Enhancing Patient Flow and Safety in Healthcare Settings
This comprehensive information addresses the importance of managing patient flow, regulatory requirements, portals of entry in healthcare facilities, challenges related to increasing inpatient census and high ED boarder times, commitment to efficient access to care for patients and families, and the consequences of ED boarding. It emphasizes the critical need for effective communication between key areas and roles to ensure patient safety and timely care delivery.
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Center for Patient Placement Improving Safety through Excellence in Patient Access Brian Laneau, MSN, RN Clinical Nursing Director, Center for Patient Placement Therese Hudson-Jinks, MSN, RN, NEA-BC Chief Nursing Officer & Senior Vice President Patient Care Services
Regulatory Requirements The Joint Commission Leadership Chapter o LD.04.03.11: The hospital manages the flow of patients throughout the hospital. o Rational: Managing the flow of patients throughout their care is essential to prevent overcrowding , which can undermine the timeliness of care and, ultimately, patient safety. Effective management of system-wide processes that support patient flow can minimize delays in the delivery of care.
Portals of Entry Source of admissions/inpatient volume: Operating Room Procedural Labs o Electrophysiology o Cath Lab o Interventional Radiology Ambulatory Clinics Emergency Department Referring Facility Transfers ED-to-ED Transfer requests
Challenges Increasing inpatient census High ED boarder times > 200 mins OR Holds Opportunities for enhanced communication between the following key areas and roles Case Management Hospitality ED OR Inpatient Care Areas Admitting Outside Facilities MDs and others
Access: Our commitment to our patients & families, care team & affiliates Efficient Access to Care for Patients in Need of Expert Care at Tufts Medical Center and Floating Hospital for Children Coordinated care 24/7 -- 365 Data driven process Highly Reliable processes o Right patient o Right level of care o Right time o Cared for in the right care team 5
Consequences of ED Boarding Patient s leave without being seen (LWBS) Weiss, S., Ernst, A., Derlet, R., King, R., Bair, A., Nick, T. (2005). Relationship between the National ED Overcrowding scale and the number of patients who leave without being seen in an academic ED. The American Journal of Emergency Medicine, 23(3), 288-294. Delays in care Horwitz, L.I., Green, J., Bradley, E.H. (2010). US Emergency department performance on wait time and length of visit. Annals of Emergency Medicine, 22(2), 133-141. Increase in medical errors Kulstad, E.B., Sikka, R., Sweis, R.T., Kelley, K.M., Rzechula, K.H. (2010). ED overcrowding is associated with an increased frequency of medication errors. American Journal of Emergency Medicine, 28(3), 304- 309. Increase in overall length of stay Foley, M., Kifaieh, N., Mallon, W. (2011). Financial impact of emergency department crowding. The Western Journal of Emergency Medicine, 12(2), 192-197. Increase in mortality Singer, A.J., Thode Jr., H.C., Viccellio, P., Pines, J.M., (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329.
Interventions Structure: Creation of a communication and decision making hub- Center for patient placement Process: Data driven process enhancements CPP ED
Structure: Center for Patient Placement Hospitality Nursing Supervisor EasCare Patient Central Staffing Case Management Triage RN Admitting
Systems Visibility Tufts MC = RAPID VIEW Room And Patient Information Display Siemens RCO Invision HIS Cerner Soarian Clinicals Medhost EDIS FacilityFit (Transport and EVS) 10
Process: A Day in The Life of the CPP Proactive Management vs. Reactive Decisions Weekly OR Schedule Forecasting Forecast Staffing Daily Hand-Off with CPP Nurse Supervisor (Night to Day Shift) Daily Safety Huddle Led by CNO, CEO Bed Meeting CAPP Rounds(Communication and Patient Planning Rounds) Expected Day of Discharge Discharge Appointment End of Day Huddle (Current State Reconciliation for Discharges) Next Day Preview:Discharges, OR Volume, Scheduled Admissions, Etc. Nurse Supervisor Rounding o o
Process: Emergency Department Case Management Role Collaboration with Floors Clinical Leader Forum ED Boarder Committee Daily Processes A.M. Contact CPP for Availability of Med/ Surg Beds & ICU Beds Review of Current ED Volume & Staffing Recommendation for In-House Placement ED Observation Level of Care ED Volume Surge Priority Alert Code Help o o o o o o o o
Role of EVS & Transport Everyone is on the team 13
Reporting Data Driven Processes Monthly Patient Progression Meeting s by Product Line; LOS Management Reporting Available @ Facility, Product/ Service Line, Unit, & Patient Level Key Capacity Statistics Key Performance Indicators Care Progression Events Patient Placement Performance Bed Request Process Discharge Planning & Utilization Review Metrics Resource Management Bed Turnaround (EVS)
Results Enhanced Operations while increasing volume ED Boarder Time reduced from > 200 mins to ~ 120mins Door to provider time reduced by 21% (34 mins) LWBS reduced by ~ 20% to < 2% (~ 1.7) Near elimination of Code Help (1-2/year) Enhanced communication Near elimination of OR Holds
Emergency Department Visits and Admits 4500 4000 3500 3000 2500 Visits 2000 Admits 1500 1000 500 0 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17
ED Boarder Time Relative to ADC 350 300 235 250 223 222 220 214 203 210 206 201 198 199 188 186 174 188 186 184 200 162 161 163 160 157 159 154 145 145 153 151 147 143 142 150 125 130 120 120 106 100 50 0 Avg ED Boarder time (mins) Inpatient ADC Linear (Avg ED Boarder time (mins)) Linear (Inpatient ADC)
ED: LWBS Average per Month 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 2015 2016 2017
Overall LOS Index Trend TuftsMC Overall LOS Index ( < 1 is Better) With Outliers
Commitment to Patient Safety Safety huddle focus Review of ED safety event reports ED-Floor handoff process Infection prevention and isolation precaution reports Case management involvement on outside hospital transfers when clinically indicated
