At New York Methodist Hospital (NYM), an uncoordinated system for bed turnover at patient discharge caused overcrowding in the emergency department (ED) and became a serious issue. As many as 25 patients might be kept waiting in the ED during high-volume periods, which created numerous challenges for the Brooklyn, N.Y.-based hospital. The ED received 65,295 patients in 2007; however, the ED was at risk of losing revenue from turning patients away because it was at operating capacity. Hospital administrators often overstaffed their environmental and patient-transport teams because they couldn’t accurately predict their needs. And, due to the overcrowded conditions and long waits, patient satisfaction also suffered.

NYM has a deep-rooted tradition of providing excellent and compassionate care to the people of Brooklyn. A member of the New York-Presbyterian Healthcare System and an affiliate of Weill Cornell Medical College, NYM recently celebrated the 125th anniversary of receiving its charter and the completion of its newest building — a state-of-the-art patient-care pavilion. The seven-story, 100,000-square foot structure houses the renovated and greatly expanded ED, which includes 45 adult beds, a 10-bed pediatric unit and a separate OB/GYN section, as well as adult and pediatric triage rooms.

Insufficient Data

Hospital leadership quickly identified the root causes for the prolonged bed-turnover times: “There was minimal accountability,” says Kathleen Mazza, assistant vice president of nursing. The bed-turnover process required members of different teams within the organization to perform many sequential tasks. However, the system to communicate the discharge orders, patient transport and room cleaning requests was paper-based and labor intensive.

The time between when unit clerks enter discharge orders to when beds are turned over for new patients has been reduced. Ninety-five percent of discharges that used to take up to several hours are completed within five to 15 minutes.

Damian Zambrana, NYM operations coordinator, spent more than an hour each day gathering the data necessary for bed turnover. “I had to go floor-by-floor, patient-by-patient looking for pending discharges,” says Zambrana. “The old process was very time-consuming.” In addition, the process couldn’t provide hospital leadership with the information they needed to make data-driven decisions because they had no data to hold their staff members accountable, only anecdotal information, which didn’t show the entire picture.

Administrators believed that an electronic bed-tracking system would help solve many of these challenges. NYM’s IT team met with key members of the administration, nursing, admissions, transportation, environmental services and revenue cycle departments to discuss solutions that would best fit everyone’s needs. After researching a number of possibilities, the majority of users favored implementing an electronic bed-tracking board that featured a beeper system that alerted staff when tasks were assigned.

An Outside-the-Box Solution

Several of the systems being considered cost nearly $500,000 and presented systems integration issues. If the organization adopted a separate bed tracking application, it would have to be interfaced with the other hospital systems and users trained to operate it.

The IT department was worried it might face user adoption issues. “We challenged them to look outside of the box,” says Robert Dulak, NYM’s IT director. “We needed to think about what we were really trying to do, which was to improve patient throughput and manage the bed-tracking process.”

Senior management tasked the IT team to use its existing order entry capabilities to notify of bed availability. NYM had been using the Cerner Millennium PowerChart, PowerOrders and computerized physician order entry solutions in its ED since 2003. “We realized we had a lot of what we needed already in place,” says Dulak. “It’s about what you’re trying to accomplish rather than the bells and whistles [of a new application],” he says. “Since we already had these systems in place, and they were widely accepted, the Cerner solution had the advantage. We didn’t want to have to go back and forth between two systems.”

The IT department designed a set of orders within the Millennium system that automates the bed-turnover process. This set enables teams to monitor waiting tasks and informs the next team when tasks are completed. The transportation team created a designated dispatcher who notifies the teams when orders are completed and new tasks can begin.

Once a patient is ready to be discharged, the unit clerk places an order for transportation. The admitting team then places an order to discharge the patient. Upon completion of that order, the environmental team receives an order to clean the bed. All teams can access the same task list to see pending transportation, discharge and cleaning orders. The IT department also developed custom management reports to evaluate the success of new processes.

Since the IT team developed the new order sets themselves, the hospital incurred no additional software or support expenses. The team created one order set called “Bed Tracking” that included a transport order. It also created two nested-order sets called “Patient Discharge” and “In-House Transfer.” These new order sets were created using new code sets. Task lists and requisitions also were created to print to admitting, environmental services and transport departments. The overall time to create these orders took less than a day, but the IT department spent about 45 days testing and refining its design.

The hospital purchased new computer terminals and printers for the environmental and transport teams who now needed access to the new system. The organization also trained 600 nurses and more than 100 full- and part-time staff members.

Better Accountability, Fewer Complaints

NYM has been happy with the results it has seen since implementing the system in January 2008. The time between when unit clerks enter discharge orders to when beds are turned over for new patients has been reduced. Ninety-five percent of discharges that used to take up to several hours are completed within five to 15 minutes. The hospital also has seen a 25 percent improvement in the time it takes for a discharged patient to receive transportation away from the hospital facility.

Zambrana says that instead of going floor-to-floor to various departments to gather patient discharge data he can now access all of that information electronically. “The patient task list allows me to see any pending required transport or cleaning,” he says. “I used to have to go to the department and look over their shoulders. Now, I don’t even have to bother them with a phone call. I don’t have to wait in line for them to give me this information — I can get it all in one click.” Zambrana says that the pending discharge list is his favorite part of the new system. It enables him to avoid overloading floors that have a lot of dirty beds, and better manage patient flow into the hospital.

Patient relations also is seeing fewer complaints from patients related to crowding and wait times. End users report being very satisfied with the system, saying they would not want to return to the manual process. Communication, accountability and teamwork also have all markedly improved.

Because the data comes in electronically, focus on workflow and bed-turnover processes has improved. The IT team considers the project a success as well, especially considering they were able to derive more value from the existing system. As one manager of the IT department stated: “Every time we simplify the IT world of our organization, it’s a success for us.”

July 2008