Managing Length of Stay Using Patient Flow — Part 2
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Last month, we reviewed the fundamentals to patient flow concepts and theories. We talked about how demand and capacity management theories can be applied to health care settings. And we talked about the need for health care organizations to take a proactive approach to managing patient flow on a daily basis.
Now that we have covered the fundamentals, let’s begin to discuss how to break this large concept into manageable parts. Patient flow management is a huge issue to tackle because of its wide reach throughout any health care organization. There is virtually no department or discipline that does not have some effect on patient flow. To begin, let’s consider placing patient flow processes into three major categories:
Each of these larger categories can then be subdivided into more manageable groupings.
Access and Patient Flow
Patient access has to do with the ways in which a patient enters a health care system and all the processes associated with that access as well as associated outcomes. They include:
- precertification (denials);
- emergency department;
- bed tracking and management;
- utilization review and transfers.
The admission process is affected by many departments, including patient access/admitting, nursing, and ancillary services. If this process is an issue in your hospital, a team may want to look at the process from beginning to end. A good rule of thumb to consider is that whenever there is more than one department or discipline involved in a process, then the best way to address the problem is by convening a workgroup that can meet and work the problem out as a group. The goal of the team would be to identify any areas needing improvement. The team may find that the delay is in admitting, or it may be on the nursing floor after the patient has arrived at the unit but before the nurses have completed the process. Redundancies in the process should also be reviewed as patients frequently will be asked the same questions over and over again. This is dissatisfying for the patients and a waste of time for the staff.
The admission process can also be affected by the time of the day. If your hospital admits larger numbers of patients at certain times — for example, in the mid-to-late afternoon — then these peaks in volume can result in delays in the process. This issue relates to our earlier discussion about the need to discharge patients when they are clinically ready, rather than at an arbitrary time of day such as 10 or 11 am. This kind of batching can result in placing undue volume overload on the other affected processes. In this case it would be the admitting process, but it might also include the laboratory, radiology and nursing. All these departments would be affected by batched admissions and result in a process delay.
Patients typically arrive at the hospital in the categories of “planned,” “urgent” or “emergent” admissions. These patients are registered in different ways. Errors made during the registration process can have a negative effect all the way through the inpatient experience and ultimately have a negative effect on the discharge planning process. The case managers need accurate insurance and patient address information in order to begin and manage discharge planning. Registration errors can be a patient safety issue as well. For patients who are incorrectly registered, it is possible that a duplicate medical record number may be assigned to them. This can lead to errors in patient care as information from prior admissions is not accessed or used. For this reason and others, the hospital may want to consider a performance improvement project if registration errors are a concern. The performance improvement team may want to understand the types of errors and the frequencies with which they occur as well as when they occur. For example, do errors occur more often on emergency admission on the night shift? What types of errors are they? Are they duplicate medical record errors, errors in Social Security numbers, or the spelling of patient names? How will these issues affect patient safety, discharge planning, billing or denials?
Registration errors can often affect precertification denials. Precertification denials occur when the managed care company is not notified in a timely manner that one of its members is being admitted to the hospital. The team may want to take a look at these denials and ask the following questions:
- Do they correlate with registration errors?
- Do they happen on particular shifts or days of the week?
- Do they occur when staffing is short?
- Are they more likely to happen in admitting or the emergency department?
As the team gathers information, it can share it with the access department or the admitting department staff so that they can begin to understand the effect of these errors on other departments down-stream. It is not uncommon for a department that is at the front end of a process to not know the ramifications of its work on other departments or disciplines further along in the process.
Finally, the team should work directly with the access department’s leadership to correct the errors. The team should revisit the issue on a regularly scheduled basis so that so that any slippage can be caught and corrected as soon as possible.
The Emergency Department
Much of the focus on patient flow has been aimed at the emergency department. As has been discussed, emergency department overcrowding resulted in a Joint Commission standard in 1995 that focuses on this issue and how hospitals are working to correct it. Overcrowding in the emergency department can be caused many factors including:
- a rapid influx of patients to the ED, particularly at certain times of the day and days of the week;
- physician or RN staffing shortages in the ED;
- delays in ancillary services such as radiology or laboratory;
- a slowing of discharges from the hospital causing a backlog in the ED;
- delays in transportation;
- an increase in the inpatient length of stay.
For most hospitals, the majority of admissions enter through the emergency department. This is particularly true for medical patients. The ED’s processes can affect flow for admitted as well as treat-and-release patients. Typical emergency department processes should be monitored and managed on a regular basis in order to determine where the greatest problems lie. In addition to measuring these sub-processes, they should also be measured separately for admitted versus treat-and-release patients. The more specific the data can be, the greater the likelihood of identifying the specific areas of bottlenecks and correcting them as needed.
Emergency department processes should include the following:
- time to triage;
- time from triage to seen by physician;
- time from seen by physician until disposition determined;
- time from disposition to bed assignment;
- time from bed assignment to placed in bed;
- turn-around time for radiology tests/treatments/procedures and results reported;
- turn-around time for laboratory tests/treatments/procedures and results reported;
- turn-around time for initiation of treatment of admitted patients;
- length of stay for admitted patients;
- length of stay for treat-and-release patients;
- diversion rate (reported time that the ED is not accepting ambulances due to overcrowding and capacity management issues);
- number of patients who left without being evaluated by an MD, PA or nurse practitioner.
Your hospital’s ability to track each of these sub-processes will be dependent on a number of elements being in place. The hospital will need to have some form of automation in the ED that allows it to track these timeframes. Prior to automation, most EDs relied on “logbooks” to monitor statistics. It is well understood that these logbooks were often inaccurate and/or incomplete. In order to capture the level of detailed information listed above, an ED tracking system is essential.
Over time you may determine that you don’t need to track each and every process. As you collect the data, some of the processes may be working quite well while others seem to be broken. If you are finding that this volume of data is too much or overwhelming, you may want to remove the indicators that are always within the expected benchmark. This may make the data more manageable and/or more meaningful. The amount of time you want to spend on collecting the initial set of indicators will be dependent on your hospital and the outcomes you initially collect. However the process is accomplished, it absolutely must be done in concert with the emergency department team and ED medical leadership. It is likely that the ED is already collecting a lot of this data for regulatory purposes, and you will be able to piggyback onto that.
It is no secret that most EDs report some level of overcrowding, and the goal is to take pressure off the ED by addressing the processes internal to the ED as well as the throughput throughout the hospital. Organizations must think about ED overcrowding much more broadly than just as an ED problem. The hospital must consider the roles of other areas of the hospital in improving ED efficiency and patient flow. We will review these as we continue our discussion on patient flow.
Management of patient beds, including assignment of those beds and turnaround time for vacated beds, is an important component of patient flow. Many hospitals have assigned this function to an RN or group of RNs who can manage the assignment of clinically appropriate beds to patients throughout the hospital. Some hospitals have even gone as far as staffing this process around the clock. Queuing beds for post-operative patients and new admissions, as well as managing the internal transfer and bed assignment processes, can all fall under the role of this group of nurses. By allowing the bed management staff to coordinate the bed assignment process, there is greater likelihood that congestion will be reduced as bed assignments are proactively coordinated and managed.
There are a variety of software applications for bed management that can help with these processes as well. Using a combination of a central bed management station along with “mini-bed boards” throughout the hospital allows the bed management staff to actively and real-time manage the movement of patients into, through, and out of the hospital. Anticipating discharges and operating volume for the following day are other important pieces of this process that assist in ensuring that the ED, PACU and operating rooms do not get backed up, causing a myriad of other problems in capacity and throughput.
Electronic bed boards also help with housekeeping throughput as the housekeeping staff can be notified electronically when a bed is ready to be cleaned, and the cleaned bed can then be posted in to the electronic system for the bed management nurses to assign.
Issues to be considered when setting up these programs include the hours of operation and the number of staff members required. Hours of operation will depend on when your hospital’s discharge and admission processes are most active. The number of staff members will depend on the size of the hospital as well. Many hospitals have staff members on duty seven days a week for a minimum of twelve hours per day. However, each organization has to determine its requirements based on activity on weekdays versus weekends, busiest time of the day and so on. It is always a good idea to consider a “pilot” to see how many staff are minimally needed to make the process work best.
The hospital should also consider having the bed management staff be part of the case management department. There are so many components of bed management that relate to case management processes that this makes good sense. Examples include patients going on or off telemetry, or in and out of the intensive care units. The bed managers will also have to work very closely with the department of nursing on internal transfer issues such as isolation beds or other specialty bed requirements of a clinical nature.
Utilization Review and Transfers
Preadmission utilization review should be a formal part of any case management department. Planned admissions should be reviewed by a case manager for appropriateness of the level of care based on each patient’s clinical condition and needs. This position is typically located in the access or admitting department. The case manager performing this function should also review transfers and direct admissions to ensure that the correct level of care is identified based on the patient’s clinical needs and condition.
For hospitals that have a smaller volume of these types of admissions, or for small hospitals in general, a combined role for the emergency department case manager can be a consideration. This role can also be combined with transfers as well. Some hospitals, if they deal with large number of transfers in and out of the hospital, may have a fully staffed “transfer” center. This can be particularly important in hospitals that do transplants. These “units” are staffed 24 hours a day, seven days a week.
Whichever way your hospital chooses to staff this process, and regardless of where it is located, it is important that a pre-admission utilization review process be in place. As we have discussed in prior months, the routes of entry to the hospital must be case managed. These typically include the ED, planned and urgent admission processes, and transfers. While many organizations are moving toward case management in the emergency department, they are still neglecting the planned admissions and transfers. By not case managing these admissions, the hospital remains vulnerable for inappropriate admissions and inappropriate transfers.
Throughput and Patient Flow
We have now discussed the issues of greatest concern when managing patient flow, including the points of entry and pre-admission to the hospital. This first category, “access,” includes a variety of departments, disciplines and processes integral to ensuring that the hospital admits the clinically appropriate patients and that the admissions process is smooth and results in the least amount of errors. Of course, the next broad category we will discuss is the “throughput” process.
As we learned when looking at the admission or access processes, we will learn that there are a variety of inpatient processes that affect the flow of patients through the inpatient direct care experience. These processes will affect a number of issues, including length of stay, cost per day and cost per case, the quality of care provided, patient safety and patient satisfaction, among others. Throughput, our second category, considers all the internal processes of the hospital that touch patients as they move through the acute care continuum. They are integral to the management of length of stay in an environment where most of the low-hanging fruit has already been picked. The ability to manage and sustain a short length of stay in an environment where lengths of stay are already short is a challenge at best.