Improving Patient Throughput In the Emergency Department Introduction St. Vincent’s Medical Center, a 501 bed facility located in Jacksonville, Florida, provides general medical and surgical care to the North Florida Region. St. Vincent’s admits over 26,000 patients annually. The average occupancy rate is approximately 84% with the Emergency Department (ED) peeking at 100% for approximately 4-12 hours daily. The hospital is struggling with availability of bed space. This shortage of available beds creates a bottleneck in the ED on high census days.
Bottlenecks are created in the ED when there is a shortage of inpatient beds to place admitted ED patients.
Thus, patient flow, or throughput, is becoming more and more important. Like all healthcare facilities, the chief goal of the organization is to serve patients and the community. With this in mind, few people equate a hospital with being a service business that competes for customers and resources. With the healthcare industry becoming more and more competitive, the importance of service cannot be overstated.
Improved patient flow would serve two purposes: provide better service and to attain financial goals. If the hospital cannot provide adequate service, then business will suffer. Moreover, financial reimbursement from Medicaid is now based in part on the “pay for performance” concept, giving patients more choices where to receive their medical care. Improved patient flow will increase revenue, reduce costs and waste, and improve service (Mayer & Jensen, 2009). Thus, the business case for improving patient flow is intriguing.
The hospital relies on admissions from the emergency department. The ED is a strong contributor to the net operating income of the hospital. Each patient admitted into the hospital through the ED brings approximately $7,500 in revenue. Approximately 33% of all patients admitted to this hospital are admitted through the ED. Maintaining an efficient flow of patients through the ED is essential to the financial well-being of the hospital. Being able to serve more customers simply equates to more money.
Many of these potentially paying customers turn away and leave the ED because the wait is too long. This wait is cause by a bottleneck in the ED because there are simply no inpatient beds in which to place the patient. Ten patients holding in the ED effectively reduces a 50 bed department into a 40 bed department, reducing the number of patients seen in a timely manner. This created an opportunity cost of lost income from patients who leave without being seen (LWBS). Using an approximate 4% LWBS rate, this could equate to $6,000,000 of lost revenue annually.
Just reducing this LWBS rate by 1% would make a great impact. It is clear that a solution must be identified in order to improve the patient throughput of the hospital. Step 1: Define the Problem At times of high inpatient census, there is a shortage of inpatient beds. This shortage of inpatient beds prevents the timely movement of admitted ED patients to an inpatient unit. When there are no inpatient beds into which to place admitted ED patients, a bottleneck is created in the ED. The flow of the patients through the ED is constrained by the availability of inpatient beds.
Many times, even though a patient is ready to be discharged, barriers arise which prevent a timely discharge. The barrier could be as simple as waiting for a ride home to arranging for home health care. Some patients discharged to skilled nursing facilities are delayed in the room waiting for ambulance transportation or an open bed at the destination. With the continued increase in ED patients due to the economy, this constraint could lead to major losses of potential revenue for the hospital. Historically, the solution to the throughput problem has been to attempt to discharge inpatients before 11 am.
This initiative has been unsuccessful for the most part and does not appear to be feasible with the constraints placed on inpatient units such as timely physician rounding, and patient transportation issues. Patients arriving in the ED are triaged by a nurse then placed in an ED room according to their acuity. After being evaluated by a physician, the patient is either released to home or admitted. When the decision is made for the patient to be admitted, a request for an inpatient bed is placed to nursing administration who then assigns an available bed.
If there is not an appropriate bed available, the patient must remain in the ED bed. This effectively reduces the capacity of the ED causing the department to either divert patients or patients will leave without being seen. Every patient who is diverted or leaves without being seen is lost opportunity cost to the hospital. Patient Volumes Patient volumes vary greatly in the ED. There are, however, patterns noted in census fluctuations according to the day of the week. High census days are historically early in the week, while lower census usually occurs later in the week.
On days when the census is high throughout the hospital, there will be patients holding in the ED awaiting inpatient beds. The following graph depicts the number of patients holding in the ED by month during the past fiscal year. This graph depicts the total ED volume by month for the past fiscal year. Step 2: Develop Criteria Feasibility Criteria: 1. Maintain Current Budget The budget for this project will be based off of excess funding from the department. Due to the budget for current fiscal year and the next fiscal year being made there is no budget specified for the new project. . Uphold Safety and Quality Standards The Joint Commission safety standards must be upheld at all times while implementing and maintaining any processes on hospital site or with hospital funding. All quality standards that are in practice throughout all departments of the hospital must be maintained with said project. 3. Current Skill Sets Associates needed to staff the special project will need to be able to do so using only the current skill sets of close departments. This will allow the cost to bring in new associates to be minimal, due to on the job training practices.
If feasible no new associates should be brought in to support the new project. Before hiring externally, internal PRN and part-time associates should be considered if qualified for the position opening. 4. External Support System The nurses assigned to the new project will play a vital role in ensuring that all current associates that will in any way be affected will have minimal inconvenience. The affected associates will also require maximum knowledge of the importance of new processes put into place. 5. Patient Accommodation The new project will have to be able to accommodate excess patients.
Every year there are approximately 2,680 excess patients turned away due to lack of space. To justify future funding for this project this number of patients turned away annually must be reduced by 60%. Reducing this number will increase profits for the department and hospital as a whole. Optimality Criteria: 1. Patient Demand The ability to maintain changing patient demand while constantly providing quality care for each patient. Allowing each patient to enter the system with minimal inconvenience to them or other hospital departments. 2.
Optimal Staffing To be able to successfully implement and withhold the standard of care a minimum of 2 registered nurses must be on duty at all times. Both registered nurses on duty will act independently from the other areas of the medical facilities so their primary focus can be to succeed in all aspects of new project. 3. Budget Constraints The current budget must be maintained through whichever project is selected. There is an excess budget of $80,000 for the remainder of the current fiscal year and $300,000 excess for next fiscal year.
The excess cannot be 100% consumed by the option chosen due to future unknown circumstances. 4. External Support System The nurses assigned to the new project will play a vital role in ensuring that all current associates that will in any way be affected will have minimal inconvenience. The affected associates will also require maximum knowledge of the importance of new processes put into place. Step 3: Select Model The feasibility criteria and optimality criteria have been set by historical and current facts.
Both criteria were held to limitations due to current demand, current budget and current staffing. The criteria were set as to not overextend the hospital, staff, patients and all other resources. Each project will be evaluated thoroughly using a sensitivity analysis to rate them 1-5, with 5 being the most feasible or the optimal solution. Once each alternative has a ranking of 1-5 we will eliminate all ranked other than 5. When the most optimal solution has been selected the staff will begin working on the process to begin phasing the project in.
Once the project has been completely started data will be collected. The data collected will include: * Number of patients utilizing process * Average time in process * Number of patients leaving without care * Waiting time for patients to enter process Once all data has been collected over a one month period the head nurse of department will evaluate all data for accuracy. After the data is deemed accurate the project team will compare all information to the previous 1 year. If a decrease of excess patients is reported, then the project will continue for another month to re-evaluate.
If an increase of excess patients is reported the data will be compared to increase in local crimes or any current epidemics. If it is found there is a current epidemic or an increase in crime the project will continue for another month until re-evaluation. If there is no increase in crime or no current epidemic the project will be shut down. If the operation is shut down then the 4th rated project will be implemented following this same process. Step 4: Identify and Evaluate Alternatives 1. Add Additional Emergency Department staff
The hospital can create two new staff positions – STAT/Acuity RN – filled by Registered Nurses to act as “floating” nurses. The position will require that the RNs work within the ED, but also to provide direct patient care to a variety of inpatient units throughout the hospital during times of peak activity. The additional hands on deck will assist in opening up beds in the inpatient centers and improve the flow of admitted patients. 2. Centralize Bed Management Develop a centralized bed management system which is controlled by a RN-staffed patient flow center.
This flow center would coordinate all admissions for admitted patients in order to improve the flow hospital-wide and more specifically, patients admitted from the ED. It would combine all bed control functions, admitting nurse functions and front-end utilization review nurse activities (HFMA, 2012) by implementing a web-based electronic bed board to provide a real-time snapshot of the bed statuses across the Hospital. Part of this management system would include scheduling discharges at earlier hours, to also free up beds in and outside of the ED. 3. Create a “Swing Unit”
Incorporate a multi-purpose unit to serve as a holding area for patients awaiting admission from the ED or discharged patients awaiting transportation (ed-improving patient satisfaction) Across from the ED, the same-day surgery center is not utilizing all bays. Each bay consists of 6 beds. The Swing Unit will be created in the additional bay the same-day surgery center is not currently using. The Swing Unit will need to be staffed outside the current ED, so there is no additional effect on the patient flow from the ED. 4. Add Additional Emergency Department Beds
The Hospital can increase the current capacity of approximately 400 ED beds in order to improve patient flow. In order to increase the number of beds, the hospital would need to build onto the hospital or convert another department into additional ED space. Additional bed in the ED 5. Increase Inpatient Capacity Throughout Hospital The Hospital can restore “ghost rooms” – rooms that have the capability to house inpatients but have been converted to other purposes such as nursing or administrative offices (Bazzoli, Brewster, Liu & Kuo, 2003).
Step 5: Select Optimal Alternative and Perform Sensitivity Analysis The following decision matrix was created using the optimality criteria determined in Step 2. Each criterion was rated on a scale of 1 to 5, with 5 being the highest score. Each criterion was also given a weight to determine its importance in determining the optimal alternative. Based on these calculations created within the matrices, the alternative to ‘Create a “Swing Unit”’ was ranked with the highest score, 4. 25.
Alternatives| Patient Demand| External Support System| Budget Constraints| Optimal Staffing| Add ED Staff| 4| 2| 2| 2| Centralize Bed Management| 1| 4| 5| 5| Create a “Swing Unit”| 5| 3| 4| 4| Add ED Beds| 3| 1| 1| 1| Increase Inpatient Capacity| 2| 5| 3| 3| Alternatives| Patient Demand| External Support System| Budget Constraints| Optimal Staffing| Total| Add ED Staff| 2| 0. 5| 0. 2| 0. 3| 3. 00| Centralize Bed Management| 0. 5| 1| 0. 5| 0. 75| 2. 75| Create a “Swing Unit”| 2. 5| 0. 75| 0. 4| 0. 6| 4. 25| Add ED Beds| 1. 5| 0. 25| 0. 1| 0. 15| 2. 00|
Increase Inpatient Capacity| 1| 1. 25| 0. 3| 0. 45| 3. 00| Weights| 50%| 25%| 10%| 15%| 100%| The current data is weighted based on the assumption that Patient Demand is the most important factor in this analysis, with External Support System next and Optimal Staffing and Budget Constraints following behind. In order to the determine the impact the actual outcome of a particular variable will have if it differs from what was previously assumed, a sensitivity analysis was performed by slighting increasing or decreasing the weights to account for fluctuations in assumptions.
In both sensitivity analyses performed, the “Swing Unit” alternative was ranked the highest which indicates the optimum solution is robust. Alternatives| Patient Demand| External Support System| Budget Constraints| Optimal Staffing| Total| Add ED Staff| 2. 2| 0. 4| 0. 3| 0. 2| 3. 10| Centralize Bed Management| 0. 55| 0. 8| 0. 75| 0. 5| 2. 60| Create a “Swing Unit”| 2. 75| 0. 6| 0. 6| 0. 4| 4. 35| Add ED Beds| 1. 65| 0. 2| 0. 15| 0. 1| 2. 10| Increase Inpatient Capacity| 1. 1| 1| 0. 45| 0. 3| 2. 85| Weights| 55%| 20%| 15%| 10%| 100%| | | | | | |
Alternatives| Patient Demand| External Support System| Budget Constraints| Optimal Staffing| Total| Add ED Staff| 1. 8| 0. 5| 0. 3| 0. 3| 2. 90| Centralize Bed Management| 0. 45| 1| 0. 75| 0. 75| 2. 95| Create a “Swing Unit”| 2. 25| 0. 75| 0. 6| 0. 6| 4. 20| Add ED Beds| 1. 35| 0. 25| 0. 15| 0. 15| 1. 90| Increase Inpatient Capacity| 0. 9| 1. 25| 0. 45| 0. 45| 3. 05| Weights| 45%| 25%| 15%| 15%| 100%| Step 6: Implementation The sensitivity analysis rated the swing unit as the optimal solution. This rating is due to the fact that the extra resources required and the impact on the entire operation is minimal.
The swing unit utilizes areas that are already constructed, requiring only necessary items being moved in and out to accommodate the goal of the project. Staffing requirements were extremely feasible with this alternative due to the fact that only 2 nurses per shift are required to maintain levels of quality in all areas. The 2 nurses per shift were already on staff as PRN and had requested full time positions previously. The nurses selected for this project have until the start date at the beginning of the new quarter to implement the processes required.
During this time leading up to the start of the swing unit, the nurses will be setting up the unit, training other nurses, and educating all who will be affected by new unit. It is projected that in the first month 45% of excess patients will benefit from the swing unit. The 2nd month will increase by 5% until the goal is reached of 60% decrease in waiting patients. The number is projected to sustain 60% decrease until more swing units can be opened. With the projected success of a decrease in waiting patients and an increase in income, the 2014 fiscal year budget will have an allocation for a hospital wide swing unit.
At this time we can look at the payoff of this endeavor and calculate a break-even point if construction were to be used to increase the number of patients that a swing unit can accommodate. References Bazzoli, G. J. ,Brewster, L. R. , Liu, G. & Kuo, S. (November 2003). Does U. S. hospital capacity need to be expanded? Health Affairs. Retrieved from http://content. healthaffairs. org/content/22/6/40. full Healthcare Financial Management Association (2012). Unclogging patient flow in the ED and beyond. Retrieved from http://www. hfma. rg/Publications/Leadership-Publication/Archives/Special-Reports/Spring-2012/Unclogging-Patient-Flow-in-the-ED-and-Beyond/ Mayer, T. & Jensen, K. (2009). Hardwiring flow: systems and processes for seamless patient care. Gulf Breeze, FL: Fire Starter Publishing. Walrath, J. M. , Tomallo-Bowman, R. , & Maguire, J. M. (2004). Emergency department: Improving patient satisfaction. Nursing Economics, 22(2), 71-4, 55. Retrieved from http://ezproxy. ju. edu:2048/login? url=http://search. proquest. com/docview/236936193? accountid=28468
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