The Quality-Cost Connection - Plan now for those high-census situations

Review and update protocols

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Is your hospital prepared for a pandemic or any clinical crisis circumstance that results in an unusually high rate of admissions?

The influenza vaccination shortage in fall 2004 served as a reminder of the need to constantly review and update protocols for handling high utilization situations.

For health care institutions, a high rate of hospitalizations could tax an already overburdened system. Many hospitals already have emergency preparedness plans that could be adapted to high census planning. If your organization has not already done so, now is the time to reevaluate protocols for handling high-census situations. Special consideration should be given to several areas.

The greatest challenge of treating patients during a pandemic is the real possibility of reduced staffing levels due to employee illness. Ideally, all staff members, physicians, and their families receive a flu immunization.

However, this might not have been possible because of the vaccine shortage. So be prepared for higher than normal illness rates among staff, physicians, or their family members. To ensure adequate staffing during high utilization, your facility’s time-off policies and procedures should address staffing needs adequately.

Unplanned absences or previously scheduled vacations may need to be denied or cancelled to achieve adequate staffing during times of clinical crisis.

Facility policies and employee union contracts should be flexible to ensure sufficient staff coverage so that safe care can be given to the larger than usual emergency department (ED) or inpatient populations. It may be necessary to use RNs or other health care professionals in administrative roles for patient care activities; however, the current clinical competence of these people must be considered.

Make sure your ED is prepared to handle high patient volume. Urgent care or fast-track areas in or adjacent to the ED may need to be converted to patient treatment areas.

Appoint a triage officer

If you don’t already have a triage officer to manage patient flow, consider appointing one during times of high utilization. This person can make appropriate patient referrals to local physicians’ offices or community health centers when ED treatment is not required.

Recheck your transfer procedures. It may be necessary to send patients to other hospitals when your ED is experiencing unusually heavy patient volumes or when your facility is in danger of exceeding inpatient bed capacity.

Review your policies for admitting and scheduling elective procedures. How and when will your facility implement contingency plans such as limiting elective admissions or canceling scheduled surgeries?

If a high number of flu-related admissions occur, it may be necessary to control elective utilization of your facility. Such limitations not only allow for redistribution of staff and equipment, but also reduce the risk of elective patients contracting influenza from already hospitalized patients.

Of course, your facility should have isolation plans for patients admitted with complications of influenza or any other contagious disease. Under ideal circumstances, patients with suspected or diagnosed influenza should be in a private room.

During a time of high census, private rooms are unlikely to be available, and containment of infection may be difficult. Some patients are dependent on certain health care procedures or treatments (e.g., dialysis) that must continue during high-census situations. For these patients, it is especially important that they receive an annual influenza vaccine and are cared for by health care workers who have been immunized.

Consider performing elective or necessary procedures or treatments in an outpatient area or ambulatory care unit to reduce the chance that these patients are exposed to inpatients infected with the influenza virus.

Effective utilization management activities are critical during periods of high census. If your facility has ineffectual physician advisor support for utilization problems, consider appointing temporary medical triage officers to manage patient flow.

The medical director or service chiefs could function in this role. Be sure a sufficient number of triage officers and case managers are allocated to the appropriate units to facilitate timely discharge or transfer of patients to home, a skilled nursing facility, or other facilities.

Careful monitoring of critical care bed utilization is especially important to ensure patients are expeditiously transferred out of these units. When inpatient utilization is high, consider creating a patient discharge holding area or discharge lounge to free up bed space.

The committee responsible for utilization management must be actively involved in recommending and enforcing procedures for dealing with high-census situations. Start by confirming there are adequate protocols for bed management across the organization.

These protocols should address how and when the decision will be made to admit, transfer, and discharge patients. During the period of high census, the director of case management should monitor utilization and bed availability carefully.

The following types of data should be gathered at least daily and reported to triage officers, the medical director, utilization committee chairman, and senior leaders:

  • average number of available intensive care unit beds (adult and pediatric);
  • average number of available medical ward beds (adult and pediatric);
  • average number of available ED beds;
  • average waiting time for nonambulatory patients to be seen in the ED;
  • average waiting time for ambulatory patients to be seen in the ED;
  • average number of patients in the ED waiting to be seen;
  • average number of patients waiting for inpatient beds (in ED, clinics, post-anesthesia recovery, etc);
  • average number of area hospitals on ED diversion.

After the bed utilization crisis is over, the natural response is to breathe a sigh of relief and ease back into the business-as-usual mode. However, don’t relax quite yet! As soon as possible following the end of the crisis is a perfect time to evaluate how your facility did at managing the large volume of patients. Some systems or protocols may not have worked well and need redesigning. Don’t overlook the opportunity for this hindsight analysis. Evaluation of lessons learned from the high-census situation will assist in responding to future crises.

The utilization committee should coordinate this evaluation, asking questions such as:

  • Was the high-census procedure activated appropriately to free up or add patient beds to accommodate multiple admissions? Was it activated too soon or too late?
  • Did all departments effectively assess and triage patients to the appropriate level of care?
  • What could the medical staff have done to facilitate transfer of patients to the most appropriate level of care?
  • Was the hospital able to efficiently procure necessary resources (e.g., supplies, equipment, staffing, holding beds)?
  • Were scarce resources adequately and appropriately rationed?
  • What additional resources and mechanisms are needed to procure the needed supplies, equipment, and staff during the next utilization crisis?
  • Were nonmedical resources (i.e., security, sanitation, water, and transportation) sufficient during times of unusually heavy patient volume?
  • Were infection control practices adequate to maintain patient safety?
  • Did the physician clinics have an efficient communication mechanism to alert the hospital of incoming patients?
  • What other resources does the hospital require to ensure patients are adequately cared for during times of high census?
  • What recovery and mitigation efforts can be taken now to reduce problems during the next surge of patients?
  • What community resources would help to reduce the burden of unusually high admissions?
  • What nonmedical resources may be needed in the event (e.g., security, law enforcement, sanitation, water, transportation)?

Insights without implementation produce no results. Where opportunities for improvement are identified, the committee should spell out action plans to harness the ideas that result from the lessons learned discussions.

The impact of the high-census debriefing depends on making clear decisions on how to use the insights gained. That includes spelling out who is responsible for seeing that each insight is disseminated quickly and put into practice. The utilization committee should receive regular feedback on the progress of protocol or procedure revisions. Don’t wait until the next bed utilization crisis to find out that nothing has changed.