Patient Flow Unplugged:

1. Patient Flow Unplugged: JCAHO Guidelines and the Flexible Unit Tim Gee, Principal Medical Connectivity Consulting Cheryl Batchelor, Executive Director Clinical Operations FirstHealth Moore Regional Hospital

2. Learning Objectives • Understand the “elements of performance” for the new JCAHO LD.3.15 standard • Learn four categories of potential patient flow optimization solutions • Understand the Flexible Unit care model, elements required success, and outcomes

3. JCAHO LD.3.15 • Leaders assess patient flow issues within the hospital, the impact on patient safety, and plan to mitigate that impact. • Planning encompasses the delivery of appropriate and adequate care to admitted patients who must be held in temporary bed locations, e.g. Post Anesthesia Care Unit and Emergency Department areas. • Leaders and Medical Staff share accountability to develop processes that support efficient patient flow. • Planning includes the delivery of adequate care, treatment, and services to those patients who are placed in overflow locations, such as corridors. • Specific indicators are used to measure components of the patient flow process and address the following:          * Available supply of patient bed space          * Efficiency of patient care, treatment, and service areas          * Safety of patient care, treatment and service areas          * Support service processes that impact patient flow • Indicator results are available to those individuals who are accountable for processes that support patient flow. • Indicator results are reported to leadership on a regular basis to support planning. • The hospital improves processes related to patient flow identified as inefficient or unsafe. • Criteria are defined to guide decisions about initiating diversion.

4. Meeting the Standard • Take a leadership position on patient flow, making a resource commitment to study, plan and execute patient flow solutions • Make a serious effort to understand the root causes impacting patient flow in their hospitals • Map out a strategy and plan to address the root causes (don't forget measuring results) • Be able to demonstrate resulting flow improvement changes and their results • Any issues of patient safety must be addressed immediately

5. Four Categories of Change • Organizational and procedural changes • Team rounding – bed briefing, discharge rounds • Dedicated admissions nurse • Facility changes • Extended short-stay recovery unit • Observation unit • Capacity management software applications • Provides patient/bed status and automates workflow between staff and departments • Tele-Tracking, Hill-Rom (Navicare), StatCom, Premise, Awarix • Acuity Adaptable care model

6. The Flexible Unit Care Model • Other terms: universal bed/unit, variable acuity, acuity adaptable, flex bed/unit, flexible monitoring, house-wide monitoring • Definition: Reduce ICU utilization and patient transfers by keeping the patient in the same room from admission through discharge, adjusting staffing, therapy and surveillance based on the level of care and patient acuity. • Result: Caring for patients in the most appropriate, lowest cost setting.

7. ED OR ICU Cath Lab Other Diverts General Med/Surg Floors Discharge Admit Benefits • Avoid ICU admissions • Reduce off-service admissions • Reduce ICU readmissions

8. Requirements • Flexible monitoring • Monitor any patient anywhere on the unit • Devices appropriate for bedside, transport and ambulatory patients • Policy and procedure changes • Admissions criteria and enforcement • Update for new meds • Surveillance and alarm notification policy • Monitoring criteria, alarm response

9. Flexible Unit Requirements • Staff impact • Training for monitoring, alarms and meds • Implementation planning • Communications with medical staff • Survey staff and patients before and after implementation • Measure results using LOS by DRG and reduction in transfers

10. FirstHealth of the CarolinasWorking Together…First in Quality, First in Health • Private, non-governmental, not-for profit health care network serving 15 counties in the mid-Carolinas • 611 Licensed Beds (3 Hospitals) • Rehabilitation Center • Skilled Nursing Facility • Clinics – (dental, pain, sleep disorders)

11. FirstHealth of the CarolinasWorking Together…First in Quality, First in Health • Family Care Centers • Fitness Centers • Laundry • Hospice • Home Care • Charitable foundations • CCT/EMS Services • Health Care Plan

12. 2004-2005 Hospital Outcomes • Solucient Top 100 Hospital (2004, 2005) • Distinguished Hospital Award – Patient Safety (2004, 2005) • Distinguished Hospital Award – Clinical Excellence (2005) • Rated #1 in North Carolina for following services: Cardiovascular, Cardiology and PCI

13. 2004-2005 Hospital Outcomes • Specialty Excellence Award – Cardiac Services (2005) • Specialty Excellence Award – Orthopedic Services (2005) • AA Credit Rating by all rating agencies

14. Define “The Problem” • Discharges exceed 24,000 • Visits to FirstHealth Family Care Centers exceed 72,000 • Emergency Department visits exceed 87,000 • EMS serve more than 27,000 patients Volume, Volume, Volume

15. Measure … • Demographics • Admissions (Direct, ED) • Service-line placements • LOS (hospital, ICU, medical DRG’s)

16. ED Visits

17. Current Patient Flow Strategies • Flexible monitoring system (1992) • Increased monitoring demands • Significant manpower (location of monitors, patient transfers) • System capacity • Patient Placement Coordinator • Service-line patient placements

18. Current Patient Flow Strategies • Communication patterns • Contingency plan / high census policy • No history ED diversion • LOS

19. Continued Improvements • Flexible telemetry surveillance – wireless house-wide flexible monitoring (2000) • Increased number of monitors • Extended monitoring capability to ancillary services • Extended monitoring capability to hallways and elevators • Extended monitoring capability to Women & Children Services

20. Continued Improvements • Extended monitoring capability to Behavioral Services • Extend monitoring capability to Emergency Department Observation Unit • Improved information/history to physicians • Potential for multi parameter monitoring

23. Continued Improvements • Patient Placement Coordinator/Communication • Electronic network-wide communication regarding high census • Pertinent signage • Daily Interdisciplinary Bed Task Force • Interventional Cardiology Unit/Cardiac Cath “bed board” • Rapid Admission Unit (2003) • IT improvements (Electronic Medical Record, PDA’s, FirstView)

24. Continued Improvements • Length of stay • Implementation of Hospitalist Service (2003) • ED LOS • Average medical discharges per day • Medical DRG – average LOS

25. Consult Requested ► Removed From Track

26. Average Medical Discharge/Day

27. Medical DRG Length of Stay

28. Outcomes • Improved monitoring capacity • Pre-admissions delays average 34 patients / month • Post-admission delays average 0 patients / month • Decreased time spent locating monitoring equipment • Pre-implementation 30 minutes • Post-implementation 0 minutes • Monitored patients LOS from 5 days to 3

29. Outcomes • Improved patient safety • Expansion of monitoring to nontraditional areas • Decreased inappropriate ICU placements • Post partum patients • Behavioral Services patients • Sleep apnea post operative patients

30. Control • Sleep apnea post operative patients (2003-2005) • Algorithm for patient placement • Multi-parameter monitoring • Rapid Response Team (2005) • ICU nurse, respiratory therapist, hospitalist • Multi-parameter monitoring • Maintain philosophy of No ED Diversions

31. size LOS reduction Creating Beds Through Shorter LOS Assumptions: 85% occupancy, 5.2 days LOS Reference: 2002 Maximizing Hospital Capacity, Health Care Advisory Board, Washington DC

32. size LOS reduction “Effective” RNs Gained Assumptions: 85% occupancy, 5.2 days LOS Reference: 2002 Maximizing Hospital Capacity, Health Care Advisory Board, Washington DC

33. Substantial Financial Improvements Assumptions: 85% occupancy, 5.2 days LOS, freed beds filled with national average case mix Reference: 2002 Maximizing Hospital Capacity, Health Care Advisory Board, Washington DC

34. Results • Improved monitoring capacity • Decreased admissions delays • Decreased LOS in Emergency Department • Decreased LOS on monitor • Decreased ICU admissions

35. Results • Improved patient safety • Expansion of monitoring capabilities into non-traditional patient care areas

36. Results • Improved equipment efficiency • Decreased time spent locating telemetry monitors • System expansion using SpO2 monitoring • Sleep apnea patients

38. Bibliography • JCAHO Patient flow standard • JCAHO Official Comments on New Patient Flow Standard, Urgent Matters newsletter, Vol 2, Issue 1, http://www.urgentmatters.org/enewsletter/vol2_issue1/P_wiseJCAHO.asp • ICU over utilization • Pew, Cecily, Managing Patient Flow, Strategies and Solutions for Addressing Hospital Overcrowding,, published 2004, JCAHO, 147 pages. http://www.jcrinc.com/publications.asp?durki=6972&site=4&return=78 • Ambulatory Care-sensitive Conditions: Clinical Outcomes and Impact on Intensive Care Unit Resource Use, Burr, et al., Southern Medical Association, Vol. 96, No.2, February 2003, pp 172-178. <http://www.lww-medicalcare.com/pt/re/medcare/abstract.00007611-200302000-00013.htm;jsessionid=C2DnepQGhuwgYFhmvitb0koPiea4wvIJdiPHDm4Lr9sffoheU2RD!1563931552!-949856031!9001!-1> • Can Intensive Primary Care Prevent Primary Intensive Care? Taylor, David E. MD, Southern Medical Journal, Vol 96(2), February 2003, pp 122-123. <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12630633&dopt=Abstract> • Right Patient? Right Bed? A Question of Appropriateness, Dawson, et al., AACN Clinical Issues, Vol. 11(3), August 2000, pp 375-385. <http://www.aacnclinicalissues.com/pt/re/aacn/abstract.00044067-200008000-00005.htm;jsessionid=C2CZPesbwb1BRjhBDgaf44jI758ANu2Y6qo2fFjw2ct1TbVFL8OS!-264389797!-949856032!9001!-1> • The Emergency Department Case Manager: Effect on Selected Outcomes, Gautney, et al., Lippincott’s Case Manager, Vol. 9, No. 3, pp 121-129. http://www.lippincottscasemanagement.com/pt/re/lippcasemgmt/abstract.00129234-200405000-00003.htm;jsessionid=C2F2KhDA6EXwYSuDbDbWS1P9OHUcMGu4vgRa28F3WEa7z2LE1CkJ!1563931552!-949856031!9001!-1 • Patients Readmitted to ICU’s; A Systematic Review of Risk Factors and Outcomes, Rosenberg, Andrew, et.al., Critical Care Reviews, Chest, 182, 2, Aug 2000, pp492-502 <http://www.chestjournal.org/cgi/reprint/118/2/492?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=rosenberg&fulltext=ICU+readmitted&searchid=1115077355571_12913&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=chest>

39. Bibliography • Patient flow optimization • Institute for Healthcare Improvement, “Transforming Care at the Bedside”, Rutherford, Pat, et al., 2004 <http://www.ihi.org/IHI/Products/WhitePapers/TransformingCareattheBedsideWhitePaper.htm> • Remote Control, Feeney, Tracy, Advance for Nurses, Vol 5, Issue 15, July 5, 2004, pp 14-16 http://nursing.advanceweb.com/common/EditorialSearch/AViewer.aspx?AN=NW_04jul5_n4p14.html&AD=07-05-2004 • Urgent Matters, “Bursting at the Seams: Improving Patient Flow to Help America’s Emergency Departments”, Sept 2004 <http://www.urgentmatters.org/pdf/UM_WhitePaper_BurstingAtTheSeams.pdf> • Institute for Healthcare Improvement, “Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings”, 2003 <http://www.ihi.org/IHI/Products/WhitePapers/OptimizingPatientFlowMovingPatientsSmoothlyThroughAcuteCareSettings.htm> • Flexible Monitoring in the Management of Patient Care Processes: One year After the Pilot Study, Jones, Catherine, et al., Lippincott’s Case Management, Vol. 6 No. 2,Mar/Apr 2001, pp 88-94 <http://www.lippincottscasemanagement.com/pt/re/lippcasemgmt/searchplusresults.htm;jsessionid=C21pfk4NVJeS7wabGT60GmMqVeCVpl6iVHUFCiJ2zAVdrwn254UJ!1563931552!-949856031!9001!-1>

40. Contacts • Tim Gee • tim@medicalconnectivity.com • Cheryl Batchelor • cbatchelor@firsthealth.org • Download presentation • www.medicalconnectivity.com/stories/NTI2005 • www.medicalconnectivity.com/categories/patientflow