Rapid-cycle testing cuts bed turnaround by 85%

Change in notification process critical to success

[Editor’s note: A new report from the Urgent Matters Learning Network, Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments, identifies best practices from 10 hospitals selected as participants in an initiative to help hospitals eliminate ED crowding. Each participating hospital developed and implemented strategies to improve patient flow through the ED and to reduce overcrowding. (See resources, below, for information on how to obtain the report.) EDM looks behind the results to the strategies and methods that achieved them. With this issue, we begin a series of articles that will examine just what made these programs special and successful.]

Would you believe it was possible to slash the average time it takes to clean and turn around beds from 164 minutes to 24 minutes? Well, get ready to become a believer, because that’s exactly what the ED at the University Hospital in San Antonio did. And that’s just one of several successes achieved through rapid-cycle testing, the focus of its participation in the Urgent Matters Learning Network.

In rapid-cycle testing, you first assess your current status, then implement a quick change and track it for three or four days, explains David Hnatow, MD, FACEP, FAAEN, medical director of the University Hospital emergency center and chief of emergency medicine at the South Texas Poison Center, both in San Antonio. "Then you ask, Did it work, or do we need to further change the process?’" he says.

Hnatow met with an inpatient team three times a week and asked them to come up with process improvement ideas that could be tried. Potential candidates were identified through Excel spreadsheets created by hospital staff, which were used to track different processes.

"Without the ability to track metric data, it’s hard to see your problems," Hnatow explains.

One of the first projects undertaken was the bed cleaning turnaround time, because, as Hnatow notes, "Our average was 164 minutes, and we were told the benchmark was 40 minutes." The notification process was not adequate, it was determined, so with the housekeeping supervisor’s enthusiastic support, "Christmas in July" was established. It consisted of a jar with green and red labels; a red label placed in the jar by ED staff let housekeeping know there was a dirty bed; housekeeping put a green label in the jar when the bed was clean.

"We ran this for three or four days and got it down to 60 minutes," Hnatow says. "When you have 40-60 discharges a day that adds up."

Improvement has continued, and today the average is down to 24 minutes.

"Housekeeping was our first success; it came early in the project, and that got people’s attention," he adds.

With the rapid-cycle testing approach, Hnatow and his staff were able to test out 52 approaches in one year. Naturally, not all were successful, but staff were willing to at least give them a try.

"The thing about rapid-cycle testing is, if you know you’re only going to have to try it for three days, most people will say OK,’" he notes. "Just make sure you have pre-testing data and test data, so you can compare results."

Here are a few of the more beneficial changes achieved through this approach:

  • Changing the policy that required nurses to remove bed linens. "This was to avoid needlesticks for housekeeping, but we had had a needleless system for years, so we no longer needed that policy," says Hnatow.
  • Establishing a discharge lounge. A sign was put in every room saying, "We will try to discharge you early in the day."

"We have a number of indigent patients who have trouble getting transportation," he explains. "If they are stable, we now take them down to the lobby to our discharge lounge, which is supervised by a nurse, and it’s amazing how fast people can get transportation."

  • Putting a physician assistant out front in triage. Now, patients with minor problems are seen right at the door.

The project, which started in May 2003, still is going today, Hnatow adds, even though it officially ended in April 2004. "The project is now becoming the facility’s quality improvement model," he says. "We recently had a [Joint Commission on Accreditation of Healthcare Organizations] site visit, and they were very impressed with what we had done."


For more information on rapid-cycle testing, contact:

  • David Hnatow, MD, FACEP, FAAEN, Medical Director, Emergency Center, University Hospital, San Antonio, TX; Chief of Emergency Medicine, South Texas Poison Center, San Antonio. Phone: (210) 358-2078. E-mail: hnatow@uthsca.edu.
  • The report, Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments, can be found at www.urgentmatters.org. A link to the report is found under "Latest News."