I have worked with many hospitals concerning patient throughput – it is one of those issues that every hospital struggles with. A common issue of efficient patient throughput is moving ED admitted patients safely and quickly from the ED to nursing units. There are many barriers to this process and a Kaizen event or A3 problem solving team should be utilized to identify the issues and direct the improvement team to action.
One barrier that is top of the list in many organizations is an effective handoff on patient conditions from ED nurse to floor nurse.
There are three prominent ways to facilitate handoff communications:
- Assigned ED RN calls floor nurse and gives verbal report
- Assigned ED RN transmits a patient SBAR to the floor nurse
- Face to face communication between ED nurse and floor nurse
There are also three prominent ways to move patients from ED to the floor:
- ED RN or tech moves patient him/her self to the floor
- Transport moves ED patient to the floor
- Floor nurse retrieves patient from ED and moves patient to floor him/her self
Recently I helped to facilitate a hospital to problem solve and develop a process that worked best for its environment. Let’s recap how they looked at the problem through Lean eyes:
On transport, “best practice” dictates to have face-to-face communication whenever the ED moves a patient to the floor and give handoff directly to the floor nurse (and likewise when the floor retrieves the patient from the ED). However, the key flaw in both of these approaches is that it removed their critical resource (ED RN or floor RN) from their respective units for at least 30 minutes—an identified waste that limits patient care.
Their solution was to have Transport move patients to floor units (with an RN to accompany if patient is monitored). This minimized a key waste – time RNs are off their units, but the problem of handoffs still existed. Their existing process required verbal reports between RNs. They observed a significant time waste with staff playing telephone tag – the measured average was 50 to 60 minutes for the ED RN and floor RN to actually connect for a verbal handoff.
Their solution was to electronically send an SBAR report to the floor units from the ED. The Lean team designed the form to include all the pertinent information. Now phone calls are only used if the floor needs clarification or if ED nurses need to discuss any special circumstances or outlying issues not included on the SBAR report.
After the transporting and handoff problems were solved, they tackled the patient waiting waste surrounding the timing of the admit moves. A Kaizen team was developed and the event resulted in the following process to minimize their patient waiting problem:
- As soon as the admit order is entered, a bed request for the level of care should be made and bed should be assigned within 5 to 10 minutes (if a clean and staffed bed is available).
- The assigned ED RN should then assemble the patient SBAR report and transmit to the correct floor within 30 minutes of the admit order being placed.
- When the ED sends the SBAR report to the floor, they should contact Transport with a target to respond of 10 minutes or less.
- If Transport has to wait for more than seven minutes while a patient is being readied, they should not be required to stay and a new transport should be requested.
- The floor units should have 15 minutes to respond to the sent SBAR and at that time, the patient should be moved to the floor unit.
- Transport should contact the floor to indicate that they are on the way.
This process requires vigilance by all parties but ensures safe and efficient patient movement.
How does you your hospital improve patient throughput? Are you following “best practice” or have you problem solved to develop your best process?
Today’s blog was written by Bob Watson, senior manager with HPP.
Bob leads Lean Healthcare transformations for HPP and provides consulting services in a variety of areas within healthcare. Bob has developed training for Lean, Six Sigma and DFSS. He has also spoken at several Healthcare, APICS and ASQ functions.
Bob received a Bachelor’s and Master’s degree in Industrial Engineering at Rensselaer Polytechnic Institute.