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It wasn’t the first time we had this type of meeting – more than 150 patients were in the Emergency Department, over 35 of them already with admission orders, just waiting. PACU was getting full and all operating rooms were in full swing, and not many of those were outpatients. Where were they going to go if we didn’t have inpatient beds? Transfer Center has been asked to stop accepting transfers even though as the Regional Medical Center, we really are the best choice for the Valley’s residents when they need a higher level of care. Staff everywhere was working very hard to resolve the patient flow. Physicians, nurses, house supervisors, directors, environmental services, transporters, were all putting inextra time trying to move patients and create room. It was Wednesday at 2:30 p.m.
The following day I looked at a daily management report and the report read: “Hospital occupancy rate, 79%”. Why were we unable to take care of the patients we had, let alone turn patients away, if we weren’t actually full? I was thinking about that question when I went on rounds the next morning. I walked past a sign near the front entrance elevators that’s probably been there for decades.”Please plan for patient discharge from the hospital by noon”. How long has that been up there…and what would it mean if we could make that really happen?
I started looking at data regarding demand for inpatient beds. Each day we discharge around 70 patients and admit about the same number. For the most part, we get admissions in three ways:
All three result in a demand for beds in the middle of the day and peak by early evening. 8 a.m. surgical cases start coming out of recovery and are ready to head to an inpatient floor around 11 a.m. and the operating rooms (while never actually closed) see a decrease in demand after 3 p.m. Those patients are generally ready to go to the floor around 6 p.m.
In the emergency department, patients arrive all day long but the peak of demand starts to grow at around 10:30 a.m. and will build to a crescendo by 8 p.m. with a drop off in arrivals after 11 p.m. Most of hospital-to-hospital transfers are an extension of a smaller hospital’s emergency department volumes and follow the same curve as our emergency department.
So if demand for additional inpatient beds begins around 11 a.m., when do we tend to have beds available? Of the patients we discharge, only 4% on any day, actually leave by 11 a.m. Even extending the study until 2 p.m., we only see 24% of our discharges leave by that time. Between 11 a.m. and 2 p.m. every day, we have a backlog that is being created in our hospital that causes a lot of extra work, while resulting in patients getting care in less than optimal settings. There are often times when the emergency department has more inpatients than most of our inpatient care units! This backlog is not good for our patient; it is not rewarding to our staff, who are asked to do additional duties in less than optimal care settings; it is not helpful to our physicians as the patient’s access to their services becomes delayed. I am certain that it is reflected in patient satisfaction scores that while improving, are not at the level that I see when I talk with staff and see their passion and commitment for excellence.
I am proud to say that nursing leadership has jumped in with a renewed zeal and commitment to driving a discharge by 11 a.m. initiative. You are likely to hear a lot about this over the weeks and months ahead. A lot of processes and work flows will need adjustment to make this change. By no means is this a nursing issue only. Physicians, ancillary departments, admitting, housekeeping, transportation, the list goes on in terms of who will be involved as we embark on this journey. Re-thinking the work so that we are preparing for discharge from the time of admission likely will change some work flow items such that work previously done by day shift personnel might be better assigned to afternoon or night shift. It will take all of us pulling together. The good news is that when we fix this, and we will fix this, everyone will be better off. I have no doubt that if we can get the patients to the right place at the right time, the outstanding service level that staff is really providing will come shining through and be reflected in patient satisfaction scores that rival the best.