says. Nevertheless, patients who are ready should be transferred at the earliest possible time, she stresses.

• Develop dedicated capacity for high-volume activities and procedures. "Predict the need and develop the dedicated capacity," the Institute report indicates. This involves ensuring that physicians are up-to-date at all times on the 20% of patients who are most likely to be sicker or not responding to optimal care than others, Witte says.

On that basis, identifying patients who are likely to transfer within 24 hours can be easier. The average ICU stay ranges around five days, which is down from 10. That alone should help yield indicators on transfer candidates, says Kosnik. To prevent bottlenecks in times of urgent need, at Overlook nurses keep track of at least one patient who can be transferred as the need arises. The status of the patient is re-checked hourly to assess changes, Levy notes.


1. Institute for Healthcare Improvement. Reducing Costs and Improving Outcomes in Adult Intensive Care. Boston; 1998.