Patient Flow Unplugged:

1
Patient Flow Unplugged

• JCAHO Guidelines and the Flexible Unit

Tim Gee, Principal Medical Connectivity Consulting
Cheryl Batchelor, Executive Director Clinical
Operations FirstHealth Moore Regional Hospital
2
Learning Objectives

• Understand the elements of performance for the
  new JCAHO LD.3.15 standard
• Learn four categories of potential patient flow
  optimization solutions
• Understand the Flexible Unit care model, elements
  required success, and outcomes

3
JCAHO LD.3.15

• Leaders assess patient flow issues within the
  hospital, the impact on patient safety, and plan
  to mitigate that impact.
• Planning encompasses the delivery of appropriate
  and adequate care to admitted patients who must
  be held in temporary bed locations, e.g. Post
  Anesthesia Care Unit and Emergency Department
  areas.
• Leaders and Medical Staff share accountability to
  develop processes that support efficient patient
  flow.
• Planning includes the delivery of adequate care,
  treatment, and services to those patients who are
  placed in overflow locations, such as corridors.
• Specific indicators are used to measure
  components of the patient flow process and
  address the following          Available
  supply of patient bed space         
  Efficiency of patient care, treatment, and
  service areas          Safety of patient care,
  treatment and service areas          Support
  service processes that impact patient flow
• Indicator results are available to those
  individuals who are accountable for processes
  that support patient flow.
• Indicator results are reported to leadership on a
  regular basis to support planning.
• The hospital improves processes related to
  patient flow identified as inefficient or unsafe.
  
• Criteria are defined to guide decisions about
  initiating diversion.

4
Meeting the Standard

• Take a leadership position on patient flow,
  making a resource commitment to study, plan and
  execute patient flow solutions
• Make a serious effort to understand the root
  causes impacting patient flow in their hospitals
• Map out a strategy and plan to address the root
  causes (don't forget measuring results)
• Be able to demonstrate resulting flow improvement
  changes and their results
• Any issues of patient safety must be addressed
  immediately

5
Four Categories of Change

• Organizational and procedural changes
• Team rounding bed briefing, discharge rounds
• Dedicated admissions nurse
• Facility changes
• Extended short-stay recovery unit
• Observation unit
• Capacity management software applications
• Provides patient/bed status and automates
  workflow between staff and departments
• Tele-Tracking, Hill-Rom (Navicare), StatCom,
  Premise, Awarix
• Acuity Adaptable care model

6
The Flexible Unit Care Model

• Other terms universal bed/unit, variable acuity,
  acuity adaptable, flex bed/unit, flexible
  monitoring, house-wide monitoring
• Definition Reduce ICU utilization and patient
  transfers by keeping the patient in the same room
  from admission through discharge, adjusting
  staffing, therapy and surveillance based on the
  level of care and patient acuity.
• Result Caring for patients in the most
  appropriate, lowest cost setting.

7
Benefits

• Avoid ICU admissions
• Reduce off-service admissions
• Reduce ICU readmissions

8
Requirements

• Flexible monitoring
• Monitor any patient anywhere on the unit
• Devices appropriate for bedside, transport and
  ambulatory patients
• Policy and procedure changes
• Admissions criteria and enforcement
• Update for new meds
• Surveillance and alarm notification policy
• Monitoring criteria, alarm response

9
Flexible Unit Requirements

• Staff impact
• Training for monitoring, alarms and meds
• Implementation planning
• Communications with medical staff
• Survey staff and patients before and after
  implementation
• Measure results using LOS by DRG and reduction in
  transfers

10
FirstHealth of the Carolinas Working
TogetherFirst in Quality, First in Health

• Private, non-governmental, not-for profit health
  care network serving 15 counties in the
  mid-Carolinas
• 611 Licensed Beds (3 Hospitals)
• Rehabilitation Center
• Skilled Nursing Facility
• Clinics (dental, pain, sleep disorders)

11
FirstHealth of the Carolinas Working
TogetherFirst in Quality, First in Health

• Family Care Centers
• Fitness Centers
• Laundry
• Hospice
• Home Care
• Charitable foundations
• CCT/EMS Services
• Health Care Plan

12
2004-2005 Hospital Outcomes

• Solucient Top 100 Hospital (2004, 2005)
• Distinguished Hospital Award Patient Safety
  (2004, 2005)
• Distinguished Hospital Award Clinical
  Excellence (2005)
• Rated 1 in North Carolina for following
  services Cardiovascular, Cardiology and PCI

13
2004-2005 Hospital Outcomes

• Specialty Excellence Award Cardiac Services
  (2005)
• Specialty Excellence Award Orthopedic Services
  (2005)
• AA Credit Rating by all rating agencies

14
Define The Problem

• Discharges exceed 24,000
• Visits to FirstHealth Family Care Centers exceed
  72,000
• Emergency Department visits exceed 87,000
• EMS serve more than 27,000 patients

Volume, Volume, Volume
15
Measure

• Demographics
• Admissions (Direct, ED)
• Service-line placements
• LOS (hospital, ICU, medical DRGs)

16
ED Visits
17
Current Patient Flow Strategies

• Flexible monitoring system (1992)
• Increased monitoring demands
• Significant manpower (location of monitors,
  patient transfers)
• System capacity
• Patient Placement Coordinator
• Service-line patient placements

18
Current Patient Flow Strategies

• Communication patterns
• Contingency plan / high census policy
• No history ED diversion
• LOS

19
Continued Improvements

• Flexible telemetry surveillance wireless
  house-wide flexible monitoring (2000)
• Increased number of monitors
• Extended monitoring capability to ancillary
  services
• Extended monitoring capability to hallways and
  elevators
• Extended monitoring capability to Women
  Children Services

20
Continued Improvements

• Extended monitoring capability to Behavioral
  Services
• Extend monitoring capability to Emergency
  Department Observation Unit
• Improved information/history to physicians
• Potential for multi parameter monitoring

21
(No Transcript)
22
(No Transcript)
23
Continued Improvements

• Patient Placement Coordinator/Communication
• Electronic network-wide communication regarding
  high census
• Pertinent signage
• Daily Interdisciplinary Bed Task Force
• Interventional Cardiology Unit/Cardiac Cath bed
  board
• Rapid Admission Unit (2003)
• IT improvements (Electronic Medical Record,
  PDAs, FirstView)

24
Continued Improvements

• Length of stay
• Implementation of Hospitalist Service (2003)
• ED LOS
• Average medical discharges per day
• Medical DRG average LOS

25
Consult Requested ? Removed From Track
26
Average Medical Discharge/Day
27
Medical DRG Length of Stay
28
Outcomes

• Improved monitoring capacity
• Pre-admissions delays average 34 patients / month
• Post-admission delays average 0 patients / month
• Decreased time spent locating monitoring
  equipment
• Pre-implementation 30 minutes
• Post-implementation 0 minutes
• Monitored patients LOS from 5 days to 3

29
Outcomes

• Improved patient safety
• Expansion of monitoring to nontraditional areas
• Decreased inappropriate ICU placements
• Post partum patients
• Behavioral Services patients
• Sleep apnea post operative patients

30
Control

• Sleep apnea post operative patients (2003-2005)
• Algorithm for patient placement
• Multi-parameter monitoring
• Rapid Response Team (2005)
• ICU nurse, respiratory therapist, hospitalist
• Multi-parameter monitoring
• Maintain philosophy of No ED Diversions

31
Creating Beds Through Shorter LOS
200 beds 300 beds 400 beds 500 beds 600 beds
0.25 days 8 12 16 20 25
0.50 days 16 26 33 41 49
0.75 days 25 37 49 61 74
1.0 days 33 49 65 82 98
Assumptions 85 occupancy, 5.2 days LOS
Reference 2002 Maximizing Hospital Capacity,
Health Care Advisory Board, Washington DC
32
Effective RNs Gained
200 beds 300 beds 400 beds 500 beds 600 beds
0.25 days 6 9 12 15 18
0.50 days 12 18 24 30 36
0.75 days 18 27 36 45 55
1.0 days 24 36 48 61 73
Assumptions 85 occupancy, 5.2 days LOS
Reference 2002 Maximizing Hospital Capacity,
Health Care Advisory Board, Washington DC
33
Substantial Financial Improvements
Beds Gained 38 70 125
Patient Days Gained 13,977 25,269 45,664
Admissions Gained 2,688 4,859 8,781
Contribution Income 4,976,634 8,997,304 16,258,878
Assumptions 85 occupancy, 5.2 days LOS, freed
beds filled with national average case mix
Reference 2002 Maximizing Hospital Capacity,
Health Care Advisory Board, Washington DC
34
Results

• Improved monitoring capacity
• Decreased admissions delays
• Decreased LOS in Emergency Department
• Decreased LOS on monitor
• Decreased ICU admissions

35
Results

• Improved patient safety
• Expansion of monitoring capabilities into
  non-traditional patient care areas

36
Results

• Improved equipment efficiency
• Decreased time spent locating telemetry monitors
• System expansion using SpO2 monitoring
• Sleep apnea patients

37
(No Transcript)
38
Bibliography

• JCAHO Patient flow standard
• JCAHO Official Comments on New Patient Flow
  Standard, Urgent Matters newsletter, Vol 2, Issue
  1, http//www.urgentmatters.org/enewsletter/vol2_i
  ssue1/P_wiseJCAHO.asp
• ICU over utilization
• Pew, Cecily, Managing Patient Flow, Strategies
  and Solutions for Addressing Hospital
  Overcrowding,, published 2004, JCAHO, 147 pages.
  http//www.jcrinc.com/publications.asp?durki6972
  site4return78
• Ambulatory Care-sensitive Conditions Clinical
  Outcomes and Impact on Intensive Care Unit
  Resource Use, Burr, et al., Southern Medical
  Association, Vol. 96, No.2, February 2003, pp
  172-178. lthttp//www.lww-medicalcare.com/pt/re/med
  care/abstract.00007611-200302000-00013.htmjsessio
  nidC2DnepQGhuwgYFhmvitb0koPiea4wvIJdiPHDm4Lr9sffo
  heU2RD!1563931552!-949856031!9001!-1gt
• Can Intensive Primary Care Prevent Primary
  Intensive Care? Taylor, David E. MD, Southern
  Medical Journal, Vol 96(2), February 2003, pp
  122-123. lthttp//www.ncbi.nlm.nih.gov/entrez/query
  .fcgi?cmdRetrievedbPubMedlist_uids12630633do
  ptAbstractgt
• Right Patient? Right Bed? A Question of
  Appropriateness, Dawson, et al., AACN Clinical
  Issues, Vol. 11(3), August 2000, pp 375-385.
  lthttp//www.aacnclinicalissues.com/pt/re/aacn/abst
  ract.00044067-200008000-00005.htmjsessionidC2CZP
  esbwb1BRjhBDgaf44jI758ANu2Y6qo2fFjw2ct1TbVFL8OS!-2
  64389797!-949856032!9001!-1gt
• The Emergency Department Case Manager Effect on
  Selected Outcomes, Gautney, et al., Lippincotts
  Case Manager, Vol. 9, No. 3, pp 121-129.
  http//www.lippincottscasemanagement.com/pt/re/lip
  pcasemgmt/abstract.00129234-200405000-00003.htmjs
  essionidC2F2KhDA6EXwYSuDbDbWS1P9OHUcMGu4vgRa28F3W
  Ea7z2LE1CkJ!1563931552!-949856031!9001!-1
• Patients Readmitted to ICUs A Systematic Review
  of Risk Factors and Outcomes, Rosenberg, Andrew,
  et.al., Critical Care Reviews, Chest, 182, 2, Aug
  2000, pp492-502 lthttp//www.chestjournal.org/cgi/
  reprint/118/2/492?maxtoshowHITS10hits10RESUL
  TFORMATauthor1rosenbergfulltextICUreadmitted
  searchid1115077355571_12913stored_searchFIRST
  INDEX0sortspecrelevancejournalcodechestgt

39
Bibliography

• Patient flow optimization
• Institute for Healthcare Improvement,
  Transforming Care at the Bedside, Rutherford,
  Pat, et al., 2004 lthttp//www.ihi.org/IHI/Products
  /WhitePapers/TransformingCareattheBedsideWhitePape
  r.htmgt
• Remote Control, Feeney, Tracy, Advance for
  Nurses, Vol 5, Issue 15, July 5, 2004, pp 14-16
  http//nursing.advanceweb.com/common/EditorialSear
  ch/AViewer.aspx?ANNW_04jul5_n4p14.htmlAD07-05-2
  004
• Urgent Matters, Bursting at the Seams Improving
  Patient Flow to Help Americas Emergency
  Departments, Sept 2004 lthttp//www.urgentmatters.
  org/pdf/UM_WhitePaper_BurstingAtTheSeams.pdfgt
• Institute for Healthcare Improvement, Optimizing
  Patient Flow Moving Patients Smoothly Through
  Acute Care Settings, 2003 lthttp//www.ihi.org/IH
  I/Products/WhitePapers/OptimizingPatientFlowMoving
  PatientsSmoothlyThroughAcuteCareSettings.htmgt
• Flexible Monitoring in the Management of Patient
  Care Processes One year After the Pilot Study,
  Jones, Catherine, et al., Lippincotts Case
  Management, Vol. 6 No. 2,Mar/Apr 2001, pp 88-94
  lthttp//www.lippincottscasemanagement.com/pt/re/li
  ppcasemgmt/searchplusresults.htmjsessionidC21pfk
  4NVJeS7wabGT60GmMqVeCVpl6iVHUFCiJ2zAVdrwn254UJ!156
  3931552!-949856031!9001!-1gt

40
Contacts

• Tim Gee
• tim_at_medicalconnectivity.com
• Cheryl Batchelor
• cbatchelor_at_firsthealth.org
• Download presentation
• www.medicalconnectivity.com/stories/NTI2005
• www.medicalconnectivity.com/categories/patientflow