Patient Flow Enewsletter
Volume 1, Issue 6
Thursday, July 15, 2004
Resources in this article:
More and more hospitals are experiencing mergers and consolidations in today's increasingly competitive health care environment, yet face the challenge of doing so without affecting the quality of patient services. After Lincoln General Hospital (LGH) and Bryan Memorial Hospital - both located within the city limits of Lincoln, NE - merged to form BryanLGH Medical Center in July 1998, the hospitals were faced with uncharted territory: how to work together to solve emergency department (ED) flow problems.
Already a big enough problem to solve individually, East and West campuses were charged with coming up with one solution as a merged facility. By successfully establishing communication between the Medical Center's two campuses, BryanLGH was able to improve both ED patient flow and campus-wide internal hospital communication between in-patient and ED services.
Although BryanLGH East and West had been addressing ED flow problems for several years, it had been viewed as primarily an ED problem. As in-patient beds filled up, patients were held in the ED, causing a backlog of ED patients in the waiting room. As a newly merged organization, BryanLGH Medical Center was addressing other issues as well. Lincoln has become home to a large number of immigrants from a variety of countries. Nebraska ranked fifth in refugee resettlement per capita with states of population less than two million in 1990. Issues related to placement of these patients, interpreter services and increasing numbers of patients added to overcrowding issues.
"Even with the number of things happening, we found it hard to change an accepted practice or the 'status quo' in the hospital, whether the practice was working or not," said Ruth Radenslaben, clinical director, BryanLGH Medical Center. "Then, our grant writer spotted the opportunity for the Urgent Matters grant and approached me about it, encouraging me to submit the grant as a merged facility - East and West. We put together a team of people including ED, quality improvement, utilization review and our diversity coordinator to develop the grant."
Buy-In and Implementation
After receiving the grant, an Urgent Matters task force committee consisting of managers from both East and West campuses was formed to oversee the execution of the grant program. The committee strategically planned the program's execution, giving priority to the creation of tools to measure in-patient and ED flow so that the appropriate data could be collected in both East and West.
"After data collection, we discovered many issues that were keeping us from good ED flow, but they were all things we could work on," said Radenslaben. "For example, we noticed the ER was seeing a large number of mental health patients, but there was room for improvement in the process for moving them through the ER."
The committee immediately started working to tackle these issues. By coordinating with staff in the ED and mental health observation/triage unit, the committee was able to determine that an ED physician needed to get involved early in the process to rule-out any medical problems in the mental health patient. A brief mental health triage was done, the ED physician did the medical screen, and then the mental health triage could be completed. This alone shortened the time mental health patients were in the ED by 30 to 60 minutes and allowed earlier medical screening.
Additionally, ED patients were not being seen in a timely manner, because there was not an efficient process for informing nurses/physicians about new patients. In immediate response, a chart rack system was put into place. (This was later replaced with a computerized patient tracking system, but the early manual process helped develop a computerized flow.) When the patient was placed in a room, the chart was put in the "nurse to see" rack. After a nurse would see a patient, the patient's chart went onto a rack for the physicians - they instantly knew that a patient was ready to be seen. After the doctor saw the patient, the chart would go back on a rack for nurses, so the nurses knew the patient had orders to be completed or was ready for dismissal.
One of the most important changes to come out of the joint effort between East and West was the line of communication that the collaboration opened between in-patient and ED services. Administrative nursing supervisors, in-patient managers and ED managers began meeting every other week and devised a new, consistent process for admitting patients. It shortened the admission steps significantly, increased the communication between the ED nurse and the accepting unit nurse and improved the level of collaboration.
| "Although it took several months, once everyone agreed, we all left the room with a commitment to make the new process work," said Radenslaben. "A rapport was finally developed between the ED and in-patient services - we had never really worked together to solve problems before." The new system was implemented on a trial basis in a few units for two weeks. |
After the trial period, the hospital's Urgent Matters committee met to work out some kinks. This admission process has now been in place for four months on both campuses. Staff and patient satisfaction has improved. There is consistency in admission flow, and internal relationships have been enhanced. The admission nurse trial has not yet been implemented, but will continue to be considered as a viable option. Radenslaben said it was well received by all areas, however budget of the positions has not yet been determined.
Lessons Learned
"Early into the Urgent Matters grant, we felt that we had the support of ED managers, physicians and staff to look closely at our systems. Because we had not anticipated looking at our in-patient processes, we had not worked closely with the in-patient directors and managers in preparing our grant. As a result, convincing in-patient staff that they needed to be part of a major data collection and trial process was suddenly a big challenge for the team," Radenslaben said. "Luckily one of the in-patient nursing directors saw this as an opportunity to look at their internal flow problems and got involved. We were then able to begin doing data collection and rapid cycle tests in some key in-patient areas."
Radenslaben said it was a good team, but that if she had it to do over, she also would have involved more in-patient staff early on in the grant writing. "We had a much better team to solve problems when we had increased representation. Now we can come together and not only talk about problems, but work on resolutions."
Radenslaben also recommends putting time into promoting the project internally throughout the hospital. She suggests taking information about the project to internal administrative and service meetings. "A lot of people didn't know what the Urgent Matters program was. So when we would seek assistance, we had to keep explaining the project," she said. "Taking time to make sure that hospital staff knows what you're doing and why you're doing it is important. I think we would have gotten better initial reception had they known what was going on."
The Urgent Matters grant has started to shed light on several areas that Radenslaben feels can be improved to further help ED flow, like lab draws and radiology exams. "The Urgent Matters grant helped us to organize our data, make recommendations, quickly trial new ideas and accept or reject them based on outcome. With the help of our consultants, we were able to pull together our ED and in-patient managers and make some hard decisions that allowed us to trial and implement really helpful changes."
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Ruth Radenslaben, RN, BS, MA
Clinical director
BryanLGH Medical Center
Lincoln, NE
