Improving the Emergency Department Handoff to Facilitate Inpatient Throughput
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Session F presented Friday, September 15, 2017
Purpose: Emergency Department (ED) throughput has been identified as a major factor that can impact care and quality throughout the hospital (Handel et al., 2010). Delays in patient flow may derive from nursing handoff issues, availability of beds, and policies that inhibit patient transport (Baker & Esbenshade, 2015).. This project aimed to eliminate delays in throughput and maximize patient flow.
Design: This quality improvement (QI) project used lean principles and a Plan-Do-Check-Act (PDCA) cycle to ensure that change was sustained.
Setting: This project was conducted in a suburban, ANCC Magnet recognized hospital with 136 beds (including 16 ED beds). The hospital experiences 24,010 ED visits and 6,619 admissions per year.
Participants/Subjects: An ED Lean Admission Team was assembled, including executive leadership as well as team members from the ED and selected hospital units. This multidisciplinary team included unit secretaries, registered nurses (RNs), and the admissions coordinator. The ED Lean Admission Team created interventions which were then carried out by nurses, unit secretaries, and patient transporters throughout the hospital.
Methods: An existing patient flow management system was already used in the ED. The team collected data for categories of patient beds. “Ready to Move” (RTM) indicated that the patient was prepared for transport. “Occupied” meant that the bed was in use and could not be assigned to another patient. Beds marked as “In Progress” were in preparation for new patients, while “Clean” beds were immediately available for new patients.
The team examined data regarding the above bed statuses, bed-tracking data, transport data, and the unit secretaries’ management of logs regarding times for bed requests and patient arrival. After collecting three months of data, the team focused on several interventions to decrease the time between RTM and Occupied status. Key issues included: nurse availability for report, a policy to prohibit admissions during shift change, confusion over nurse assignment for upcoming admissions, electronic health record (EHR) patient assignments, Rooms erroneously marked “clean” in the tracking system, pager errors, and staff pushback. The team devised actions to address these key issues, including education, process improvements (for nursing, unit secretaries, and environmental services), and creating a reward plan. The PDCA cycle ensured that process was checked on a regular schedule, which helped to fine-tune the process.
Results/Outcomes: The improved processes enabled inpatient call for report to be reduced from 24 minutes to an average of 10.7 minutes (55% decrease). Bed status from RTM to Occupied was reduced from 78 minutes to 65.1 minutes (17.1% decrease). Additionally, the time to assign an empty bed to Occupied was reduced from 59 minutes to 43 minutes (27% decrease).
Implications: The pull process allowed inpatient RNs control of patient flow, which allowed them to better organize their admission workflow. Clinically, this project increased the timeliness for access to inpatient care. Bedside nurses helped create many of the streamlined interventions for their units, thereby providing opportunities for nursing autonomy. Metrics are being followed to investigate the impact on HCHAPS scores and financial impact.