09 May 2007

Moving the Meat (Part Two)

OK, this is a little off the intended path of discussion, but ERNursey asked so nicely I can’t deny her . . . I was intending to focus on how the ER doctors can make themselves more effective at moving the meat, but as she and Anon point out, a huge part of this is the hospital side. If you board an admitted patient for, say, 12 hours, which is not uncommon, you are losing that bed from the pipeline through which you have to move the rest of your patients. Had the patient gone upstairs expeditiously, you could have pushed four more patients through that bed; they remain in the waiting room, increasingly pissed off and possibly sicker.

So what is it that effective hospitals have done to address the problem?

Caveat: none of these items is free. All generally involve resources, either administrative, staffing, or physical space. If your hospital it telling you that there are no resources available of any sort to address ER overcrowding, you are behind the eight-ball. Your best bet is to make the compelling argument that ER crowding is a hospital problem and try to get them on board with a system-wide improvement plan. Any plan that involves only the ED is going to fail.

I think of it this way: in order to admit a new patient, several events need to occur.

  1. The Bed: There needs to be an empty and ready bed upstairs.
  2. The System: The bed needs to be flagged as available and assigned to a new patient
  3. The Transfer: The patient, and care of the patient, transfer to the new unit

The Bed:
The bed needs to be empty ASAP. This means that the patient previously occupying the bed must be discharged, and the earlier the better. Engage the hospitalists and encourage them to do discharge rounds earlier in the day or more than once daily. Develop clinical paths to shorten hospitalizations. Employ discharge planners on the floors to identify patients who could be discharged but have not been, to find alternative facilities for patients who no longer need acute hospitalization (i.e. rehab or nursing homes), and to generally expedite the discharge process. Once the former inpatient is gone, turning that bed over needs to be a priority. Create rapid response teams in the Housekeeping corps to priority-clean open beds ready for patients. The hotel industry is the ideal model for this sort of program.

The System:
An empty bed does you no good if nobody knows it is available. There should ideally be a patient tracking board to make administrative staff aware the bed is ready; there are electronic products that do this already, or a clipboard/grease board still work. Sometimes the nurses on the floor delay notifying the supervisor that a bed is ready because they do not want to get another patient right away. There should be a single individual tasked solely with the mission to assign beds and shuffle patients to optimal utilization. We call the role the “Bed Czar.” This person should be roaming the hospital at all times keeping his/her finger on the pulse of bed availability. Traditionally this has been done by a nursing supervisor along with other administrative tasks; more recent thinking is that bed assignment at a medium-size or larger hospital is a big enough task to require a dedicated individual.

The Transfer:
Once a bed is ready and assigned to a patient the transfer still has to take place. Nursing leadership is essential in expediting this function. The ritual of “report” is almost sacred among nurses, but is itself one of the biggest barriers to the transfer. How many times is it that a transfer is delayed because the floor nurses are in report or about to take report? Or you can’t find an ER nurse to give report because they are engaged in patient care? There are many creative solutions and I do not presume to have an opinion on the relative strengths of each. The ED nurse can fill out a report form and fax it to the floor. Or you can have the nurse give a bedside report upon the patient’s arrival to the floor. Or there can be a designated “Admission Nurse” on the floor to accept all new admissions regardless of other activities on the floor. Also, staffing an “Admissions facilitator,” ideally a nurse, in the ED can provide many functions to expedite the transfer: calling report, bugging the doctor to write orders, communicating with the Bed Czar to orchestrate the bed assignment, etc. It’s hugely helpful in my experience. And last but not least, the patient does need to be physically moved upstairs, and if you do not have transportation techs, that too will slow you down. Make admits priority pages for transportation.

Ultimately none of these items will solve the problem if your hospital is just too small. But they will, especially if engaged as part of a large-scale efficiency program, allow you to get the maximum utilization of the resources that you do have. There are other creative solutions, like having an “Express Admissions Unit” which is a euphemism for a holding area for admitted patients. Or having a subunit for discharged patients awaiting their final release. Anon suggested just moving the patients upstairs and parking them in the hallways. Tempting as that sounds, it’s just passing the problem along. What I have outlined above will provide solutions (or partial solutions) to the problem. This is not really my area of expertise – it’s just what I have gathered listening to our hospital leadership team work on our system. Take it with a grain of salt, and remember that free advice is usually worth about what you paid for it.


  1. The other alternative reduces the number of patients who go in to the ER in the first place:

    How 'bout giving us peons who have urgent conditions a place to go besides the ER? There's a pediatrician's office in our area that's open only weekends, evenings and holidays. They can even set broken bones and give stitches. It's great. On the other hand, the urgent care centers in our area close soon after the regular doctors' offices do, which is useless. If you break a bone during Saturday martial arts practice and the urgent care center isn't open, you can't very well wait until Monday, so perforce it's off to the ER, instead. Believe it or not, most people who are in severe pain but not dying really don't want to go to the ER. We just want a competent professional to fix the problem. Surely some doctors have to realize the money to be made (and the job security) working the night shift...?

  2. It's a tricky problem. Another issue is the types of beds available (how many critical, tele, etc.) In our ER I think something like 10 out of 30 beds are set-up for critical patients (we can do portable "tele-packs" in others).

    I am frequently called in to the ER to clear patients for DVT so that they can be discharged immediately. The day they start discharging patients from the floor at 3am will be the last day I get any sleep...

  3. kc saul:
    Good idea. I've thought about opening a cash only urgent care that is open evenings and weekends only. Unfornately, such a practice would violate both of my current contracts. These clincs do exist (so-called boutique medicine), usually in tourist areas. I know for sure there is one in Santa Fe. Some people are uncomfortable with the idea, but with a cash system, you completely eliminate the middle man and prices are much more reasonable. $100 to sew up a simple laceration, for example. I know that if I were traveling and had an after-hours urgent concern, I would be happy to know there would be an efficient, if slighly more costly to me, solution.

  4. Ray, I don't know why the cash only thing has to be there. The pediatrics practice I mentioned takes our insurance. In fact, it's cheaper to see him than to go to the ER.

    The other thing, it occurred to me, that would cut down on unneeded visits would be if prescriptions were treated like checks. Or at least, perhaps certain classes of prescriptions could be treated like checks. Maybe it would cost more in the short run, but the doctor and the insurance company would get the "check" and have to mark it against the patient's health insurance account. You'd be able to catch the doctor-shoppers that way. If the grocery store can spit your check back because you bounced one at another branch of the same supermarket, why couldn't the same thing happen with prescriptions?


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