Case Management Insider: Managing Length of Stay Using Patient Flow – Part 3
By Toni Cesta, PhD, RN, FAAN Senior Vice President Lutheran Medical Center Brooklyn, NY
In the last two issues of Case Management Insider, we discussed issues associated with identifying and monitoring patient flow. This month we continue our discussion with a focus on the elements of patient flow associated with the inpatient setting. These issues relate directly to the provision of care as well as the progression of care for patients as they move through the acute-care continuum.
Understandably, there are a large variety of processes that touch patients as they transition through the hospital experience. Each of these processes must be evaluated individually as well as part of the larger process. Let’s begin by looking at those processes most common to the inpatient experience.
When beginning to look at patient flow, you may not think that you have a problem with a particular process or department. However, you may want to consider starting off by doing an assessment of all relevant departments, as we will discuss below. This way your hospital can identify those areas that need work, versus those that are not problematic. This provides a baseline that should be re-evaluated annually as needed.
Pharmacy turnaround times include the time from when the physician writes the order until the medication arrives to the floor. Although your hospital may not have overall issues with medication turnaround, it might want to take a look at chemotherapy turnaround or similar turnaround times for newly admitted patients. Many times the first doses of a newly admitted patient create the most delays. These delays affect quality of care as well as length of stay and can ultimately have a negative impact on patient flow. Chemotherapy administration falls into this category.
Throughput in the laboratory is a complex process. It involves a host of smaller processes, some of which are automated. In general, the following are the processes that should be analyzed on the initial assessment and then as needed after that.
Laboratory Turnaround Times
The first thing to consider is the turnaround time for specific tests. In working with the staff in the lab, the benchmarks for the various lab tests should be gathered. While some tests can be completed rather quickly, others may take longer. If the same expectation for turnaround time is applied to all tests, then some will always be outside the expected timeframe. Review your top blood tests with the lab and set realistic time frames for each test. Then establish the current turnaround times and focus on those tests that are outside the expected benchmarks.
The Accessioning Process
The accessioning process is the process that includes the time from when the specimen is received in the lab until it is processed and placed into the equipment for analysis. This process can get bogged down if the phlebotomists “batch” blood and send multiple specimens to the lab at the same time. The staggering of specimen delivery can reduce the likelihood of these kinds of back-ups in the accessioning process.
The Way in Which Morning Blood Work Is Drawn and Processed
The morning blood draw process will have a direct impact on the accessioning process. If the blood is batched, this will result in a delay in all the blood work being completed. Batching blood can overwhelm the lab when an overflow of blood work comes in all at once. Staggering the blood draws on the nursing units is the first step. The next step is to have the blood sent to the lab in small batches so that the lab can keep up with the volume.
Blood Work for Discharged Patients
Another issue to evaluate is the potential delays in discharge that may occur while the team is waiting for blood work to come back. If this is a common problem in your hospital, you may want to consider labeling this blood work differently. For example, the blood tubes could be labeled with a red bar around them to alert the laboratory staff that this blood work belongs to a patient who is expected to be discharged that day. This blood work might then be expedited so that the clinical staff can get the results earlier and the patient can be discharged sooner. This process should be particularly considered on units where there is a higher percentage of “short stay” patients, such as a cardiology unit.
Turnaround time for radiology services is another key patient flow process. Radiology encompasses so many diagnostics and treatments that it cannot be neglected when studying and assessing patient flow. The turnaround times from the physician’s order until the tests are completed are the key processes that should be evaluated. Most radiology systems do not capture this information so that in the absence of an electronic medical record it may be difficult to gain this information for analysis. Most systems monitor the time from when the test was done until the results are reported. While this is an important part of the process, as case managers we are also interested in the time it takes to actually do the test after the doctor orders it. However, if you are able to get this information, it can be quite valuable.
The absolute turnaround times are vital to this analysis, but there are other variables to consider. These would include the time of the day in which the test was ordered as well as the day of the week. When looking at the day of the week, weekends should be analyzed separately as there are usually more delays on Saturdays and Sundays.
Each of these metrics should be benchmarked against the expected turnaround times, which should be determined by the radiology leadership. Each test should have an expected turnaround time that is based on industry standards. These standards can be found in the radiology literature and should be re-evaluated annually.
Because there is such a large variety of tests done in the radiology arena, you may want to consider selecting those that represent highest volume in your hospital.
Another area to evaluate includes both internal as well as external transportation. Internal transportation has to do with the movement of patients within the hospital, including from one unit to another as well as from one department to another. When evaluating these turnaround times, patient transport from the ED should be evaluated separately from transportation within the hospital. Also to be considered are any departments or areas that use their own transportation staff. This is often true for emergency departments. These departments should be monitored separately as their turnaround times could be quite different from departments using a centralized service.
Other sub-processes might include the time to arrive to a test, versus the time to return after a test. Typically, the time it takes patients to return to their room after a test is longer because there is less pressure to get them to that location than there is to get them to the diagnostic test.
As with most processes that we are discussing, it is important to look at the time of the day and the day of the week. Staffing patterns will often dictate the turnaround time and may lead to the need for additional staffing at certain times or days.
Transportation external to the hospital is also important to consider. External transportation has to do with ambulances and other paid-for-transportation services. When evaluating these, be sure to look at the company and the type of service as well as times of the day and days of the week. The data should also be segregated into groups that indicate whether the transportation was ordered the same day or the day before. When transportation is ordered the same day as it is needed, the wait times tend to be longer than when it is planned for the day before it is needed. This kind of information can be used when speaking to the case management and medical staff so that they can see the impact of planning for discharge the day before the patient is actually going home. Patients waiting to leave because of transportation delays can back up the ED, the PACU, and can backlog housekeeping and other ancillary services.
Perioperative services are impacted by patient flow because of patient flow delays in other parts of the hospital. Not unlike the emergency department, they are the recipients of delays downstream from them. Most perioperative services track and monitor their own patient flow data. If this is the case in your hospital, then it will be easy enough for you to tap into this data. If not, then you will have to work with the department to begin to collect it.
High-level perioperative analysis should include the following:
• the time the patient enters the operating room until the procedure starts;
• the procedure start to the procedure stop time;
• the procedure stop time to the patient exiting from the OR;
• the time from the patient exiting to the next patient starts.
When evaluating the entire perioperative process, however, one must consider more than just what happens inside the operating room. All of the perioperative processes can have a positive or negative impact on patient throughput and length of stay and are important to any patient flow analysis.
Other perioperative processes include the following:
• preadmission testing processes and delays;
• operating room turnaround times (as above);
• PACU turnaround times;
• PACU delays due to overcapacity in the intensive care or telemetry units;
• cancellation rates and reasons, including cancellations within 24 hours of surgery and within one week of surgery;
• operating room booking process.
Perioperative processes should be segregated by ambulatory surgery versus inpatient surgery. This is important because ambulatory surgery cases usually have a shorter operating room time as well as recovery time. They will positively skew data on more complex inpatient procedures and therefore should be kept separate and reported separately.
Cancellations for surgery are an important metric, as they may indicate problems with other processes such as pre-surgical testing, patient communication and education, among others.
The Nursing Department
The staff nurses and nurse managers play an important role in the management of patient flow. Many elements of patient progression are dependent on the interventions associated with direct patient care that are performed by nurses. Examples of these include:
• progressive ambulation;
• diet progression;
• patient education particularly around self-care, medications and disease processes;
• transitioning from IV to PO medications;
• pain management.
Nurse managers, staff nurses and case managers should think and function as a team when it comes to patient flow. Attending daily patient care rounds is a good way to make this happen. This is particularly true if the rounds are conducted at the bedside. By rounding at the bedside, the team can visually assess the patient in terms of their environment, i.e. foley, IV, ambulation, etc., and work together to break down any barrier in care progression. Over time, patterns of delays can be identified and corrected in a unified and collaborative fashion.
Clearly, the case managers are the leaders in patient flow management. However, as we have seen throughout this series on patient flow, the entire case management department must work collaboratively with all departments throughout the hospital to facilitate patient flow. Patient flow is one of the key roles of the case manager. The case manager, in the role as coordinator and facilitator of patient care, identifies and corrects patient flow barriers as they occur. In this role, the case manager ensures that delays at the point of care are identified and corrected. This unique role affects quality of care, operational efficiency, cost and length of stay. It places the case manager in a strategic position to identify and correct delays as they occur and before they become problematic. When the problem cannot be corrected directly by the case manager, the issue has to be directed to the case management leadership, the physician advisor, or the director of the department in question.
The case management department should have contacts in each ancillary department. This individual is the key contact for the department with whom the case manager can interface when something needs to be expedited. As issues are identified during walking rounds or at any point throughout the day, the case manager has a contact person to work with who has been prospectively identified. Once the issue has been identified, it should be entered into the case management database for aggregation and analysis later. The data will help to identify patterns and trends that need to be corrected on a go-forward basis.
Physician practice patterns may affect as much as fifty percent of the patient flow delays in a hospital. Issues to address as they relate to the role of the physician include:
• physician practice patterns around resource utilization and length of stay;
• ventilator use for chronic patients, including weaning attempts and patterns;
• end-of-life issues such as use of critical care beds and obtaining advance directives;
• discharge delays;
• transfer issues, such as non-notification to the receiving hospital;
• misuse of the ED;
• outpatient work-ups;
• bypassing the admission process;
• bypassing the precertification process;
• critical care and telemetry bed usage;
• delays in moving patients out of critical care beds or off telemetry, thus adding to the cost of care and length of stay and reducing throughput.
The discharge process is another key process in terms of patient flow management. Issues for consideration include:
• Discharge planning staffing patterns, particularly understaffing and/or lack of vacancy coverage for vacation/holiday or sick time coverage. Delays over the weekend will bottleneck processes on Mondays and Tuesdays. The combination of staffing shortages as well as lack of weekend coverage can both contribute to delays that will carry over into the following week.
• Discharge patterns, especially delays on weekends, holidays and evenings.
• Discharge delays associated with physician’s order writing, family delays or transportation delays.
• Availability of continuing care services in the community.
• Patient financial issues such as insurance coverage for community services. These may affect the case manager’s ability to obtain services in the community and may delay discharge.
• Delays associated with pre-authorization delays attributed to managed care companies or government payers.
As lengths of stay shorten across the country, opportunities to continue to reduce length of stay become more difficult to identify. Monitoring care progression processes is the foundation of patient flow and requires daily point of care monitoring as well as data analysis retrospectively.
Each case management department should create a patient flow infrastructure that includes daily monitoring and correction as well as a database that allows for collection of information that can be used later for analysis and performance improvement.
In next month’s issue of Case Management Insider, we will review a couple of different patient flow report cards that can be used to monitor delays and bottlenecks across the continuum of care.