Challenges with In-Patient Throughput
How have you addressed in-patient throughput issues?
Over the past year, the “boarding” situation in the ED has grown. Some mornings, we have 30 patients who have waited over night for a bed. Most days, there are 10+ patients waiting. Usually these are medicine patients but sometimes they include ICU, stepdown, and cardiac telemetry patients. We have added 15 staffed medicine beds over the past year, frequently “board” medicine patients on surgical floors (which sometimes backs up the OR and/or PACU), hold patients in the ICUs who are ready to transfer to the regular floor, and have increased case management and social worker coverage.
Even on a good day, we experience delays in moving patients and our ED order to actual admit time is far above the best practice benchmark of 2 hours. The average discharge time from an in-patient medical/surgical bed is between 3 and 4 pm.
As I talk to some of my CNO colleagues, this seems to be a challenge across the country. What strategies have you implemented to improve throughput and earlier discharges times? How do balance teaching and patient care? (I am at an academic institution.) How do you get buy-in to make changes?
We have worked on this as well. Some of our implementations which had success –
1. Built an “anticipated DC within 24 hours” order. This fires tasks to –
a. Nursing: finish patient education, identify caregiver for education, notify ride, start teach back
b. Unit Secretary: schedule follow-up appointments and tests
c. Case Management: arrange appropriate DME
2. To go lunches – patients get two “to go” lunches when they leave before noon – one for them, one for their ride
3. Physician Dashboard – percent DC orders completed before 1030, with goal of 50%
4. Community education with local skilled nursing facilities/adult family homes with limited success
We were having success with this (13% DC before noon to around 30%); we recently changed EMRs, and workflow has expectedly changed with it. We also lacked our tracking dashboard; the new one has not yet been built.
We don’t have many beds, so we have to manage our discharges aggressively since we don’t really have the ability to board patients. For us discharge planning starts on admission, when are they anticipated to leave and where are they going. I realize for some patients this is an unknown, but for many, you can estimate pretty accurately. Communicate with physicians the day before discharge to encourage them to fill out the necessary paperwork or computer work ahead of time and not on the day of discharge. Most EHR’s let discharge information be filled out in advance. Encourage physicians to round on patients that are to be discharged that day first, so that the process can start and then round on the patients that are not leaving yet later.
I love the idea of to go lunches from jjmurray.
We have also struggled with patient throughput and have implemented a number of initiatives.
Having Hospitalists round on patients that are likely to be discharged first thing in the morning.
Hospitalist writing the discharge order the day before likely discharge so that all team members or aware and can prepare the patient/family.
Expected date of discharge (EDD) on white boards in the patients room so that patient and family know what to expect.
Addition of further information on the White boards at the main nursing station so that barriers to discharge can be addressed early.
We also experimented with a discharge lounge, where patients that were discharged but had delays in pick up could wait.
How did the discharge lounge work for you? We have attempted this twice without success (about 4 years ago and again at the end of 2015/beginning of 2016). Physicians and nurses had excuses as to why a patient could go there. The few patients that went there, didn’t like it. We even put a large screen TV, comfy couches, recliners and a stocked refrigerator and gave the patient a $10 voucher to the coffee/snack shop near it.
We have talked about experimenting with a discharge lounge as well. I would love to hear more about how it worked.
We face currently the same problem in our academic hospital and decided (among a lot of process improvements on the ER) we gonna create an ACU. This will be an 20 bed acute admission ward adjacent to the ER. The thought is that approximately half of the people which will be admitted to our ACU can be discharged within 24 hours. The other half will move out to one of the speciality wards in our hospital, are transferred to another hospital because the problem is not an academic one, ore are transferred to a local community nursing bed if they only need care and cure. We have arrangements with a few hospitals in the region for specific type of patients. Local community nursing beds is a new initiative: our geriatric specialist have taken up the challenge to build a small in-patient care facility together with GP which fills the gap between hospital and home-care. especially older people who suffer from a relative small medical problem not necessarily prompting admission but have to much care problems to be send home are excellent candidates for this new facilities. The ACU itself, alleviates the wards from handling admissions in the middle of the night, which makes it easier to have them staffed properly.
We are faced with exactly this problem (not only in Cork University Hospital [CUH] but throughout the entire Irish hospital system) and we have implemented over 120 different change inititives that collectively have made the attainment of sustainable solutions to the flow of patients through ED more achievable. These can changes can be viewed in our booklet on Unscheduled Care on http://www.cuh.hse.ie/About-Us/Patient-Quality-Safety/The-Change-Programme-2013-2016/Unscheduled-Care-Patient-Pathway/
The attainment of sustainable solutions is critical because embedding change such that it becomes part of the organisation’s DNA and culture is really difficult.
We are now working on getting almost 200 patients who are in CUH over 14 days discharged to community settings in order to create acute bed capacity.
We have Medical decision unit- sort of overflow ward from ER; works to en extent from abt point of view. But still a problem
I agree as well and we all face the long and frustrating holds in the ERs. We have done significant work on increasing efficiencies on the inpatient units to help this. One thing we have done is standardize the rounding on the medical units, so all teams, interdisciplinary, are rounding at the same time and gives structure and more efficiency. In addition, we have created a standard rounding tool that enhances the structure. We have also identified physician leaders for each unit that are held acountable for delivering the process. In general this has improved our throughput significantly.