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Continuity is the key to successful process improvement. That’s lesson No. 1 from a group of children’s hospitals looking for ways to improve bed control — the art of having beds ready for patients as needed and getting those patients quickly from one unit to another. Sponsored by the National Association of Children’s Hospital and Related Institutions (NACHRI) of Alexandria, VA, and MMP, a health care consulting firm from Bainbridge Island, WA, the meeting last May included 13 hospitals, 10 of which participated in a similar meeting in 2000.
"I think the biggest thing that struck me is that change is hard," says Lynne Lostocco, RN, MSN, NACHRI’s field director of management information services. "Change is a slow process, and I think it behooves us to find ways to keep people excited and motivated."
In this work to improve bed control, there is no "end" to get to, Lostocco says, and if you find yourself achieving one step and calling it the ultimate goal, perhaps you are asking the wrong questions. Even among the facilities that made the most dramatic improvements, Lostocco continues, many were able to take an idea from that second meeting that might push them further forward. "Sustaining change is a very hard thing. Maybe it’s not a surprise, but it was evident at the second meeting."
Participants in the May meeting reflected different starting points for the work ahead. Some had attended the first meeting, while others were new. Even those ready and willing to jump on the bed-control bandwagon had problems because new members lacked the foundation established in the first meeting. Overall, the second meeting trumpeted the successes of participants. Lostocco notes that the collegiality of the group was instrumental in that success. Despite each institution’s unique set of problems in bed control, members participating in the project have been able to learn from each other, she says. "Networking provides its own opportunities. Over and over, hospitals contacted other members of the group to discuss processes, policies, and positions."
During the year, several issues became evident:
Different facilities had different approaches to those issues, and some certainly had more success than others. At Miami Children’s Hospital, one of the toughest issues to tackle was wait times in the emergency room (ER) that resulted from trying to push patients into units. Patients who waited too long left without being seen.
According to Maryann Henry, RN, nursing administrative director of emergency/trauma services at the 268-bed hospital, the proportion of patients leaving without being seen was 7% to 8% at the facility last year, compared to a national norm of about 4% to 5%. Now, they have reduced it to 1% or less. Wait time in the department overall was six to 12 hours, including five to six hours in the waiting room. "You used to have to wait up to a day for a bed," says Henry. Now that wait is 2.5 hours for urgent cases and 60-90 minutes for nonurgent cases. "That’s one of the lowest in the county."
Fixing the problem required dealing with congestion on the units, explains Jill Tahmooressi, RN, director of medical surgical services at Miami. "We implemented an automatic bed tracking system," Tahmooressi explains. "Originally, nursing would call environmental and leave a message. They would call back. Then they called admitting. It was just a game of phone tag to let someone know a bed is vacant and had to be cleaned for the next child."
The new system is automatically linked with the admission/discharge/transfer computer system. "If a child is discharged, nursing calls a special number and enters a code. This beeps the housekeeper on that floor, and she knows that bed is vacated. There is no direct telephone communication." she says.
If the nurse is busy and doesn’t make the call, the system will automatically beep the housekeeper. Different codes let housekeeping know whether someone in the ER is waiting and they need to clean that bed next, or if it is a child due out of the operating room (OR) and a "regular clean" will suffice. "The housekeeper has a certain amount of time to respond, and if there is no response, then the system automatically calls a supervisor," Tahmooressi points out.
Goal benchmarks were established for each of the three types of requests: A stat request has to be cleaned within 40 minutes of a child vacating the bed; "clean next" calls require the job to be done within 45 minutes; and "regular clean" gives housekeeping an hour. So far, the average is 59 minutes for stat, 83 minutes for the relatively new "clean next" option, and 59 minutes for regular clean. "I don’t think everyone is really comfortable with the new option, and I think that will go down over time," she adds.
Another way the hospital improved, says Henry, was to fax reports to units rather than wait to give verbal reports. "Ten minutes after we fax the report, we send the patient up to the floor," says Henry. "No more waiting on hold."
If by chance the room isn’t ready, the child is put into a clean treatment room while housekeeping finishes. Or, says Tahmooressi, "if the bed isn’t there, we’ll settle the child in the room on a stretcher or in a wheelchair. The culture of give us another hour’ just isn’t allowed any more."
Getting the changes implemented required some selling, says Henry. "We had to sell it to operations, administrators, and nursing directors," she notes. "But once we got their buy-in and provided inservices, they understood that this was about improving patient care, not making life difficult."
Emphasizing that they are "here for the children" helps them accept the changes, Tahmooressi says. "And top administration support reinforces the message. They get praise for implementing and improving through what hasn’t been an easy program."
Henry agrees there are a number of reasons for facilities to care about bed control. "Every patient who leaves without being seen is revenue out the door," she says. "We are a freestanding facility, so patients can go anywhere. Lots of hospitals are setting up pediatric ER units. And if those physicians practice at our hospital, they won’t want patients sitting in our waiting room. They want care started at once, so physician as well as patient satisfaction is at risk, too."
The job isn’t over yet at Miami. The hospital is implementing a bed-management-peak census plan that includes four different stages, including the most critical, "code bed," which means there are no vacancies at all. The stage will be disseminated daily to staff via e-mail, Tahmooressi explains. "A lot of people work in isolation and may not know we are having a bed crisis. This has a checklist defining what each person has to do and who is responsible for what."
Henry says another new program will provide admitting nurses with appropriate training so they can start IVs, draw blood, or start patients on antibiotics as warranted. "That will get care started right away, even in the admitting department."
Laurie LaPenotiere, RN, CEN, emergency department nurse manager and interim vice president of nursing at the 150-bed Children’s Hospital in San Antonio, says the facility was able to improve its bed control by concentrating on the communications issues. "We had a bed-control plan. We instituted admission express and clinical admitting. We had preadmissions testing and a discharge waiting area, but we still had wait times of up to 12 hours in the ER," she says.
No one knew what was going on throughout the facility. "We had just a single bed-control person for a campus with 600 beds total and since so many of them were adult beds, they weren’t always aware of specific pediatric issues" such as not wanting a 2-month-old sharing a room with a 16-year-old. The problem grew so great that often physicians would just send patients to the ER rather than send them through admitting. That cost money. "And there are five other hospitals within a mile of us, so patients would leave. We have great care, and we knew that. But we weren’t efficient."
The answer to the problem lay in stitching together a lot of little pieces to what the hospital already had in place. "We instituted a patient-placement matrix that shows what kinds of patients go where. We included a query on surgery scheduling asking where the physicians wanted patients to go post-op. We started using taxi vouchers and a system shuttle bus to get patients home. And we gave a phone to bed-control personnel rather than just a pager. That way physicians could actually call someone. We not only had a discharge waiting area, but we started using it and publicizing it."
The result is a 30% decrease in ER admissions. One year later, ER wait times are down from 225 minutes to 175 minutes. At the same time, overall patient volume has increased 25%. "But we aren’t finished yet. We will be extrapolating our system to all 600 beds and are still looking at ways to improve communication," says LaPenotiere. "It’s still hard to get in touch with charge nurses. Should we use pagers or cell phones? We are trying to experiment by having the nurses page bed control when discharges are pending. We are looking at our worksheets to see what beds are full, who is in them, and what patients are coming in. We hope to have a teletracking system at the end of this year that will tell us automatically what beds are available."
The lessons learned by NACHRI members aren’t just applicable to children’s hospitals, Lostocco says. "Anyone can look at the issue and benchmark with peers," she says. "Process flow is process flow, and it doesn’t really matter if you are talking about pediatric patients or adult patients. There are only nuances, like the kind of bed you need." A neonatal patient whose outcome could turn quickly from good to bad has a parallel in the cardiac patient who also has critical timing issues attached to his or her recovery. "The time frames vary, but you can still learn from the information we have gleaned throughout this process."
This isn’t just a nursing issue, says LaPenotiere. "This includes everyone from physicians to housekeeping, and that makes it important to every hospital." The key is to improve communication among all of those stakeholders and make it a primary focus, LaPenotiere continues. "You need a warrior to go forward and get it done. You have to change the paradigm to one where everyone recognizes you can do something better. And it’s a gift you can give the patient: an easier transition to the hospital."
In an age where patients are referred to as customers and believe in their inevitable "rightness," finding ways to streamline their entrance into the system is a way to make them happier from the start, Lostocco notes. The upshot is better patient satisfaction scores, more likelihood that a patient would return to your facility, and a potential competitive edge. "Fixing bed control really catches the public eye."
[For more information, contact:
• Jill Tahmooressi, RN, Director of Medical Surgical Services, and Maryann Henry, RN, Nursing Administrative Director of Emergency/ Trauma Services Miami Children’s Hospital, 3100 S.W. 62nd Ave., Miami, FL 33155. Telephone: (305) 666-6511.
• Laurie LaPenotiere, RN, CEN, Emergency Department Nurse Management and Interim Vice President of Nursing for Children’s Hospital, 7700 Floyd Curl Drive, San Antonio, TX 78229. Telephone: (210) 575-7777.
• Lynne Lostocco, RN, MSN, Field Director, Management Information Services, NACHRI, 70 Shannon Drive, Warwick, RI 02889. Telephone: (401) 732-8111.]