Throughput department reaps dramatic rewards

Software system tracks patient beds in real time

At one time, the emergency department (ED) at Seton Medical Center in Austin, TX, sometimes had to hold patients overnight because there wasn't a bed available, and local physicians complained that they could not get patients admitted when they needed to.

To improve patient flow, the hospital staff divided into several teams, focusing on four key areas: ED diversion, post-anesthesia care unit (PACU) holding, patient access to the facility, and in-house and out-of-house transfers. Ultimately, these teams merged to form the patient throughput department.

"We saw a need to facilitate patient flow, particularly when the census was high," says Patricia Ramming, RN, throughput manager. "Since the creation of the department, the bed turnaround has improved, and we've made huge strides toward rapid intervention and initiation of care."

She further states that the goal of the department is to smooth and prioritize patient care and flow. In addition to creating the new department in the spring of 2004, a number of other initiatives, including a computerized bed-tracking system, have had a dramatic impact on patient flow.

Consider these achievements:

Before the initiative was begun, the average holding time in the PACU was 120 minutes per patient. In the last three months of 2004, the average total hold time per month was just 180 minutes for all patients.

In 2003, the hospital had to divert patients brought by emergency medical services a total of 458.24 hours because there were no beds. In 2004, the time dropped to 49.57 hours.

In December 2003, the average patient stayed in the ED for 296.26 minutes before admission. In November 2004, the time had dropped to 190.22 minutes.

The patient throughput department operates 24 hours a day, seven days a week with a full-time equivalent staff of 17. "Our department looks solely at patient throughput from all avenues, whether direct admissions, admissions from the surgical center, the emergency department, or from another hospital," Ramming says.

Department staff include house supervisors, express admissions nurses, and nonclinical bed board staff.

1. House supervisors:

The house supervisor’s job is to facilitate patient flow and place the patients who need to be admitted based on critical needs and available beds. They are RNs who cover the hospital 24 hours a day, seven days a week and give approval for accepting patients into the system. The house supervisors all have critical care experience and are part of the hospital’s critical response team.

"We adjusted the shift time of the house supervisor so they can make rounds on the units before the on-coming shifts arrive. That way, if an issue comes up, the house supervisors are there and accessible," Ramming says.

2. Bed board staff:

The bed board department is the central hub for bed placement. All requests for bed placement come into the department, and all bed assignments come out of the department. The hospital established one number where physicians and/or hospital transferring patients can call for admissions.

Nonclinical staff take admissions information and bed requests and enter them into the computerized bed-tracking system.

The unit receiving the patient will be notified automatically by the system. If the sending hospital need an accepting physician, staff refer them to the physician on-call for the needed specialty. If a clinical aspect is needed, the nonclinical staff will contact the house supervisor for assistance.

3. Express admissions nurses:

The express admissions team was created in response to a time study that showed it took an average of 180 minutes for the nurse on the floor to admit the patient.

"That's too long to initiate care. We created the express admission team to step in to provide rapid treatment," Ramming says.

The express admissions nurse floats through the hospital and helps whenever needed. For instance, if the bed board staff see that the telemetry floor has five admits, they ask the express admissions nurse to go up and help.

The express admission team gets the paperwork started, conducts a history and physical, initiates any stat orders and tests, draws blood, places an IV, and addresses any home medication issues.

Team members work Monday through Friday from 9 a.m. to 11 p.m. and Saturday and Sunday from noon until 1 a.m.

The hospital uses bed-tracking software, which gives the house supervisor access to the status of every bed in the hospital.

The system is updated when a patient leaves, when housekeeping begins cleaning the room, and when a room is clean and available for another patient.

The hospital made the environmental services department a part of the patient care team. Using the computer, the throughput office can track turnaround times on the bed and set priorities for which room should be cleaned first.

"The computer system allows us to prioritize where the housekeeping staff should clean for better patient flow. The system helps the housekeeping department monitor what is going on, and because there is limited access to the system, they’re no longer being pulled in 20 different directions," Ramming says.

Any unit that admits patients can enter information into the computer requesting a bed. These include the ED, surgery, imaging, and the cardiac catheterization lab.

Charge nurses key in information about patient transfers and discharges. The request goes to the throughput department.

"At first, the charge nurses were hesitant about giving up control of the beds, but now they have expressed satisfaction with the new system because it allows them to be back on floors taking care of patients instead of being tied up on telephone calls," Ramming says.

A daily bed briefing, a short meeting, is held every morning and attended by charge nurses from every floor, managers and directors of every department, housekeeping, plant operations, case management, central supply, human resources, and biomedical.

The team discusses bed and staffing issues and addresses any issues that maintenance needs to attack that day.

They tabulate the available beds and how many people are expected to be admitted. The house supervisor takes those data and runs the plan for the rest of the day.

For instance, if the intensive care unit (ICU) is at capacity and the staff know that surgical patients will need to be in the ICU, the ICU team facilitates moving patients out.

[For more information, contact:

  • Pat Ramming, RN, Throughput Manager, Seton Medical Center, Austin, TX. Phone: (512) 324-3258. E-mail: pramming@Seton.org.]