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Important tool for disaster preparedness, ED overcrowding
A scoring system for assessing which patients are most ready to be discharged from the hospital can be an important emergency preparedness tool, suggests Pat Orchard, CCM, CHE, director of health services for Horizon Blue Cross Blue Shield of New Jersey, based in Mount Laurel. "It’s a methodology for tracking acuity," says Orchard, who has worked as a case manager in a variety of settings. "A lot of organizations have acuity systems but use them for determining nursing staffing ratios — [a defined number of] acute patients to a nurse."
The same concept, she points out, can be extremely valuable when used to determine a patient’s readiness to be transferred to the next level of care. Hospitals that categorize patients in some format indicating "readiness to transition," Orchard adds, can move quickly and efficiently in the event of disaster or even ED overcrowding. "When you’re talking about capacity, what comes in must go out," she notes. "The balance has to be there. If not, there’s a tremendous amount of delay."
Typically, organizations focus on input — getting ED patients into treatment rooms and then to the nursing floor, for example, Orchard says. "But if you don’t address output, managing patients to move them out efficiently and effectively, you don’t solve the throughput problem," she points out.
Without a system for categorizing patients, she says, hospital staff faced with high-capacity moments may spend hours trying to free up beds. "Say, for example, you had to move 40 people out of the hospital because there was a disaster in the community," Orchard adds. "Nurses are [examining] every patient in the hospital to determine readiness [to move]. Everyone is running in circles trying to find beds."
If a scoring system is in place, however, the patients who are most ready for discharge already will have been identified, and — after physician orders are obtained — can be moved quickly and easily, she says.
The first step in implementing such a system is to establish criteria [for acuity levels] and categorize patients based on those criteria, Orchard advises. "You can use numbers, or letters, or any kind of scoring you want, but you are scoring the patient based on readiness."
Whether the scoring grid is based on 1 to 4, 1 to 3, or something else, the information can be put into the computer system and pulled out in a report when needed, she says. "If you’re using a score of 1 to 4, those patients who are leaving in the morning, waiting for nursing home placement, or finishing one more course of treatment may be 4s. "This is a basic acuity system, but it’s based, not on clinical findings, but on the transition capability of the patient," Orchard explains. "How quickly can they transition to the next level of care?" she asks.
These are patients about whom physicians say, "Maybe they can go tomorrow, or maybe they should stay one more day," Orchard adds. "Some physicians don’t move patients as fast as they could."
From a managed care perspective, she says, some might question why such patients still are in the hospital if they can be discharged safely. But the fact is, they are there, she continues. "Maybe the physician hasn’t been in yet, or the physician was in that morning and test results weren’t back then. Multiple inefficiencies are out there," Orchard notes. Once a scoring system is in place, she adds, "at least you know where to focus your attention."
"Have a set of parameters," Orchard suggests, "so that when you do get in a crunch, you’re able to turn quickly to the high-level patients who can be moved out immediately. Make sure physicians have agreed to the process and to the scoring system the hospital has developed."
Whether the physician must be called when the process is put in motion — as the result of a crowded ED or a natural disaster — depends on the policies of the organization, she says. "Most would call to get the discharge order."
Assessing and scoring of patients should be done daily or even twice a day, depending on the hospital census, Orchard recommends. "If done in conjunction with nursing or case management rounds," she adds, "the time required should be minimal."
System came out of 9/11 response
Virtua Memorial Hospital of Burlington County in Mount Holly, NJ, was one of the facilities that got a call on Sept. 11, 2001, asking staff to find room for a possible deluge of patients seriously injured in the attack on the World Trade Center, says Dee Page, RN, director of case management. "We were one of those hospitals in the Northeast that were in close enough proximity that we thought we would have an influx of patients," she explains. "On Sept. 11, we got a call about 10 a.m. and were told to be ready. At that time, it was thought that we would have a lot of sick and injured patients," Page continues.
By 11:30 a.m., the hospital had emptied 62 beds in preparation for the expected patients, but unfortunately, most of the victims turned out to be casualties, and the beds weren’t needed after all, she adds.
The quick and the dirty
That experience, however, led to the development of a quick and dirty way to determine which patients could be moved on a daily basis, she says, not only in the event of an emergency, but to address throughput. The case management department established a scale of 1 to 4, with 4 being the lowest acuity rating, "the patient closest to the door," for whom there is a discharge plan in place, and 1 indicating an intense level of acute care, Page says. Next are the 2s, who require a significant level of care — patients in a step-down unit or maybe telemetry.
The level 3 patients require acute care but are progressing, she continues. "These may be postoperative patients, or those who are being treated aggressively and showing improvement, but who are not primed enough to go to a skilled nursing facility."
"There could be a fifth tier," Page notes, "a shaded area that would more or less indicate a patient who is being observed. If you wanted to push the envelope, you could add this level."
A departmental flowchart shows each patient and the rating code for the person’s status. (See "Patient Readiness Ratings.") The patient’s readiness level is determined at admission and reassessed daily, she says. The readiness rating also is entered into a web-based system that includes utilization review and discharge planning information, Page adds. "Pieces of that documentation are printed and placed in the chart, and the rest lives in the system as a lifetime record."
Patient Readiness Ratings
Source: Virtua Health, Mount Holly, NJ.
That system is helpful at the time of discharge, she says, because it documents where patients are sent or referred. "Where we fall short [with the patient readiness rating] is that nursing does not use it with us," Page points out. "The nursing department has not decided to go along with this," she says.
The nursing department had a readiness project of its own — a color-coded system that was tied to staffing ratios as well as patient acuity," says Page. "What that meant to them was that, if census and acuity goes below certain levels, the staffing is adjusted. As soon as they see the coding, they know they need extra staffing or that there are empty beds.
"The [nursing project] never got off the ground, but we continue to use our system," Page adds. "We know at any time how many beds are occupied by a particular type of patient."
In addition to its value during times of overcrowding or crisis, she notes, the patient readiness score helps caregivers prioritize the workload, if a case manager is not there, and take a more proactive role in assisting physicians with discharge decisions. "In our documentation system, we have an RC [review case] due date," Page explains. "For instance, if you have a managed care patient, and have just done a review with the payer, and the payer authorizes a three-day stay, technically, you wouldn’t have to look at [that case] for three days."
System helps prioritize
While that system helps in managing caseloads, she points out, "the readiness rating goes beyond the obligation to see the patient again." There might be six patients on the case manager’s list who require acute care and are progressing, Page adds, but the readiness check could reveal that one of those patients is now a 4. The case manager then can suggest to the physician that the patient might be ready for an earlier discharge, she says. "So it helps them further prioritize — it’s very valuable in that respect.
"It used to be that if you knew you were being paid for three days, you left it alone, but we really don’t feel that way anymore," Page points out. "It’s better to have your beds filled with people who are really sick. It’s better for the patient if you can move beds sooner."
With abdominal surgeries, insurance companies often authorize lengthy stays, and patients may be ready for rehab or discharge sooner, she adds. "The theory of Fill your beds; fill your beds’ doesn’t work anymore."
In terms of the readiness scoring system, the focus of the case manager’s day is with the 2s and 3s, Page says. "With 2s, you want to make sure you can move them through the system to a more appropriate bed, or ask, Have they finished that course of treatment? Do they need to be transferred to another facility?’"
With 3s, she adds, the idea is to make sure they are not the next patients to be designated as 4s. With 4s, the discharge plan is complete and just needs to be activated, Page notes. "If someone was told yesterday that [he or she] could move to rehab today, that patient would have been a 4 yesterday."
System not labor-intensive
When the time comes to empty some beds quickly, case management — the only department using the patient readiness system — gets the first call from one of Virtua Memorial’s bed-flow coordinators, she says. "We often go on divert here — beds are full, and we have to send patients elsewhere — and [the coordinator] comes to us right away, asking, What can we do to open some beds?’"
When that call comes, Page says, "We go right to the 4s and make some calls to physicians to let them know there is a crunch. Sometimes, they say they’re in the hospital and will be up to discharge the patient. They almost always want to see the patient."
With elderly patients who will be transferred to nursing homes, she notes, the case managers often will have gotten a heads-up that, for example, the patient still is receiving treatment, but this will be the last day. In those cases, Page adds, the discharge might be all sealed up for a particular date.
Although the readiness system is an internal mechanism for the case management department at present, Page says she would like to see it fully implemented at all the Virtua Health campuses. "It’s not labor-intensive at all," she notes. "It’s putting a sticker on the chart. On those days when we’re short-staffed, or even when we’re full and somebody wants to organize the day, it helps to have [the rating]. Instead of relying on a whole lot of other people for information, the case managers can look at the scale and see what they have, and know which patient to address first," Page adds.
[Editor’s note: Pat Orchard can be reached at firstname.lastname@example.org. Dee Page can be reached at (609) 267-0700.]