The challenges of patient flow within a hospital are both systemic and cultural. In January 2005, The Joint Commission introduced a new Leadership Standard, "Managing Patient Flow," in an effort to mitigate internal impediments to patient flow issues by holding hospital leaders accountable for the problem.
Bed tracking
In an effort to expedite bed turnover and patient throughput, Scripps Mercy Hospital, Chula Vista, Calif., a 183-bed acute-care facility, implemented Pittsburg-based TeleTracking's Bed Management Suite, which includes bed tracking, pre-admit tracking, and transport tracking modules.
Essentially, the solution is comprised of two parts, explains Donna Hewitt, patient logistics supervisor, Scripps Mercy Hospital. First off, it's a notification system that informs housekeeping when a bed has been vacated and is in need of cleaning, it also reports pending and confirmed discharges, and notifies transport staff to move patients throughout the system. The second element to the solution is the computerized bed board, which is a large screen that displays the status of every bed throughout the hospital.
Although patient data can be automatically transferred from the hospital's ADT (admission discharge and transfer) system to the TeleTracking system, Scripps still uses manual entry to input information such as bed status or pending discharges into the solution.
However, this isn't always a perfect scenario, as manual data entry can be the point of failure for many systems warns Hewitt. "Your system is only as good as the data that is being plugged in."
When Scripps first implemented the system, in January of this year, the inputting of data was not as accurate as it should have been, she says. However, Hewitt contends that making this function part of a nurse's job responsibility and holding them personally accountable for erroneous data went a long went a long way towards combating this problem.
After ironing out some cultural challenges, such as having staff members incorporate TeleTracking into their daily routine, Hewitt says the system is working well, and has significantly reduced the number of phone calls amongst staff looking for beds, while also providing the ability to allocate staff from light workload areas to heave discharge areas. In addition, she says the solution enables the hospital to take in more direct admissions from the community. In other words, physicians wanting to admit patients directly from home don't have to send them through the ED in order to get a bed.
The hospital staff has had a positive experience using the system, and Scripps has increased its patient through-put, says Sandy Freidman, project manager at Scripps. However, Friedman laments there have been numerous technical glitches that have prevailed throughout the implementation and maintenance of the system.
"TeleTracking is a young company that's growing very fast, and what's typical of companies like this that provide niche products are that they grow faster than their infrastructure allows. They start hiring people quickly and not training them well, and then we get gaps of coverage," she says.
One feature of the TeleTracking system is totally controlled by the vendor, and that has caused some problems, he explains. TeleTracking technicians have the capacity to VPN into the hospital's system, and unless they're properly trained, says Freidman, they can inadvertently cause a problem with the facility's server. "This has occurred a number of times — to the point where we considered turning the VPN tunnel off. But this was only going to increase the lead-time it took to fix a problem, so we decided to leave the VPN tunnel switched on," he says.
Although Freidman opines that TeleTracking did a good job configuring the application and training the end users, "When it came to setting up our servers, the first thing they should have done was make sure the technical environment was set up correctly before they started installing the software, and they didn't do that." Because the servers were not installed properly, TeleTracking's application crashed, and had to be re-installed. "This was obviously extremely time-consuming and frustrating, but these types of technical problems are improving," assures Freidman.
Patient time stamps
Some hospitals are combating their patient flow issues by implementing a system beyond basic bed tracking.
In May of this year, Methodist Hospital, Omaha, Neb., a 430-bed acute-care facility, implemented Navicare Patient Flow solution, provided by Hill Rom (Batesville, Ind.), which enables staff to track patients throughout the entire continuum of care.
"We looked at a number of systems, but this was the only one that offered us an enterprise-wide solution, and therefore gave us the ability to track a patient from the point of admission all the way through to discharge," says Ruth Freed, vice president, patient services, Methodist Hospital.
The premise of the Navicare system is based on "time stamps," says Tim Klenke, director of workflow solutions, Hill Rom. "Patients receive a time stamp at various point of care, for example, when they arrive, when each caregiver sees them, when they enter the OR, even when the incision is made," explains Klenke. According to him, the system is highly configurable, meaning that hospitals have the ability to simply use the basic time stamping functionality or implement a variety of more complex triggered events, alerts and identifications.
Freed further explains that staff can access a real-time view of a specific patient in any location throughout the hospital on any one of the facility's computers. However, "what is really unique about the Navicare system is its FamilyVue module. We now have a screen in the cafeteria that allows family members to track the progress of a patient through surgery," she says.
The FamilyVue component is fed by the tracking system in the OR, explains Freed. Patient's names are coded to protect their identity, but family members in possession of the code can see exactly where they are in the continuum of care.
"If my dad's going through bypass surgery, I can look at the screen to find out what room he's in, whether they've started the surgery, even if the first incision has been made," says Klenke. It's also particularly helpful if a patient's surgery has been bumped. "If family members can see that their loved one is still waiting for surgery to begin, they aren't left wondering why a two hour procedure is taking four hours," says Freed. It provides a great level of family knowledge and empowerment, she explains.
Implementation of this system has resulted in a reduction of phone calls by 60 percent in the OR. "This has obviously freed up our staff's time, which in turn has improved productivity," says Freed. The emergency department is satisfied because caregivers can now see the number of beds that are open at any time, she says. "We only implemented this system in May of this year, so we still need to collect data from surgeons and physicians to see if the system has improved patient flow through the OR, but I suspect that it has," Freed explains.
Smoothing surgical flow
In 2001, Saint John's Regional Health Center, Springfield, Mo., a not-for profit 866-bed tertiary hospital, began working with a group of hospitals across the nation in an effort to improve patient flow, says Christy Dempsey, former vice president and director of perioperative services, St. John's.
"Back then, hospitals pointed to the ED as the cause of huge bottlenecks, and the reason why patients weren't moving fluidly throughout the system. What Eugene Litvak (board chairman and chief scientist of PatientFlow Technology, Boston) pointed out was that it's not really the ED that's driving the bottleneck, but the elective surgery schedule," Dempsey explains.
According to Litvak, the reason for this is that most hospitals impose artificial peaks in their surgical cases by bumping ED cases to perform elective surgeries, which offer greater reimbursement levels. The result is a backlog of patients in the ED who can't receive treatment because all the beds are being occupied by elective admission patients. "So you're poor cousin in the ED with a broken leg has to wait for the surgeon to complete a hip replacement in the OR," he says.
What PatientFlow Technology did at St John's, Dempsey says, is separate scheduled and unscheduled admissions in an effort to smooth surgical flow. "This meant that operating rooms that were designated as only containing scheduled surgeries were not allowed to have any add-on cases or emergency cases in it," she says. "PatientFlow identified the appropriate number of unscheduled and scheduled operating rooms by day and by hour."
Dempsey warns it's an extremely technical procedure that involves the collection and analysis of a variety of data from a hospital's existing network of information systems, such as its ADT and OR information systems. "PatientFlow inputs this data into a complex algorithm to provide an optimal solution for a hospital's elective surgical case load," she says.
Dempsey suggests that smoothing out elective surgeries over the week is "truly a change in thinking and culture." Generally speaking, hospitals will allow surgeons to work whenever they want. Often surgeons look to perform bigger cases at the beginning of the week so that those patients are out of the hospital by Friday, and nobody has to cover the weekend shift, she explains. They can also fill their block times however they like, so there's no way to plan for the number and type of bed that is available post-operatively, Dempsey says. "Getting surgeons to change the way they plan their surgeries was tough, but because our reasoning was data-driven, they were pretty compliant with the changes," she says.
By smoothing the elective surgery flow, Saint John's experienced a 59 percent increase in capacity, which meant it was able to admit 59 percent more patients through the ED into an in-patient bed, without adding beds or staff. It also experienced a 33 percent increase in surgical cases and reduced overtime by 6 percent. "The ROI was phenomenal," says Dempsey.
When asked whether Saint John's had considered implementing a traditional patient tracking application, Dempsey suggests, "They are useful in terms of seeing where the patient is, and knowing which beds are dirty and unoccupied, however, if you drill deeper, this information doesn't really help to solve the problem of overcrowding." Dempsey feels that incorporating PatientFlow Technology's solution into Saint John's has allowed the facility to combat overcrowding issues on a deeper level than if it had just implemented a patient tracking system.
Litvak agrees that utilizing the information provided by a patient tracking system is the key to solving the root of overcrowding and bed capacity issues. "We frequently forget that implementing IT in healthcare is not the goal," he says. "The goal is to provide quality of care at a low cost. I think that most hospitals are missing the layer between information technology and healthcare delivery, which I define as management. Information technology is the means to make certain decisions, but you have to take action on this information or it remains useless."
