Nurses handle most admissions, discharges

Process has improved throughput, satisfaction

When patients are admitted to or discharged from St. John’s Hospital in Springfield, IL, in many cases the process is completed by a team of nurses with the sole responsibility of admitting and discharging patients, freeing up the floor nurses to provide care for patients.

“Having a dedicated team of nurses who can perform the admissions and discharges in a timely manner has a trickle-down effect throughout the hospital. With this process, we are able to free up beds early in the day and get patients from the post-anesthesia care unit and the emergency department into beds more quickly,” says Jennifer Cullen, RN, MSN, director of professional practice for the 400-bed hospital.

Patient satisfaction scores have improved with the implementation of the admission/discharge team, she adds. “Patients want to get to a bed quickly and they want to get out of the hospital quickly. If the admission goes well and is timely, it sets the tone for the rest of the hospital stay. If it goes badly, things tend to go downhill from there,” she says.

A multidisciplinary task force developed the concept of having dedicated admission/discharge nurses as part of a Lean continuous process improvement initiative aimed at improving throughput throughout the hospital, says Pat Lucas, RN, MS, retired director of inpatient services. The task force included a Lean facilitator, staff nurses from the medical, surgical and cardiac floors, emergency department, social workers, case managers and nurse managers.

“The task force team felt that discharges were getting held up because of our processes. We mapped the patient flow step by step from admission to discharge and identified steps that were duplicates, redundant, or had no value. Then the team determined what the process would be like in a perfect world and developed an action plan as to how we could make it happen,” Lucas says.

The team determined that the nurses on the unit often gave getting patients discharged a low priority because physician rounds and initiating care took up a lot of their time, Cullen says. “When a new patient comes into the unit, the admission process increases the workload for the unit nurse, who is already trying to care for a group of patients,” she adds.

The hospital initiated a pilot project with one nurse on each of two units assigned to focus solely on the admissions and discharges. The team collected data to determine the volume of patients, the time nurses spent on admissions and discharges, and the peak times for admissions and discharges and used that information to map out the process.

They determined that 10 a.m. to 4 p.m. was the busiest time, with admissions and discharges peaking between noon and 1 p.m., and that each admission and each discharge took about an hour.

“This gave us an idea of how many nurses we needed and what the job descriptions needed to be. We continued the pilot using PRN staff until we could fill the positions with permanent staff. We gradually filled the positions with experienced nurses with medical-surgical backgrounds,” Lucas says.

The hospital has 16 admission/discharge nurses, all of whom work part time. The nurses work staggered hours, with the majority working during the peak hours. There are fewer nurses on the weekends because of the decrease in volume of admissions and discharges, Lucas says.

The admission/discharge nurses handle about 80% of all admissions and discharges. The nurses carry a telephone programmed for patient information that alerts them when they are getting an admission.

The nurses go to the unit, notify the unit nursing staff, and greet the patient. They collect the patient’s medical history and information on medications and complete medication reconciliation. The admission/discharge nurses use a checklist to communicate and hand off the information they gather to the unit nurse. The admission/discharge nurse may start the admission of an emergency department patient before the patient gets to the floor so that when the patient arrives on the unit, the history and medication reconciliation are complete. “This can be a tremendous satisfier to the patient and their family as well as the unit nurse,” Lucas says.

The admission/discharge nurses work closely with the case managers to coordinate the discharge. “The case managers know when patients are likely to go home and can inform the admission/discharge nurses about specific things to be aware of, especially home health services,” Cullen says.

When patients are ready for discharge, the nurses go to the unit, introduce themselves to the patient and go over the discharge instructions with the patient and family. “Medication reconciliation is a huge part of the discharge process, and it takes a lot of time to confirm that patients are going home with the correct medications and understand how to take them,” Cullen says.

As part of their orientation, the admission/discharge nurses go to patients’ homes with a home health nurse to observe an admission to home health services.

“It’s a real eye-opener for them to see the home health nurse trying to find out the information they need when they are opening the case of a patient just discharged from the hospital. During their observation, the admission/discharge nurses have discovered that often the home health nurses do not have everything they need and now they know what needs to be coordinated,” she says.

The admission/discharge nurses call patients 48 hours after discharge, using a scripted questionnaire, and check to make sure that the patients have filled their prescriptions, understand their discharge instructions, and answer any questions or concerns. “We have been able to immediately identify issues and problems and follow up with the nursing unit or their physician,” Cullen says.