Patient Turnaround
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Patient Flow Barriers: How Poor Bed Turnaround Roadblocks Hospital Efficiency

October 19, 2020
by
Karen Stockdale, RN, BSN, MBA

The movement of patients through a hospital system, from admission to discharge, can seem infinitely complex.  Patients enter the hospital through the emergency room, surgery, or another outpatient setting.  From there, care pathways begin to take shape: every meal, test, intervention, and outcome must be coordinated to maintain the best possible care. Hospitals have always prioritized promoting efficiency and minimizing wait times, but recent hospital crowding due to the COVID-19 pandemic has created an even more urgent need to optimize patient flow. Healthcare systems employ many tactics to improve patient flow - using Lean and Six Sigma principles, sophisticated dashboards, bed control departments, and patient flow managers.  Yet even with all these tools, it is a difficult task, prone to bottlenecks and pain points.  The nature of managing a people-based workflow gives rise to many opportunities for unpredictable “traffic jams” [1].  

Why is Patient Flow so Important?

Patient flow is critical for a couple of reasons.  The American Hospital Association (AHA) defines it as “delivering the right care, in the right place, at the right time”.  This approach helps hospitals both reduce costs and improve health outcomes.  When care is not delivered in the right place, at the right time - patient care and hospital performance suffer [4].

For example: let’s say a patient enters the hospital with pneumonia and stabilized in the Emergency Department (ED), but then needs to be transferred for continuing care in a nursing department or ICU.  If this process is delayed, then the Emergency Department staff must perform routine care on a patient that is no longer in critical condition, taking resources away from more incoming emergency patients. In addition, the ED bed is occupied longer, causing increased wait times in the ED.  Longer wait times impact metrics like Left Before Being Seen (LBBS) and left Against Medical Advice (AMA) in the ED.  These two ED metrics are linked to poorer outcomes, lost revenue, and lower patient satisfaction scores [5]. A recent article in the AAEM journal concluded that for a high-volume ED, each 1% increase of LBBS equaled $447,500 in annual lost revenue [9].

Services that are routine in nursing units such as mealtimes, medication passes, and case management, will not occur in the same way in an emergency department. The mission of the ED is to stabilize and move to a different level of care, enabling the patient to safely move to a less acute bed, which is cost-effective and requires less monitoring and staff support. In this ED example, the patient is not receiving the “right care in the right place at the right time”.  This scenario impacts not only the quality of care for this patient, but the patients that are waiting, hospital revenue, staff satisfaction, and patient and family satisfaction.  The ripple effect is far-reaching and complex [6].  

Most hospitals realize that the discharge process is a major pain point that adversely affects throughput, especially when hospitals are near capacity. When discharge-eligible patients are waiting to leave, either to home or the next care setting, it creates a backlog of patients waiting for those beds.  Patients may be waiting in ICU or ER to move to those beds, and the entire system can become gridlocked. The “traffic jam” extends from admission to discharge and back again, with complex layers of causes and effects [6].  

The bed turnaround “traffic jam” can extend from admission to discharge and back again, with complex layers of causes and effects. The ripple effect is far-reaching and complex.

Patient Outcomes

Chaotic patient flow is linked to poor outcomes: increased readmissions, higher infection rates, and higher 30-day mortality rates.  Patient safety during the hospital stay is also linked to patient flow.  The IHI states “Poor hospital-wide flow puts patients at risk for harm and increases the burden on clinicians and hospital staff.” Mismatched patient capacity and demand can lead to overburdened clinicians, opening the possibility of medical error, patient falls, and delayed care.  Readmission rates, emergency visits after discharge, and 30-day mortality rates are all standard safety indicators that all hospitals measure.  These results are publicly reported and available to patients online to review and compare facilities [6].  

Hospital Impact

Flow issues create many measurable impacts for hospitals.  Increases in patient mortality rates and readmissions are directly related to quality payment programs and can mean large penalties if these rates rise above the national average. A hospital with high readmission rates can incur as much as a 3% reduction in Medicare payments for all care in the following year. This penalty is often enough to create significant financial distress for a healthcare organization, and affected 2,599 hospitals in 2019 [7].

Heavy workloads and crowded conditions are stressful for staff members, creating pressure to move patients through and rushing care and discharge teaching.  High ER wait times and poor planning throughout the stay negatively impact patient satisfaction – causing the hospital’s reputation to suffer and value-based purchasing revenue to dip. Delayed discharges are also expensive - in the form of time spent in a hospital bed after the patient’s inpatient care is complete [7].  

Improving the Discharge Process

Hospital leaders realize that approaching the throughput problem from the back end – the discharge - frees up the system to allow more timely movement of patients. Organizations have been seeking to overcome throughput problems for years by trying different approaches to expedite discharges. Discharge processes are also deceptively complex: CMS and TJC define many factors that must be in place to accomplish a safe hospital discharge.  The patient needs to have the education, equipment, and resources to manage their care after discharge.  In addition, transportation by a friend or family member or Non-Emergency Medical Transportation (NEMT) must be arranged [2].  

Expedited discharge processes have been attempted through a couple of different methods.  One method schedules all discharges in the morning, before noon – so that beds are cleaned and ready for new patients in the afternoon. Staff must expedite large numbers of discharges at times that they are typically busy with patient rounds, treatments, and medications.  Another barrier is arranging transportation effectively to long term care, assisted living, or home [8].  

A second method is to schedule “discharge appointments” that are set in advance.  This system tends to work well with surgical patients that have a predictable course of treatment and discharge date.  Discharge needs like equipment, prescriptions and education materials can be provided ahead of the discharge time. Yet even when the discharge plan is carried out as intended, transportation delays still occur [3].  

Innovations for Improvement

Smooth hospital discharge processes depend on the coordination of several other key players.  Examples of tasks that must be completed and require coordination are:

  • Delivery of home oxygen and transport oxygen
  • Delivery of walkers, canes, wheelchairs
  • Other needed equipment such as nebulizers, dressing supplies
  • Obtaining needed prescriptions
  • Transportation to home

Nurses, social workers, and case managers are familiar with managing this complex checklist of tasks.  Phone calls, faxes, waiting, confirmation – these all take valuable time on the day of discharge that is frustrating for all, including the patient.  Some transportation options give a wide window for pickup – often as large as 3 to 6 hours.  When patients are scheduled to go to a long-term care facility, a delayed handoff takes crucial time needed to schedule care in the new facility – medications, meals, etc.  Delays cause continuing problems even after discharge.  

How can this flurry of discharge activity be better managed?  The endless phone calls and re-work by hospital departments can be streamlined and modernized with innovative patient care logistics solutions. VectorCare Hub is designed specifically to alleviate the common problems of coordinating effective patient discharges.  Features like:

  • Scheduling and coordination of tools for requesting service requests from a marketplace of credentialed local service providers
  • Messaging, status updates and maps for real-time coordination and awareness
  • Data that leads to insights and intelligence to improve collaborative work.

Imagine scheduling a patient discharge, along with delivery of equipment and transportation, with an online service request.  Then picture the ability to communicate this information effectively to the entire care team via a dashboard and real time updates.  Removing this final discharge bottleneck to the throughput chain frees up throughput and gives staff more time.  VectorCare simplifies the complexity and gives hospitals the ability to do what they do best – caring for patients.

Want to learn more about improving patient turnaround? Learn how VectorCare saved one hospital system $22million annually through reinventing their patient care logistics system.

1. "What Is Patient Flow? 2018. NEJM Catalyst. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0289#:~:text=Patient%20flow%20is%20the%20movement,quality%20and%20patient%2Fprovider%20satisfaction.

2. Achieving Hospital-Wide Patient Flow | IHI - Institute for Healthcare Improvement ". 2020. Ihi.Org. http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Hospital-wide-Patient-Flow.aspx.

3. "Try Scheduling Hospital Discharges | IHI - Institute for Healthcare Improvement ". 2020. Ihi.Org. http://www.ihi.org/resources/Pages/ImprovementStories/ImprovementTipTrySchedulingHospitalDischarges.aspx

4. "Right Care, Right Place, Right Time | AHA". 2020. American Hospital Association. https://www.aha.org/center/emerging-issues/market-insights/telehealth/right-care-right-place-right-time.

5. Jarvis, Paul Richard Edwin. 2016. "Improving Emergency Department Patient Flow". Clinical and Experimental Emergency Medicine 3 (2): 63-68. doi:10.15441/ceem.16.127. https://pubmed.ncbi.nlm.nih.gov/27752619/

6. Rutherford, Patricia. 2018. “Why Hospital Flow is Key to Patient Safety”. Institute for Healthcare Improvement blog, http://www.ihi.org/communities/blogs/why-hospital-flow-is-key-to-patient-safety

7. "CMS' Value-Based Programs | CMS". 2020. Cms.Gov. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.

8. "Are You Struggling with Early Discharges? | Today's Hospitalist". 2017. Today's Hospitalist. https://www.todayshospitalist.com/are-you-struggling-with-early-discharges/.

9. Guarisco, Joseph,MD FAAEM Chair, Operations Management Committee 2020. Aaem.Org. https://www.aaem.org/UserFiles/SepOctOperationsManagement.pdf.

10. Thomas, Shakira N., Gerald McGwin, and Loring W. Rue. 2005. "The Financial Impact Of Delayed Discharge At A Level I Trauma Center". The Journal Of Trauma: Injury, Infection, And Critical Care 58 (1): 121-125. https://pubmed.ncbi.nlm.nih.gov/15674162/#:~:text=Total%20hospital%20charges%20for%20excess,to%20have%20government%2Dsponsored%20insurance.