Patient Flow Enewsletter
Volume 1, Issue 5
Thursday, April 29, 2004
Resources in this article:
Like any hospital, providing care to acutely ill patients is a prime objective for St. Joseph's Hospital and Medical Center in Phoenix, Arizona. Since nearly 30 percent of the patients admitted flow through the emergency department, holding patients in the ED and ED closure is frustrating for staff, patients and physicians. Until now, only the ED and the house manager "owned" the responsibility of finding beds for patients. While they struggled to bed patients, the rest of the hospital went on with business as usual, even if the ED was on ambulance diversion.
With a grant from The Robert Wood Johnson Foundation's Urgent Matters program, staff at St. Joseph's began implementing a new, comprehensive Diversion Reduction Plan in July 2003. Since implementation, St. Joseph's has reduced time of ED diversions, increased hospital occupancy and improved efficiency in hospital discharges.
Leading the charge is Julie Ward, RN, MSN, Chief Nurse Executive of St. Joseph's. "We had done some previous work internally that was a perfect fit with the goals of The Robert Wood Johnson Foundation's grant - finding solutions to move patients through the ED quickly." Together with the Emergency Department Manager, House Manager and staff involved in bedding patients, they took a look at what other hospitals in the community were doing and devised a plan that best fit the needs of St. Joseph's.
Buy-In and Implementation
To develop the protocol, Ms. Ward and her team took a look at how floors deal with discharging patients and saw an opportunity to involve the house in the ED crowding problem. The result was a plan that proactively involved house staff, including patient care directors (Nursing, Case Management & Radiology); managers of patient care units (Floors, OR's ICU's & Rehab), housekeeping, transportation, lab, radiology and ultrasound; medical officer of the day and case managers, and social work.
Preliminary meetings were held with senior hospital staff to share their work and how it compared to what other hospitals were doing. To simplify implementation, there was no large approval committee; Ms. Ward and her team secured approvals as they went. Once the protocol had final approval by senior hospital staff, Ms. Ward and the hospital nursing committee educated house staff on the plan, and it was put into action. "We wanted a plan that gave everyone responsibility in diversion reduction. By giving everyone a stake in the process, staff started feeling the urgency of the situation and responded to it quickly and accurately."
See Diversion Reduction Responsibilities.
| Nursing leadership didn't hesitate in responding to the new protocol. After the protocol was first implemented, emergency crisis patient staffing meetings were held every 45 minutes after capacity was announced. |
As they became more efficient with the process, staff realized 45-minute intervals for the patient staffing meetings wasn't enough. This resulted in changing the protocol to allow 60 minutes between meetings so staff had enough time to take action on discharging patients.
"It usually takes us four to five hours to either avoid diversion or to resolve the log jam in the ED and re-open," says Ward. "If we go on diversion, then the plan immediately switches over to how we're going to get off of diversion.
Impact
Since implementation, the St. Joseph's ED actually goes on diversion more frequently than before, but stays on for significantly less time. This has led to a reduction in "leave without being seen" percentage, reducing it from a high of 21 percent to a low of 7percent with a 11 percent year to date average. Ward says, "We've learned that if we're too slow to go on diversion, then the 'leave without being seen ratio' will increase. Now if we have to divert the ED, it's easier to resolve the issue and re-open."
St. Joseph's has found that their Diversion Reduction Plan has improved efficiency in hospital discharges, increasing hospital occupancy by five percent. Three areas for improvement were identified early in the process of utilizing code diversion: lab results, radiology reports and the management of social issues. Both lab and radiology were able to respond to improve processes related to discharge. Lab changed some batching protocols while radiology began to attend daily bed rounds to be sure that tests on patients slated for discharge were read and reported. Case Management and social workers began to conduct twice a day rounds on each unit to execute that day discharges and to begin to plan the next day's discharges.
Code diversion also demonstrated that waiting for transport for patients going home or to another facility was a delay. A contract was developed with a stretcher company to provide onsite coverage for patient transportation. In addition, even if there is no diversion code, the house manager conducts "bed board" meetings three times per day to discuss discharges and any issues that may be holding them up.
Lessons Learned
"We can be confident now that when we go on diversion, it's the right choice," says Ward. "My advice to other hospitals considering a similar plan is to have a protocol Steering Committee that meets often and discusses what's going right or wrong, and what could be done better. Make sure you have a passionate owner with the power to get things done. Last, be sure to log and evaluate diversion codes right from the start. It's a good way to measure successes and identify problems as they arise."
Click here to download the survey and results.
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Julie Ward, RN, MSN
Chief Nurse Executive
St. Joseph's Medical Center
Phoenix, AZ
