New bed-placement system streamlines internal communication and expedites emergency department patient flow.
At the Presbyterian Intercommunity Hospital (PIH) emergency department (ED), which annually serves 70,000 patients in Whittier, Calif., a severe bed crunch in 2008 turned into an opportunity to improve patient flow. For years, hospital staff recognized that communications between the ED and access department, which handles the movement of patients around the hospital, was a major source of inefficiency. Communication breakdowns led to an overcrowded waiting room, a high percentage of ambulance traffic diverted to another hospital, patients waiting for long periods, delayed bed placements and staff frustration.
Yet, there was a silver lining - the bed crunch ended up serving as the impetus for a close examination of the problem and deployment of an effective solution.
"At the time, the bed-placement process consisted of a barrage of phone calls between the floor nurse, the ED charge nurse and the access coordinator," says Lisa Martinez, RN, clinical coordinator of the ED at PIH. "With no predetermined checklist outlining the details needed for each placement, moving one patient from the ED to an inpatient bed could easily involve as many as 10 calls back and forth. Additionally, the exchange of inaccurate patient history was possible because transferring medical information from the patient's chart to the access coordinator's clipboard was completed manually - making room for human error."
With numerous patients needing beds simultaneously, the access coordinator could not keep up with the volume of calls, Martinez adds. For every call answered, multiple calls were missed.
The staff was asked why bed-placement requests were routed by phone as opposed to e-mail. When the clinical team met with the IT/communication resources department to request separate e-mail addresses for the access coordinator and ED charge nurses to utilize for bed placements, Dawn Roth, communication resources director, viewed this request as an opportunity to assess the bigger picture and to offer an even better solution.
"While e-mail communication would be an improvement over the current system, IT/communication resources envisioned a Web-based, automated bed-request system that would expedite communication and reduce errors," she says.
Financial challenges addressed
Like many hospitals struggling with financial challenges, PIH did not have budget available to purchase new software and hardware. Therefore, Roth developed a plan to create a simple database that would leverage existing intranet hardware, electronic medical records and Vocera, the hospital's wireless communication system, featuring a wireless, wearable badge.
"In three months, we brought the streamlined bed-placement concept to fruition using PIH's existing systems," explains Roth. "Clinicians were involved in every aspect to ensure the solution satisfied their needs. As development of the system approached completion, we trained employees to operate the system. When the system went live, technical support was available on every shift to ease the transition."
Instead of communicating bed requests by phone and keeping track of bed assignments with a pencil and clipboard, the process became fully automated online to reflect the real-time status of each bed request and placement. The basis of the system is the back-end database that IT/communication resources developed to operate within PIH's secure intranet. The database determines the fields that are listed on the online forms, which are then used to request and assign beds through the intranet.
"Today, when an ED patient is admitted to the hospital, the charge nurse logs on to a computer and completes a simple form outlining the specifics of the patient's bed request," says Ricki Stajer, RN, administrator of care management. "The form features a series of predetermined fields, including type of bed and special requirements, such as restraints or isolation."
Additionally, the form's "comments" section offers the charge nurse a chance to offer specific information and updates. Once the charge nurse enters the patient's identification number, the bed-placement system automatically populates any additional patient information that is needed from the hospital's electronic medical records. This eliminates the likelihood that manual data entry errors will cause delays and inaccuracies that previously hindered the bed-placement process.
When the charge nurse submits a completed request form online, the access coordinator is immediately notified of the details of the request via a Vocera text message.
Assignments made immediately
When the access coordinator receives the request form alert via the Vocera badge, the access coordinator logs on to the intranet and completes a simple form to make the bed assignment. This form indicates which department and room the patient should be moved to based on the patient's requirements and bed availability. Since the system reflects real-time room availability and bed requests, the access coordinator is able to make immediate assignments using the most up-to-date information.
To make real-time bed-placement information easily viewed by physicians and nurses, a large monitor is mounted in the ED. In compliance with HIPAA regulations, the at-a-glance ED board identifies patients by displaying their age, gender and ID number and shows the status of their bed request and assignment. Additionally, a permission-driven view includes patients' identifying information with their request. Both views help manage requests by creating a prioritized work queue, providing immediate visibility across the ED, access and unit floors, revealing insights into potential bottlenecks and obstacles, and enabling proactive steps to address delays.
"By deploying the automated solution, the average time for patient bed placement at PIH decreased by more than four hours on average," says Martinez. "Bed-assignment time decreased an average of 90 percent, from two hours and 59 minutes pre-implementation to 18 minutes post-implementation. Patient placement time decreased 56 percent, from two hours and 54 minutes prior to deployment to one hour and 38 minutes following the system's implementation."
Improvements in communication also positively impacted ED volume and the diversion rate, according to Roth. "From early 2008 until April 2009, the monthly ED volume grew from approximately 5,100 patients to 5,900 patients," she says. "Over the course of a single year, monthly ED ambulance diversions decreased from approximately 80 in March 2008 to essentially none in March 2009."
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