Team approach improves hospital’s patient flow

Case managers are an integral part

Danbury (CT) Hospital takes a team approach to facilitating patient flow, with a series of initiatives coordinated by a multidisciplinary Discharge Admissions Review Team (DART) that meets regularly to assess what’s working and what needs improvement to get patients in and out of the hospital safely.

Case managers are an integral part of the patient flow initiatives, starting in the emergency department (ED) and continuing throughout the patient stay to make sure that patients receive the care and procedures necessary to keep their length of stay as short as possible.

"One of the most important things we do is provide a link between the nurses, the doctors, and all other people who touch the patient. The patient is at the center, and we are the links," says Doris Imperati, RN, BSN, MHSA, CCM, director of clinical resource management.

The case management department has helped coordinate several projects designed to facilitate patient flow, including developing discharge materials in multiple languages and creating a chart sticker that reminds physicians and the nursing staff of what they need to do to ensure the patient is ready for discharge.

Direct admissions go through the mobile admissions coordinator, or MAC nurse, who facilitates the admission process for patients and physicians.

"The MAC nurse works for the nursing department but has several years of case management experience and therefore has a good understanding of what has to happen for timely, safe patient throughput," Imperati says.

DART, headed by the chief of the medical department, includes an administrator, physicians, department heads, the MAC nurse, and representatives from case management and performance improvement.

DART meets regularly to review what is and isn’t working to get patients safely in and out of the hospital. For instance, it uncovered a problem with the hospital’s transcription service, which wasn’t completing the discharge summary transcription on time. Since most skilled nursing facilities won’t accept a patient without a discharge summary, patients were staying longer than necessary.

The team identified a transcription company that turns around the transcriptions within two hours, speeding up the discharge process.

The committee examined the time of discharge and made sure the hospital staffing was centered around the peak discharge times.

The staff work to have patients discharged by 10 a.m. or 11 a.m. but also try to discharge patients later in the day if they are ready to go home.

"As the DART committee worked to improve the process, we realized it is more important that the discharge is planned and everybody knows the plan than for the discharge to happen by 11 a.m.," Imperati says.

The team examined factors that could cause delays in discharge. For instance, most surgeons are in surgery during the early part of the day and don’t make rounds until late afternoon. Many attending physicians don’t visit their patient in the hospital until their office hours are over. When they want a test before discharge or don’t look at the results until late in the afternoon, it can delay discharge until the next day.

Every day in the late afternoon, the case managers touch base with the physicians, either by making rounds with them or telephoning them to identify patients who are likely to be discharged the next day.

The case manager puts an "A" priority next to the patient’s room number if the patient is likely to be discharged or enters "A" priority on the unit’s assignment board. This alerts the staff nurses to discuss the potential discharge with patients that evening, asking them if they have transportation for the next day and suggesting they call their family if needed.

Tests and procedures that must be completed before the patient can be discharged also are tagged as "Priority-Discharge." This means that if the patient has a laboratory test or other procedure scheduled, it is done early and the results are returned quickly.

"Case management plays a pivotal role. It’s up to them to find out what is happening with each patient and to make sure that the nurses, the transporter, the skilled nursing facility, or anyone else who needs to know is aware that the patient is being discharged," Imperati says.

The challenge is making sure the patient is ready for discharge when the family arrives, she adds. "We don’t want the family having to sit around and wait for us. The case manager coordinates with the doctor and clinical staff so that everything is ready when the family arrives."

The case managers devised a 3x5 peel-and-stick label that goes on the front of the chart, reminding the physician that the patient is going to be discharged and providing a checklist of what may be needed for discharge. "This not only helps the surgeon who might get out of surgery at 6 p.m. when the case manager is gone, but it helps any person who touches the patient know what we need to make the discharge smooth," Imperati says.

As the patients approach discharge, they are educated about their conditions to prevent readmission. "It’s a team effort between the nurses, the physicians, the case managers, and other health care team members. Our goal is to educate the patient and the family to take better care of themselves when they are back in the community. We want to reduce the number of patients coming back to the emergency room when their problems could have been avoided if the patient had been educated," says Elizabeth Adler, BSN, MHA, clinical quality manager.

The staff wrote educational booklets for patients on the medical-surgical unit and some obstetrical patients, using terms that patients could understand, telling them what to expect throughout the hospital stay, what to do after discharge, and what to do if they have certain symptoms. The booklets have been published in English, Spanish, and Portuguese.

"We recognize that we have a multicultural and diversified community, and we try to have resources to meet their needs," Adler says.

The case management office also worked with physician leaders to facilitate the creation of specific discharge instructions for each diagnosis, which can be tailored to individual patients.

"When someone is going home with heart failure, we want them to know what they weigh when they leave the hospital and what to do if their weight goes up. They can refer to specific discharge instructions to assist them as to who to contact, what to follow up, and what medications they should be taking," Adler says.

At Danbury, patient flow initiatives begin in the ED, which is staffed by a case manager who starts discharge planning before admission and ensures that the patients meet admissions criteria.

Case managers on the floor keep track of patients who are approaching discharge and notify the physicians and the rest of the clinical staff so there won’t be any delays in discharge.

When a patient comes in through the ED, the department’s full-time case manager gets involved. If the patient is going to be admitted, the case manager screens the patient to see what his or her benefits are and what kind of support system is available at home.

She talks with the family to determine if there are family members who can help with the care after discharge. If not, and it appears that the patient may need care after discharge, she starts looking at options such as skilled nursing facilities or a visiting nurse.

"Many times, patients show up with symptoms that could be treated, and they could be released back home; but because of issues in the family, it’s easier to put them in the hospital," Imperati says.

In these cases, the case manager works with the physician to make sure that the clinical reasons for admission are well documented. If the patient doesn’t meet criteria for admission, the case manager works with the patient and family to come up with other options.

"The case managers are getting good at direct nursing home placement. It’s tricky for Medicare patients because they have to be in the hospital for three nights for Medicare to cover it. So if they come to the emergency room, they have to privately pay for nursing home care unless they have Medicaid or other long-term care coverage. It’s quite a challenge," Imperati says.

The ED case managers screen for cases that don’t necessarily meet admission criteria but might meet observation criteria. For instance, a patient who has chest pain but has not had a heart attack may be able to stay overnight for observation.

"The emergency room case manager plays a critical role to make sure the patient gets to the right level of care before he or she is admitted to the hospital," Adler says. The MAC nurse assesses what unit in the hospital best meets patient needs.

"Our policy is to identify right up front what a patient’s discharge planning needs are likely to be. We want to care for the patients while they are here and not have them return because we didn’t know about their home situation or transportation problems or things like that," says Pat Morgan, RN, CCM, supervisor of clinical resource management.

Physicians who want to admit a patient directly to the hospital from the office call the MAC nurse, who gets the admissions orders from the physician and makes sure the patient is met on arrival and escorted to a room.

"It provides customer service for the physician and for the patient who is not sitting around waiting in the admitting office," Adler says.

The MAC nurse knows what’s going on in the entire hospital, where the vacant beds are, and how many discharges are anticipated during the day.

"She moves around the hospital and is on the unit when a patient leaves. She can put patients in a room quicker than the registration or admissions office can," Imperati says.

Every nursing manager in the hospital, the case management manager, and the housekeeping, facilities, and transportation managers and the administrator on call attend a 30-minute "muster" meeting each day to discuss what is happening that may affect patient flow.

"We have everyone in one room who can give a global picture of what’s going on in the hospital, vs. having meetings on the floor when that staff know only what is happening on their floor," adds Morgan.

Participants at the meeting keep in mind any disasters in the community that may affect the hospital’s census and patient flow.

For instance, when a school bus accident occurred last spring, the muster meeting was the forum the hospital used to identify plans to handle the patients.

"Everyone in every department works as a team and not as islands unto ourselves," Morgan says.

To make sure that patients’ treatment is started in a timely manner, the hospital has created the position of admitting nurse, whose sole task is to help out when things get busy. She goes to any unit that has a lot of admissions and helps with the paperwork and assessments.

The hospital’s case management model is aligned by physician, rather than geographically. The physicians know their case managers and how to get in touch with them. They work with the case managers to plan discharge from the moment the patient comes in.

"The physician-based model provides a challenge for the case managers who have to go all over the campus, but one result is higher patient satisfaction. The patients have a familiar name and face, no matter where they are on campus," says Morgan.

Danbury Hospital has an overflow unit that is opened up when the census is high. For instance, the unit was opened in January when a large number of patients were admitted for pneumonia.

The unit is used for medical patients, usually with similar diagnoses. For instance, a patient with a fractured hip would not be on the overflow unit but would go to the orthopedic unit.

The hospital’s "unit without walls" is a huge resource pool of per-diem staff including RNs, critical care nurses, nursing aides, and technicians, many of whom are cross-trained. When the census peaks, the manager of the unit without walls pulls in the staff.

"It’s a big resource pool for us, and it helps with patient safety when the census skyrockets," notes Morgan.

[For more information, contact:

  • Doris Imperati, RN, BSN, MHSA, CCM, Director, Clinical Resource Management, Danbury (CT) Hospital. Phone: (203) 739-6175. E-mail:]