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Putting an end to patient overcrowding

Smooth and timely patient flow, or throughput, is critical to patient safety, patient and staff satisfaction, and hospital revenue. At our hospital, Provena Saint Joseph Medical Center (PSJMC) in , we saw firsthand what can happen when patient flow gets bottlenecked. We also learned that fixing a patient throughput problem is likely to require a system-wide approach—and perhaps a “cultural” transformation among employees.
Part of the six-hospital Provena Healthcare System, PSJMC is a 517-bed facility with a Level II trauma center. It’s located in a desirable area with one of the fastest growing populations in the country. But by 2004, our emergency department (ED) had become notorious for long wait times—so long that nearly 5% of patients left without being seen. Some patients who stuck it out wound up staying in the ED overnight.
The situation was getting considerable publicity and harming the hospital’s reputation. Public perception of the hospital plummeted.
At the same time, a new threat loomed: Other healthcare systems had announced plans to build hospitals in our market region, which would increase the competition for patients and could put PSJMC in financial jeopardy.

Emergency department woes
Our ED problem wasn’t unusual. EDs across the nation face significant overcrowding as the number of people seeking healthcare in EDs has risen. In 2003, national ED visits numbered 113.9 million—up from 90.3 million a decade earlier. But in the same period, the number of facilities capable of treating ED patients decreased.

Quick executive action
To improve patient throughput and repair the hospital’s reputation, our new chief executive took quick action. In local newspaper ads that PSJMC bought, he acknowledged the hospital wasn’t meeting the community’s needs, and he promised to fix the problem. He immediately directed the senior executive team to put together a patient flow initiative to bring about rapid change.

Transforming the culture
As the initiative got off the ground, team members realized their biggest challenge might be cultural. Having seen many failed efforts to change ED processes over the years, some employees thought nothing could be done about the long waits and patient bottlenecks. They simply accepted this situation as the norm.
The project team realized they’d need to alter this mentality and get all employees to take ownership of the throughput initiative. They gave the initiative a distinct identity and posted signs about it all over the hospital to help embed the cultural change.
To maintain the energy behind the project, the hospital held quarterly employee forums on throughput, published weekly employee newsletters, ran progressive ads in local newspapers, and added standing agenda items to meetings.

Taking a systems approach
Some hospitals deal with capacity problems by adding more beds, building out, or making costly capital investments. But these “fixes” may not address the issue of overloading one end of the system.
Although some PSJMC employees saw our patient flow problem as strictly an ED issue, other departments had capacity issues, too. The throughput redesign team decided the best solution could come from freeing up hidden capacity and using existing resources more efficiently and effectively. To fix our ED delays and gridlocks, we’d need to improve patient flow throughout the entire system.

Redesigning patient flow
First, the project team addressed space issues, recommending conversion of some offices to bed spaces to enlarge the ED. Then they assembled four multidisciplinary teams to redesign critical throughput areas and processes—ED, case management, patient placement, and patient transport. Each team took a systems approach.

ED redesign
Our ED throughput has been redesigned so drastically hat long ED waiting times are a thing of the past. Arriving patients go through quick registration; a surveillance nurse gathers only essential information before designating the patient to the “fast-track” or the mainstream ED process. Also, ED physicians now use short order forms instead of full order sets from admitting physicians.

Case management redesign
To yield additional beds for admissions and decrease bottlenecks experienced from every point of patient entry to the hospital, case management was redesigned to promote earlier-day discharges and reduce length of stay by 0.5 to 1 day. Case managers’ caseloads were adjusted to a ratio, and a physician dedicated to case management and utilization was recruited.

Patient placement redesign
To speed bed turnaround throughout the hospital, patients are now “pulled” into open beds rather than “pushed” from areas that need to free up beds. To get a bed assignment for an ED patient, the staff places a request through our Tele-Tracking system—the bed capacity management software that has replaced our old paper-and-pencil system. After identifying an appropriate bed, the bed control department conveys the assignment to the charge nurse in the unit, using a special cell phone; the charge nurse gives the name of the nurse who will accept the patient. The transferring nurse calls in the hand-off report; if the receiving nurse is too busy to take it, the report is recorded through a system called OptiVox. The unit nurse who gets the call from the ED knows that transportation has been called and the patient will arrive within 30 minutes.

Patient transport redesign
PSJMC now uses the Tele-Tracking system to electronically track patient discharges, notify environmental services of the need for bed cleaning, and list the open bed on the electronic board in the bed control office. When a patient is ready for discharge, the system notifies Central Transportation electronically. The transporter discharging the patient then informs Housekeeping electronically that the bed needs to be cleaned. After it has been cleaned, the Tele-Tracking system receives notice that the room is ready to receive a patient.

Progress report
Our patient flow initiative was fully implemented on May 23, 2005. Since then, we’ve made tremendous gains in patient throughput. We’ve significantly reduced overcrowding, increased patient safety, and enhanced the quality of care. Our ED patient satisfaction scores have risen to the 84th percentile—a steep increase from the 29th percentile registered in the fall of 2004.
At the same time, we’re seeing more patients than before. In the 10 months after our initiative was implemented, we saw 5,612 more ED patients than we’d seen in the 10 months before. This increase has had a significant positive financial impact.
Now, nearly a year and a half after our “go live” date, patient throughput continues to improve. We expect it will take another 2 years of evaluating the system, tracking outcomes, and revising processes before our new throughput process is fully embraced and showing sustainability.
Although we implemented our changes fairly quickly, it took a lot of effort to change the hospital’s culture to one dedicated to improving patient flow. If you’re tasked with improving throughput in your facility, we urge you to start by evaluating your facility’s culture and determining the best strategies for getting resistant staff members to “buy into” your redesign plan.

Selected references
Center on Budget and Policy Priorities. The number of uninsured Americans continued to rise in 2004. Available at: www.cbpp.org/8-30-05health.htm. July 13, 2006.

Emergency Department overload: A growing crisis. The results of the American Hospital Association Survey of Emergency Department (ED) and Hospital Capacity, April 2002. Available at: www.hospital connect.com. Accessed July 13, 2006.

Institute of Medicine of the National Academies, Advising the Nation, Improving Health, Report Brief, June 2006, Washington, DC. Available at: www.iom.edu/Object.File/Master/35/014/Emergency%20Care.pdf. Accessed July 13, 2006.

Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. January 2006, pp. 277-278.

Joint Commission International Center for Patient Safety. Issue 26, Delays in treatment. Available at: http://jcipatientsafety.org/show.asp?durki=9880&print=yes. Accessed July 9, 2006.

Kirby A, Kjesbo A. Tapping into hidden hospital bed capacity. Healthc Financ Manage. November 2003:38-41.

Kathleen A. Mikos RN, , is Vice President of Patient Care Services at PSJMC in and executive co-sponsor of the hospital’s throughput initiative. Jeffrey Brickman is Chief Executive Officer of PSJMC and executive co-sponsor of the initiative. Sharon K. Baranoski, RN, , FAAN, is Director of Nursing Acute Care at PSJMC.

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