From the 2019 HVPAA National Conference
Ms. Stephanie Amport (Yale New Haven Health), Mr. Robert Malone (Yale New Haven Health), Ms. Deirdre Doyle (Yale New Haven Hospital), Dr. Brittany Branson (Yale New Haven Health), Ms. Maribeth Cabie (Yale New Haven Health), Dr. Robert Fogerty (Yale New Haven Health)
The discharge room turnover process is not optimized and given current patterns of high census and resulting back-ups in the ED. The surge plan relies on transporting patients to the floor “on dirty” where they have to wait in the hallway until their room is cleaned. Conflicting objectives of stakeholders may be adversely affecting the efficiency and effectiveness of the discharge room turnover process. An inefficient discharge room turnover process is a barrier to providing optimal patient care and experience, provider efficiency, and profitability given potential impact on LOS.
To reduce total bed turnover time and increase bed utilization by optimizing coordination between nursing, Environmental Services (EVS), bed management, and transport to achieve our goal of: right patient, right bed, right time in Medicine units.
To improve the value of delivered care, a Clinical Redesign team focused on reducing total bed turnover time (as defined by time of entry of the discharge order for a patient occupying the bed to completion of transport of the next patient into the bed) by improving coordination between nursing, EVS, bed management, and transport. The team conducted extensive workflow analysis to understand bottlenecks impacting the total bed turnover time, and determined that a multipronged approach to Real Time Patient Discharge would be necessary. Specific interventions include: 1) decision support to alert RNs when discharge orders are placed, 2) provision of individual floor data on operational workflow metrics, 3) education of staff on the high concordance between real time discharge and room turnover, 4) notification that transport is en route, 5) automation of the discharge process based on transport workflow, 6) documentation improvement to prevent errors in date or time of discharge selection, 7) Charge RN alert if post transport auto-discharge has occurred and 8) enhanced reports to support management discrepancy review and accountability. The PDSA cycles included a 4 week pilot on 3 units from campus 1 starting 8/14/18, then full Medicine roll out 9/23/18, and all services on campus 1 and 2 on 1/8/19.
The team was able to significantly reduce the average total turnaround time from discharge order to next patient to bed transport complete by 4%, from 476.7 min to 462.7 min (p<0.01) on non-observation medicine units (baseline period 9/23/17-3/18/18, intervention 9/23/18-3/20/19). Data were evaluated for the 25th to 75th quartiles to reduce outlier influence on conclusions.
The interventions increased efficiency of bed resources, EVS, and transport services, value to patients by reducing unnecessary delays, and communication amongst the interdisciplinary team.
Patients benefit from reduced boarding times in the ED or wait times in the ICU due to non-clinical issues. Real-time feedback is now available to leadership on unit performance, enabling continual assessment and rapid identification of potential opportunities for improvement. Benefits to providers and staff include greater knowledge of operational logistics as well as more efficient and coordinated patient flow through the hospital. The hospital will realize a financial benefit as well, due to improved utilization of limited inpatient bed resources and potentially decreased overall LOS. The collaborative interdepartmental teamwork provides a framework for developing and implementing capacity coordination projects across health systems.