Patient flow from ER to the wards does not flow

My organizations is a non-profit specialist care (secondary and tertiary care) hospital consisting of four main hospitals and smaller satellites. Three of the main hospitals have and ER treating multidisciplinary patients and primary care patients needing acute care or care during hours when primary care clinics are not open. Roughly half of the patients need hospital care for a few days or longer, about half the patients return home or to their elderly care home/nursing home after receiving treatment in the ER. The majority of the patients returning home are primary care patients and the majority of those taken in for hospital treatment are specialist care patients. However, there is a significant number of patients whose condition (impacted often by their age) requires treatment at primary care level hospital but who end up staying in our hospitals. This happens because the primary care hospitals lack free beds for these patients. Every day, many patients have to wait in the ER for much longer than our goal (8 hours) due to lack of free beds of the wards. Thus, the ER becomes quite crowded, and in the worst case patients end up staying in the ER more than 24 hours or even longer before there is a bed available and they get to the ward.

The wards and beds in our hospital are allocated to medical specialties. There is a ward for medicine, lung diseases, cardiology, neurology, orthopedics, GI-surgery, urology, oncology, hematology etc. Each ward receives both elective patients and acute patient, mainly from the ER, as well as patients from the ICU, CCU, and operating theatres. It happens often that for example the orthopedic ward does not take a new patient from the ER in the evening as they have new elective patients coming the next morning. Or a neurological patient has to remain waiting in the ER as the neurological ward is full while there are free beds in the pulmonary ward. The patients released from the hospital tend to leave the hospital after noon, and not very efficiently during weekends, further challenging the patient flow. We have put some effort trying to speed the release process but with quite limited results so far.

Thus, we have a challenge how to make the patient flow from the ER to the wards flow better. I would like to achieve this flow without compromising elective care. Any ideas or experience with solving this kind of a problem? Any experience of more generalized wards than we have? Do you have bed managers in your hospitals? How is that organized? Any experience on an incentive system for the personnel that would facilitate the flow?

Thank you!


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Participant comments on Patient flow from ER to the wards does not flow

  1. Thanks for sharing this: a very common and frustrating process for all involved. Yes, we do have bed managers who are quite well informed about the status of free beds all over the hospital. We have grown to a more flexible system where departments have the right on a certain amount of beds, but this is calculated on a monthly or 3-monthly basis. So, at the end of the period, you should have the amount of beds agreed on, but not on a day-to day basis. Keeping beds empty for elective cases the next day is kind of acceptable but should be transparant as many will keep their beds reserved as it’s just easier for the staff at night. Furthermore, the reason why patients get discharged at such a late hour should be examined as clearly, this is a logistical problem.Departments should get incentives to discharge patients as quickly as safely possible and for discharging patients before, say, 9 am. Should be do-able, I’d say.
    Can primary care hospitals get an incentive to accept appropriate patients better?

  2. This is very very common. We have hospitals with bed managers and those that do not have bed managers. I agree with the comment above about discharges being around noon, that seems late. We have been able to help reduce LOS in our hospitals by doing lean process improvement projects. Analyzing the process for discharges, admissions, transfers, and surge capacity can really be eye opening to the problems in the system. The key to these projects is getting front line champions (from specific departments) and someone from senior leadership involved in the project. Starting with a smaller project, registration for example, then building to the larger projects was helpful.

  3. Throughput and patient flow is a common problem for many hospitals. We have a Transfer Center that manages beds. The Transfer Center has situational awareness of all patients needing admission or transfer within the next 24 hours (ED admissions, OR admissions, ICU transfers to the floors, transfers from outside hospitals, etc.) They also can see in real time which beds are clean and which are waiting to be cleaned. The Transfer Center works closely with the in-house nursing supervisor who can help prioritize patient movement. I also agree that incentives for discharges prior to 11:00 am are very helpful, but the incentives need to apply not only to physicians but also front line staff. Some hospitals have also opened “Discharge Lounges” for patients that have been discharged from a bed but are waiting for a ride home. This can help open floor beds earlier and help to decompress the ED. You also can consider opening a short-stay or observation unit for patients expected to stay longer than 8 hours but less than 48. This has helped to drive rapid throughput, especially with the use of standardized clinical protocols and order sets.

  4. You mentioned there appears to be a cardiology floor in your hospitals. If these beds are full and creating a long wait in the ER, then one consideration for cardiology floor patients is to figure out what % of these are taken up by low risk patients admitted for “rule out MI” or “rule out CHF” or Syncope etc. If many of the beds in floor are taken up by these low risk patients, consider creating a “chest pain unit” or “Clinical decision unit” with rapid rule out protocols in one corner of the ER or in adjacent space – in conjunction with cardiology – for early discharge of patients from these units. This will avoid admission of these pts to the floor and can free up the beds.

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