why did they close all those beds in the 1990s?! · why did they close all those beds in the...

Why Did They Close All Those Beds in the 1990s?!

Amy Diane Short, Lee Ann Liska and Ann Schlinkert

2/2/2006© 2005 The University Hospital , Cincinnati

2

Presentation Overview

Appropriate inpatient admission– Transfer referral center, Diversion criteria

Streamlined bed placement– Electronic Bed board, Admitting quick list, Bed audit, Census revision

Expedited care delivery– Medical admission express unit, Pump movement, Surgical site infections

Earlier patient discharge– Manager of patient flow, Discharge transportation,

Discharge planning upon admission

Accelerated post acute discharge– Referral process, Interpreters, Extended care information network


3

Capacity Constraints: National Dilemma

Gone are the days of having too many bedsEmergency rooms are at risk of diversionPACUs struggle to keep the operating rooms productiveCath labs must compete for inpatient bedsTransfers-in from other hospitals compete for limited inpatient space Direct admits face long delaysEvery bed is in use


4

Input

ED or Direct Admit

SNF or Home Care

DispositionPatient FlowAncillaryServices

Admitting OR

CriticalCare

Med/Surg

Discharge

To open up more inpatient beds, patient flow must be addressed along its continuum

Care is provided in many different locations, at many different times, using many different processes

Patient Flow: The Continuum


5

Patient Flow: The Solution

Key areas to address:– Appropriate inpatient admission– Streamlined bed placement– Expedited care delivery– Earlier patient discharge– Accelerated post acute discharge


6

Patient Flow Project Structure: Old

Patient Flow Steering TeamLee Ann Liska (Chair)

Mavis BechtleAndrea Stewart

Patient Flow Action TeamLee Ann Liska (Chair)

Steering Team Mark Schroer, MDGreg Fermann, MD

Tim Pritts, MDMgt Point Persons (per below)

OE/BB Support (per below)Meeting frequency: bi-weekly

Appropriate Inpatient Admission

Michael GrodiAmy Short (BB)

Streamlined Bed Placement

Ann SchlinkertTerry Dunn (BB)

Expedited Care DeliveryRene Fischer

Yvette Kauffman (BB)

Earlier Patient DischargeDenise Jackson

Hewley Hinds (BB)

Accelerated Post-Acute Transfer

Peggy SogarBeth Solomon (BB)

Other Analytical ProjectsAmy Short

Trish Zapanta

Coordination with other TUH Projects

Lee Ann Liska

Coordination with other Alliance Throughput

ProjectsAndrea Stewart

Structure active from May to August 2005


7

TUH Patient Flow Project Structure: Current

Patient Flow Action TeamLee Ann Liska (Chair)

Mavis BechtleAmy Diane ShortAnn Schlinkert

Ruby Crawford-HemphillRene Fischer

Denise JacksonMark Schroer, MDJohn Deledda, MD

Tim Pritts, MD

Meeting frequency: monthly

Other Analytical ProjectsLinda Flesch

Trish Zapanta

Coordination with other TUH Projects

Lee Ann Liska

Structure active from September 2005 to present


8

Patient Flow: Metrics

MetricHCAB

BenchmarkTUH

Baseline JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV +/-

ALOS (Days) 4.6 4.9* 5.0 5.0 4.8 4.8 4.8 4.9 4.9 4.7 4.9 4.9 4.8 (0.2)

Hours on Diversion 0 44** 104 31 16 66 0 71 51 82.0 36.0 15.0 0.0 (15.0)Avg Wait Time for IP Beds -PACU (Mins) <= 60 146* 132 145 112 114 126 139 140 135 121 132 89 (43.0)

Avg Wait Time for IP Beds -ED (Mins) <= 60 434*** 457 457 455 410 288 396 377 330 392 300 272 (28.0)

Avg Wait Time for IP Beds -TRANSFERS-IN New Process (Mins)

<= 60 142**** NA NA NA 43 58 156 184 163 234 206 79 (127.6)

Avg Wait Time for IP Beds -TRANSFERS-IN Old Process (Mins)

<= 60 142**** 215 202 170 247 164 274 461 272 465 221 167 (54.7)

Modal Discharge Times (Time) 11:00am 14:00* 14:00 14:00 14:00 14:00 14:00 14:00 14:00 14:00 14:00 14:00 14:00 0.0

Transport Average TAT (Mins) 35 37** 36 35 39 39 40 40 39 46 42 36 34 (1.2)

Room Turn TAT - Regular (Mins) TBD 98** 88 92 102 101 107 110 107 115 112 118 119 1.0

Room Turn TAT - STAT (Mins) TBD 67** 67 65 67 69 67 66 67 71 70 73 76 3.0

Appropriate Inpatient Admission


10

Transfer Referral Center: Concerns

Referring physicians– Passed around on phone to other TUH physicians– Took too long to get connected to a TUH physician– Uninformed about length of time for bed– Takes too long to get a bed

Accepting physicians– Unaware of the bed situation– ED physicians concerned about direct transfers to the ED


11

Transfer Referral Center: Solutions

Give transfers-in more priority– Met with Nursing Supervisors– Asked that acuity be the criteria– Bed updates involve the Nursing Supervisors

Get Transfer Center staff access to better on-call information– Same information that operators use

Develop a paging escalation policy– Five minutes to return a page– Next pages escalate to a higher level

Transfer Center staff stays on the phone– Can facilitate the call

– Keeps tabs on the transfers’ progress– Provides regular updates on bed status


12

Transfer Referral Center: Solutions

Hire a Physician Referral SpecialistDevelop scripts– Standardize the process

Create new forms for the Transfer Center– Capture more data

Record and QA calls– Error proof the process– Train and educate– Maintain a respectful organization

Get insurance pre-certificationsDevelop an ED admitting policy– Set the clear expectations

Transfer Center staff screen for the ED physicians– One of the benefits of staying on-line


13

Transfer Referral Center

Percentage Successful Transfers-in

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

Week

Perc

enta

ge % SuccessfulBaseline 90%Target 97%

Process Change at Week 18

Week 29 dipped because of ED diversion and transfer referral center staff vacations


14

Diversion Criteria Setting Project

Worked with the Greater Cincinnati Health Council to develop citywide “at capacity” guidelinesSet up 24/7 methods of diversion communication to key TUH stake holdersRolling out “Throughput Action Plan” (TAP)Posting “Bed Alert” signsDeveloping “Peak Census Plan” for each unit


15

Diversion Criteria Setting Project

Hours on Diversion10

431

66

0

51

36

44 44 44 44 44 44 44 44 44 44 44 44 44 44 44 44 44

8272

16

0

15

020406080

100120

Janu

aryFeb

ruary

March

April

MayJu

ne July

Augus

tSep

tembe

rOcto

ber

Novembe

rDece

mber

Janu

aryFeb

ruary

March

April

May

Month

Hour

s DiversionBaseline

Streamlined Bed Placement


17

Maximized Use of the Electronic Bed board: Phase I

The manual bed board:– Difficult to see the big picture of bed activity– Many phone calls to get a bed– No easy way to check the status of a dirty room.– Inconsistent communication about bed assignment

Teletracking’s electronic bed board solution– Implemented Phase I in March 2005– Rolled out five units


18

Maximized Use of the Electronic Bed board: Phase II

The electronic bed board:– Units can see their bed activity (pending, admissions, discharges and

transfers)– No phone calls for bed placement (except ICU)– Real-time feed back on room clean status by pager– Real-time notification of bed assignment by pager– Nursing supervisors can see the bed big picture on their computers


19

Throughput team prioritized phase II as a key projectPhase II rolled out 17 more units– Implemented August 2005

Users trained on-site by vendorEnhancement on-going:– Already upgraded system– Monthly user group meeting– Meeting users’ needs



20



21

Emergency Department “Quick List”

Forms and related documentation– Puts monitoring requirements, infectious disease concerns, and downgrade

information all in one place– Facilitates getting the right patient in the right bed and prevents delays– Keeps patient from returning to the ED

The University Hospital Emergency Department Admission Form* Date: _______________________ Time: _______________________ Diagnosis: _______________________________ Condition: Good Fair Serious Critical Monitoring Requirements (Check all that apply): None General

Telemetry: O2 sat & HR only

9 CCP 4 N/E 5 N/W/E MPCU 8CCP (FMCU)

Dysrhythmia Telemetry (Dysrhythmia Care per RNs)

6S 6/N/W CSD 7NW –no r/o MI

Patient Safety Monitor/Sitter **

Reason:

Infectious Disease Concerns (All transmission based precautions need a private room):

VRE Precautions ** Airborne Precautions (Negative Airflow Room) **

Droplet Precautions **

Contact Precautions **

Other – Describe**:

Other:

AKA (Protected Patient)*

Police Hold w/ Guard **

Peritoneal Dialysis with Cycler 7NW (CMCU), MPCU, MICU

Immuno-Deficient** Other - Describe:

Downgrade: Time of Request: _____________________

Admitting Attending Approved? : Yes No

Time of Response:__________________

Please Name Any Continuous IV Medications for This Patient: ______________________________________________________________________ Type of Bed Requested : ____________________________________

Medication Nursing Units Maximum Dose Special Considerations

Amiodorone CSD, 6S 1 MG/MIN

Ativan CSD, NPCU, MPCU 10 MG/HRMay remain in stepdown if dose has not been adjusted within 6 hours

Diltiazem CSD, NPCU, 6S 5-20 MG/HR

Dobutamine CSD, NPCU, 6S 20 MCG/KG/MIN Maintanance dose or weaning to off

Dopamine CSD, NPCU, MPCU, 6S, 6NW 5 MCG/KG/MIN Maintanance dose or weaning to off

Esmolol CSD 300 MCG/KG/MIN Must be weaning to off

Insulin CSD, NPCU, MPCU 0.1 UNITS/KG/HR Higher dose must be transferred to ICU

Milrinone CSD, 6S 0.75 MCG/KG/MIN

Nitroglycerin CSD, NPCU, Patient must have telemetry monitoring

Contact Isolations Airborne Isolation Non-Orders

Room Type: Private Room Negative Airflow Room (These orders do NOT exist)

● VRE ● Rule Out TB ● Respiratory● Clostridium difficile ● Active TB ● Reverse Isolation

● Lice/Scabies● Herpes Zoster (varicella-zoster) Chickenpox ● Neutropenic Precautions

● All draining wounds not contained by a dressing ● SARS ***

● All mulit-drug resistant organisims ● Smallpox ***● Monkeypox ***● Vaccinia Reactions or disease ***● Viral hemorrhagic viruses ***● Shingles ††

Turned in as: “…with contact precautions” “…with airborne isolation” (These orders do NOT exist)

For the HUC:Enter “Contact Precautions” in the

comments sectionEnter “Airborne Isolation” in the comments

section (These orders do NOT exist)

Questions?

(General) Telemetry

Either or both:

● Heart Rate

● O2 saturation

Dysrhythmia Telemetry

Cardiac Dysrhythmia monitoring plus either or both:

● Heart Rate

● O2 saturation

Patient Needs:

TELEMETRY MONITORING CAPABILITIES

The University Hospital

Bed Assignment Reference (BAR)

Dial the Operator and page the on-call Infection Control Practitioner.

Diagnosis:

Hospital Infection Control Policy II-334 Standard Precautions/Transmission Based Precautions

Notes:

This policy is a complete listing of diseases and conditions, with the isolation precautions they require. A current copy is available on the Health Alliance Intranet

Additional Reference:

INFECTION CONTROL REQUIREMENTS

● Pertussis (whooping cough)

● Pneumonia (until diagnosed)

● All undiagnosed respiratory illnesses

● Cystic Fibrosis (with contact precautions)

● Influenza

● Meningococcal Meningitis (Neisseria)

MEDICATION LIMITS

*** For these conditions PAGE INFECTION CONTROL IMMEDIATELY via hospital operator!

†† ONLY if Disseminated (varicella-zoster) or in a immuno-compromised patient.

“…with droplet precautions”

Enter “Droplet Precautions” in the comments section

Droplet Precautions

Private Room

● Mycoplasma Pneumonia

DRAFT DRAFT


22

Conducted physical bed audit– Counted how many beds are currently in use– Counted how many head walls that could be immediately used if needed– Detailed renovation opportunities to expand bed count

Revising daily census report– Creating a tool that communicates, on a daily basis, the number of potential

beds, number of beds open for use, and the number of beds actually occupied by both inpatients and observation patients

Streamlined Bed Placement: Other Key Projects

Expedited Care Delivery


24

Medicine Admission Express Unit (MAEU)

Purpose:– Facilitate admission of medicine patients from the ED, clinics, and outlying

hospitals– Increase documentation– Improve quality outcomes– Improve throughput

What is it?– Six bed inpatient unit– Telemetry capabilities– Staff completes admission paperwork and teaching – Staff documents core measures


25


Medical Admission Express Unit (MAEU)

Fina

l Uni

tM

AE

UA

dmitt

ing

CE

C AOD decides toadmit patient.

Medical teamassigned andorder written.

HUC requestsMAEU bed in the

EBB, documentingpreferred final unit.

Is a final bedavailable?1

Admitting assignspatient to MAEU

Admitting waitsuntil final bed is

ready.

Are thereavailable bedsin the MAEU?

Admitting assignspatient directly to

final bed.

Yes

No

Yes

CEC gets pagedfor ready bed.

Patient going toMAEU?

Patient Arrivesfrom CEC.

Patient arrivesfrom CEC.

Admissionpaperwork and

teachingcompleted.

JCAHO coremeasures

documented.

Social needsdocumented.

PharmacyInsurancecoverage

documented.

Normal place RXfilled documented.

Admitting assignsfinal bed.

Patient transportedto final room.

PharmacyInsurancecoverage

documented.

Social needsdocumented.

Normal place RXfilled documented.

JCAHO coremeasures

documented.

Admissionpaperwork and

teachingcompleted.

A

A

B

Yes

BNo

-

No

Footnotes:

1. Final bed may not be thepreferred bed but may reflect use ofbed placement algorithm for 2ndand 3rd choices

Last Revised: 9/23/05

Pending transfer tofinal bed

requested in EBB.

Actual transfer isrequested in Last

Word


26


Barriers for transfer to final unit:– Bed not available (need M/F bed)– Inpatient beds at capacity– Discharge process not facilitated on admission– Bed not clean (in MAEU/or Receiving Unit)– Floor too busy to take report/shift change– Progressive Care acuity (no beds)– No orders for patient/delay in return call MD (primarily direct admits)


27

45.037.530.022.515.07.50.0

Median

Mean

987654

A nderson-Darling Normality Test

V ariance 53.1605Skewness 2.30098Kurtosis 7.63890N 165

Minimum 0.3333

A -Squared

1st Q uartile 3.2750Median 5.15003rd Q uartile 9.9333Maximum 50.7833

95% C onfidence Interv al for Mean

6.7195

11.09

8.9611

95% C onfidence Interv al for Median

4.4633 5.9626

95% C onfidence Interv al for StDev

6.5802 8.1756

P-V alue < 0.005

Mean 7.8403StDev 7.2911

95% Confidence Intervals

Summary for TAT

TUH Medicine Admissions Express Unit (MAEU)

Median TAT:

5 Hours

Data Period: 11/1 – 11/30


28

Expedited Care Delivery: Other Key Projects

Reduce non-value added movement of pumps– Pumps no longer have to go back to Central Services for cleaning– Each floor will have a room that will have enough clean IV and PCA pumps

to serve all of its units for 24 hours– Estimated go live is the end of November

OR surgical site infection– Six Sigma project found that pre-op antibiotics were twice as likely to be

given in the appropriate therapeutic time frame if there were pre-op orders

Earlier Patient Discharge


30

Nursing’s Role in Patient Flow

Manager of Patient Flow, Ann Schlinkert– Oversight of nursing supervisors, flow nurses, float nursing staff and

discharge lounge– Runs daily am logistic meeting

Flow Nurses– These registered nurses expedite discharges for all units, facilitate internal

transfers, and pull admissions into the inpatient units– Their analysis in the 3rd Qtr 05 identified key discharge bottle necks– They have been key players in rolling out better processes for planning for

discharge at admission


31

Keeping “All Beds Open”

All beds are open at all times– Beds can only be “closed” through a formal process– Requires administrative approval– Nursing supervisors are on the front line

Requires teamwork between the sending units, the receiving units, Admitting, and the Nurse Supervisors– All channels of communication must be open– All hands must be on deck to provide support

Daily am logistics meeting– Provides forum for senders, receivers, and support services to address daily patient

flow operational needs– Engenders real time process improvement and monitoring– Provides transparency about the need for beds across the house


32

Discharge Transportation Improvements

Simplified discharge transportation request proceduresGoal of 15 minute transportation response time (average)

Month # Discharge Transports

January-05 210February-05 270

March-05 347April-05 321May-05 376

June-05 305July-05 349

August-05 348September-05 335

October-05 347November-05 652


33

Discharge Transportation Improvements

Bed ID Date/Time Time Bed ID Date/Time Time622502 7/3/2005 11:11 11:11 622201 7/7/2005 00:15 0:15623202 7/3/2005 11:23 11:23 623202 7/7/2005 06:23 6:23623101 7/3/2005 11:58 11:58 622502 7/7/2005 11:17 11:17621801 7/3/2005 14:24 14:24 622601 7/7/2005 12:26 12:26623301 7/3/2005 14:26 14:26 623101 7/7/2005 13:00 13:00622601 7/3/2005 18:27 18:27 623101 7/7/2005 13:00 13:00623101 7/4/2005 07:25 7:25 622401 7/7/2005 20:11 20:11623101 7/4/2005 07:25 7:25 622901 7/7/2005 20:12 20:12622502 7/4/2005 12:59 12:59 622502 7/7/2005 23:51 23:51622602 7/4/2005 13:30 13:30 623202 7/7/2005 23:51 23:51621802 7/4/2005 16:11 16:11 623202 7/8/2005 06:28 6:28622901 7/4/2005 22:22 22:22 622501 7/8/2005 13:54 13:54622902 7/5/2005 02:09 2:09 622602 7/8/2005 14:42 14:42621802 7/5/2005 11:38 11:38 622402 7/8/2005 15:30 15:30622901 7/5/2005 11:38 11:38 623001 7/8/2005 19:03 19:03622902 7/5/2005 11:38 11:38 623101 7/8/2005 19:03 19:03622501 7/5/2005 12:09 12:09 623301 7/8/2005 19:05 19:05622401 7/5/2005 13:44 13:44 623301 7/8/2005 19:39 19:39622502 7/5/2005 15:10 15:10 621802 7/8/2005 20:48 20:48621801 7/5/2005 17:18 17:18 622001 7/8/2005 22:43 22:43623001 7/5/2005 17:32 17:32 622201 7/8/2005 23:34 23:34622301 7/5/2005 17:46 17:46 622901 7/9/2005 11:57 11:57623001 7/5/2005 19:13 19:13 622602 7/9/2005 12:16 12:16622001 7/5/2005 21:00 21:00 622302 7/9/2005 12:44 12:44622001 7/6/2005 02:25 2:25 622502 7/9/2005 12:44 12:44622201 7/6/2005 05:31 5:31 622501 7/9/2005 12:57 12:57623001 7/6/2005 10:20 10:20 622001 7/9/2005 16:41 16:41622501 7/6/2005 15:51 15:51 622301 7/9/2005 16:52 16:52622901 7/6/2005 15:56 15:56 623301 7/9/2005 18:47 18:47622301 7/6/2005 19:26 19:26623301 7/6/2005 19:26 19:26622302 7/6/2005 20:38 20:38622902 7/6/2005 22:07 22:07622901 7/6/2005 22:31 22:31

Reviewing “clustering” of EVS & transportation

requests


34

Discharge Planning on Admission

Improve the timeliness of discharge by:– Making earlier referrals to allied services– Changing discharge RX processes– Making better use of the discharge lounge– Using transportation for discharge transports

MD writes RX

MD hands RXstraight to the

patient

Unit Nurse tubesthe RX to the DL

RX goesstraight into

chart?

Pt hands DL NurseRX

DL Nurse goesinto LW and

checks patient'sfinancial class and

Act Doc.

Pt any otherfinancial class thanself pay who has

not seen by afinancial counselor

(FC)?

Is the patient inthe DL?

DL Nurse informsFC office who willsend a FC to the

pt's bed side.

DL Nurse sends ptto FC office for aSTAT financial

analysis

Pt's financialclass otherthan privateinsurance orMedicaid?

Prescription couldbe filled here.

Pt choose tohave RX filled

here?

RX filled off-site atanother pharmacy.

DL Nurse tubesRX to OutpatientPharmacy (OP)

with otheridentifying

paperwork andlogs it on the DL

RX log.

A

A RX received byOP

OP logs RX'spertinent data,

included whetheror not RX is a

controlledsubstance.

Insurance doublechecked.

Appropriate forOP to fill?

OP processes perusual procedurefor DL RX and

logged out

OP calls DL andthen sends RX

back to thedischarge lounge

Are items toolarge to fit in

the tube?

Items tubedregular or secure

as needed.

OP tech calls DLNurse

Does DL Nursedecide to pickitems up fromPharmacy?

Transportation, oradmitting staff pick

up items

DL Nurse walks toOP to get items

and brings back toDL.

In the DLPrescriptions are

processed,logged, pt signs

sticker which is puton the DL

pharmacy log.

B

B

DL Nursedispenses

medicines andother items to pt.

DL Nurse collectsthe co-pay

Is the patient intheDL?

DL Nurse explainsthat pt needs toget the RX filled

elsewhere.

DL Nurse informsfloor nurse of

situation

floor Nurseexplains that ptneeds to get the

RX filledelsewhere.


Cash, Credit, andchecks secure

tubed to OP to beprocessed

Is the patientstill on the

unit?

After a call to Unit,Pt, Family

member, or unitstaff bring co-payto DL and pick up

items. Cashier'sOffice Open?

OP tubes receiptback to DL

(happens twice forcredit cards)

Cash, credit, andchecks processedthrough cashier's

office.

Original receiptgoes to pt, copy

tubed to OP

RX transactioncomplete.

RX transactioncomplete.

No No

No

Yes

Yes


No

Yes

No

Yes

No

Yes

Yes

No

Yes

No No

Yes

No

Yes

Yes

No

Nurse sendspatient and RX to

the DL

No

Yes

Nurse tubesRX straight to

DischargeLounge? (DL)

Yes

Rumor is we still fill OHMedicaid, but not KY or IN

Notes:1. Logs in DL maintained forlegal reasons.

2. What about Psych andTransplant?

3. After hours?

Current State:

All this to get a discharge RX filled –OUCH!


35

Discharge Planning on Admission: Tools

All patients who have been discharged and:

…..Need to wait for transportation home

People who:

…..Have poor behavior/mental status – as decided by Nursing Supervisor…..Are with guards…..Are actively Incontinent- as decided by Nursing Supervisor…..Cannot transfer independently or cannot transfer with one

Mission: The Discharge Lounge will serve as a comfortable place where discharged patients may wait for transportation home. The Discharge Lounge, partnering with the TUH Financial

Counselors, will also facilitate the use of the Outpatient Pharmacy

The University Hospital Discharge Lounge

…..People who don't know where they get their prescriptions filled

People who are:

Which discharged patients can wait for their Outpatient Pharmacy prescriptions in the Discharge Lounge?

People who qualify to have their prescriptions filled by the Outpatient Pharmacy and:

Opens at 9:00 am

.….People who typically get their prescriptions filled at the Outpatient Pharmacy

…..The final eligibility determination is made by the Financial Counselor

…..Qualify to have their prescriptions filled by the Outpatient Pharmacy (See above qualifications)

Which discharged patients are potentially eligible to have their prescriptions filled by the Outpatient Pharmacy?

Which discharged patients should go to the Discharge Lounge?

Which discharged patients should NOT use the Discharge Lounge?

Vision: The Discharge Lounge will serve our discharged patients by addressing their needs one

individual at a time

Date :Unit:Pt Room # :

1. If no help is needed check "N/A".2. If help is needed check "Needs" and sign with initials.

4. Document your actions on the IPOC.5. Person who resolves the problem checks "Resolved" and signs with initials.

Needs (Initial) Referral Made Resolved (Initial) N/AExample: X AC X AC X ADS

Social Work1.Transportation home2. Safe/accessible place to go3. Something to wear home

Interpreter4. Needs interpreter

Home Health5. Home Health evaluation6. Has home oxygen

PT/OT7. PT/OT evaluation

Pharmacist8. Needs Fragmin education

Diabetes Educator9. Diabetic teaching

Unit and/or Flow Nurse10. Smoking cessation education11. Other teaching/needs**

Where are prescriptionstypically filled?

**Details & other comments:

Things this patient needs for a timely discharge

Discharge Needs Assessment (DNA)

Community Pharmacy Name:TUH Outpatient Pharmacy

3. If help will be provided by Social Work, Interpreter, Home Health, PT/OT, Unit-based Pharmacist, or the Diabetes Educator page a referral immediately. Then check "Referral Made".

CSD’s Role in The Discharge Lounge Process

DNA_______________

DNA_______________

Unit nurse checkschart for direction

as to where ptshould have RX

filled

Unit nurse handspatient the RX

Patient stops byFinancial

Counselor Officeon the way out

Script Script

Appropriate tofill RX at OP?

Patient has RXfilled elsewhere

No

Yes

Patient's socialneeds are

assessed (Willthey have a ridehome, et al) and

documented

Patient is admitted

Patient's typicalpharmaceutical

provider isidentified anddocumented

Patient's stayelapses

Transportation andpharmacy needs

evaluated and arepart of discharge

planning anddocumented in

chart

MD places thedischarge RX in

chart

A

A

If the patient goes to a community pharmacy the answer is NO.

If the patient goes to the Outpatient Pharmacy or doesn’t know, the answer is YES.

If the discharged patient needs to wait for a ride, send them to the discharge lounge regardless of medication needs.

Physicians should not hand prescriptions directly to patients.

Criteria

Discharge Upon Admission

Unit Processes


36

Discharge Planning on Admission: Data

•Number of RX’s tubed to straight to the DL since implementation of new processes were significantly lower than number before implementation

Number of Discharge Prescriptions Tubed from Six South

13

402468

101214

October 2005 November 2005

Rolled Out 10/3/05Number of Discharge Prescriptions Tubed from

CSD

1

9

0

2

4

6

8

10


Rolled Out 10/24/05

Number of Discharge Prescriptions Tubed from Seven NorthWest

6

19

0

5

10

15

20


Rolled Out 11/2/05


37


Six South

(Pre= September 2005, Post = October and November 2005)

Data Consists of Monday - Friday Disposition Home Only

Two-Sample T-Test and CI: Time Converted, Status

Two-sample T for Time converted

Status N Mean StDev SE Mean

Post 198 14:42 0.118 0.0084

Pre 107 15:25 0.118 0.011

T-Test of difference = 0 (vs not =): T-Value = -2.11

P-Value = 0.036

DF = 216

43 Minutes Earlier!


38


38 Minutes Earlier!

Seven North West

(Pre= September and October 2005, Post =November 2005)

Data Consists of Monday - Friday Disposition Home Only

Two-Sample T-Test and CI: Time Converted, Status

Two-sample T for Time converted

Status N Mean StDev SE Mean

Post 142 14:34 0.117 0.0098

Pre 204 15:12 0.118 0.0083

T-Test of difference = 0 (vs not =): T-Value = -2.09

P-Value = 0.038

DF = 305

Accelerated Post Acute Discharge


40

Accelerated Post Acute Transfer: Key Projects

Smoothed process for Drake referrals– Improved referral process and communication– In-serviced medical social work staff and rehab regarding admission criteria and

procedures

Improve referrals to interpreter services– Referrals for pre-scheduling have improved – now receive 80% advance notice on

requests for interpreter– Additional interpreters have been added to the department due to grant with the Health

Foundation of Greater Cincinnati

Extended Care Information Network - ECIN– Signed contract for software to allow electronic transfer of patient information between

long term care facilities, homecare agencies, community resources and TUH.– Implementation scheduled for March 1st.


41

Patient Flow Conclusions and Next Steps

Hard to feel the impactHolding steady during a time of increased volume


42


ActualFY 06

Budgeted FY 06

Variance ActualFY 05

FY 05 - FY 06Change

Average Daily Census

380.6 375.9 1.2% 365.7 4.1%

Adjusted Patient Days

65,131 63,016 3.4% 61,472 6.0%

Admissions 9,230 9,170 0.7% 8,733 5.7%Adjusted Admissions 13,387 13,028 2.8% 12,244 9.3%

Average Length Stay 4.87 4.84 0.6% 4.94 -1.4%

Nurse Vacancy Rate*

10.2% N/A N/A 19.7% -48.2%

* Numbers from October 2004 and October 2005

Admission Statistics


43


Capacity11/1/2005

Medicine Svcs 7NW

32 35 3 NA NA 3

Medicine Svcs MAEU

0 6 6 NA NA 6

Surgical Svcs5 STSurgical SvcsSICUTotal 17 23

11/14/2005 4

18 24 6 28 2/6/2005 10

16 18 2 20

Increased Bed CapacityUnit Capacity

7/1/2005Net Bed Capacity Gain To

Date

Planned Capacity

Date of Planned Increase

Net Bed Capacity

Gain Future

Gained17

Beds!

Gained17

Beds!


44

Beds Blocked/ Patient Holds Tracking

Ongoing data collection to monitor the number of patients waiting for inpatient beds (“holds”) as well as the number of inpatient beds being blocked


45

Patient Holds TrackingCensus

356358360362364366368370372374

CY 2004 November 2005

Admits

70717273747576777879


Total Holds

0

2

4

6

8

10

12


ED Holds

012345678


Diversion Hours

0

0.5

1

1.5

2

2.5


372 78

2 2

0

why did they close all those beds in the 1990s?! · why did they close all those beds in the...

Documents