April 13, 2009

Precious Commodity — Beds at a Premium
By Lindsey Getz
For The Record
Vol. 21 No. 8 P. 20

Some combination of technology, daily assessments, and better communication across departments can help healthcare organizations gain efficiencies and improve care.

Patient flow is a problem at healthcare facilities nationwide. In fact, a 2008 National Survey on Patient Flow Challenges and Technologies administered by StatCom, a developer of hospital operations systems and comprehensive patient throughput software, found that 89% of survey respondents admitted their facility had poor patient flow.

The concern is that poorly managed patient flow isn’t only a hassle for hospitals but can also have more serious consequences. This is particularly true in vulnerable areas such as the emergency department, where a lack of beds could put patients’ health and safety in jeopardy. “The inability to move patients from the emergency department into the inpatient setting is one of the areas where patient flow problems are most visible—and can also be the most critical,” says Diane Jacobsen, MPH, CPHQ, director of the Institute for Healthcare Improvement.

Minimizing delays to ensure that patients are transitioned to the appropriate level of care in a timely manner is key. Meeting patient needs to keep the flow smooth and steady—whether that includes getting them admitted, discharged, or simply transitioned to another area of the facility—is crucial to prevent bottlenecks that clog the system and prevent safe, effective patient care, leading to a hospital that is poorly run and inefficient.

A Critical Concern
There are many reasons behind poor patient flow, including organizations’ inability to effectively communicate between departments, a flaw that leads to problems when transitioning patients. In the StatCom survey, the leading cause of patient flow problems was identified as poor communication.

“Hospitals are made up of a lot of different ‘islands of excellence,’” says Ben Sawyer, executive vice president of client services at StatCom. “Essentially, each department—the emergency room [ER], the operating room, or therapy areas, for instance—operates well on its own. Patients who stay on just one island may have a great experience. But as soon as patients have to go from one island to another, there’s often a problem. A classic example of this is trying to get patients from the ER into a critical care bed. It happens all the time that this ends up being a huge challenge.”

To get a handle on these concerns, it’s important to examine and record data on what’s happening on a day-to-day basis at your facility, says Jacobsen. “For hospitals to be able to truly understand their ability to manage patient flow in real time, they must look at what’s available on a daily basis compared to what the demand is like,” she explains. “In other words, how many beds do you need, where do you need them, and how many do you actually have? Find the areas where the demand for beds exceeds the number of available staffed beds and plan proactively on the unit level and the system level, as needed, to minimize delays. Obviously, this might differ from day to day, but what we’ve found is that when hospitals really take the time to assess the bottlenecks on a daily basis, they’ll start to notice patterns. They’ll find areas where there are chronic bottlenecks that can be planned for and addressed.”

Selecting an appropriate solution will depend on where the congestion occurs. Some hospitals have dealt with a patient flow problem by expanding their emergency department. Despite creating more beds, this strategy may actually increase the department’s overall waiting time.

In many cases, expansion doesn’t address the problem’s true source, which may be poorly managed patient transitions. If that is the case, extra beds will likely not help ensure that patients are being cared for in the appropriate unit or area, says Jacobsen. Other hospitals hire patient flow specialists or managers whose daily job is to stay on top of discharges, walk the halls (especially between departments), and point out problem areas to help keep operations moving smoothly. Because poor patient flow is often the result of employees being too busy to stay on top of the situation, this approach can be effective.

Nevertheless, each hospital presents a unique situation. Fortunately for organizational decision makers, there is a wide range of solutions available to set them on the path to more efficient care.

Many look to technology as the answer. The StatCom survey found that 67% of respondents believed that improving technology would also improve their productivity and help better manage patient flow challenges. Sawyer says one way to look at patient flow and technology’s effectiveness for keeping it moving is to compare a hospital to an airport, another facility that constantly deals with moving parts.

“Airports manage their constant flow of planes coming in and leaving by relying on air traffic control,” he says. “A hospital basically functions like an airport without air traffic control. There’s no central hub in charge of managing flow. If you had two airplanes competing for one runway, air traffic control would deal with the problem. But when you have the ER competing for a critical bed at the same time as the operating room, there’s often no system in place to decide who gets the bed. So you have consistent bottlenecks showing up again and again, and you wind up with patients who are classified ‘left without being seen.’”

StatCom is among the companies that offer technology solutions to electronically manage hospital operations and patient flow. “If you look at the airport example again, airports know there are a limited number of gates, so they use an electronic system to manage what planes are landing and when,” says Sawyer. “They use that to determine the allocation of limited resources based on need and demand. And if they find the demand exceeds the capacity, then they will divert planes to other airports rather than risk problems.”

Sawyer adds that companies such as FedEx operate in a similar manner, using logistics technology to track packages and manage what’s coming and going. “Almost every other industry has implemented a hub with logistic software which can prioritize demands—except healthcare,” he continues. “There is no system that is prioritizing and linking information across departments and alerting departments what patients are next in line, and so there is no visibility and these bottlenecks occur.”

Jacobsen agrees that technology can be a helpful tool in better managing patient flow but says there’s more to solving the problem than applying software. “There are times when we want to think that technology is the answer, but on its own, it’s not,” she says. “For instance, an electronic bed board can be a great way to clearly visualize what beds are available, and that can be very helpful. But that’s just one aspect of the problem. The work still needs to be done with the ongoing process of understanding the demand for beds and making the adjustments needed to meet that demand. An electronic board is a tool that can help facilitate action, but it’s not going to do the work for you.”

A Downside to Technology
While many hospitals may benefit from a dose of technology, a study by researchers at the University at Buffalo (along with collaborators from other universities) found that patient tracking tools such as electronic bed boards may have negative consequences. The study focused on how new electronic patient-status boards were functioning in the emergency departments of two busy, university-affiliated hospitals. In each case, the boards replaced the traditional white boards that had been used for years.

The researchers found that using the electronic system changed the way that many healthcare providers worked, says Ann Bisantz, PhD, an associate professor of industrial and systems engineering at the University at Buffalo School of Engineering and Applied Sciences. “In complex workplaces where safety is critical, such mismatches between the way practitioners work and the technologies that are supposed to support them can have unintended consequences, including inefficiencies and workarounds, when the technology demands that people change their work method,” she says.

The manual white boards in the two hospitals not only were a place to keep track of patient names and room numbers but also served as a means of communicating patient information such as complaints, symptoms, vital signs, allergy and dietary alerts, and other important data. “There may not be a way to make those personal notes that employees make on the white board in an electronic system,” says Bisantz, who adds that even if there is, there are other issues that need to be addressed when relying on technology.

“If there’s a critical concern about a patient [such as an allergy], it may not stand out as clear when hidden in an electronic system compared to a note on the white board,” she says. “And the user may not find out about that information as quickly as they would on a centrally located white board because they have to find an available computer station and take the time to log in. If that critical note is not on the first page, perhaps the user needs to scroll through several electronic pages. The result is that the critical information is not relayed in a timely manner or may not even be noticed at all.”

Bisantz says the solution is not necessarily sticking with the white board but involving users in the design process of any new technology. For hospitals looking to acquire this technology, Bisantz recommends involving employees in the purchasing process. “Just like hospitals would be careful to ensure the system they are purchasing is operable with all the other systems and software they have, hospitals should also be sure that it’s something their employees will be able to use,” she says.

The bottom line? Solving patient flow problems may mean incorporating some aspects of technology with the caveat that it’s not necessarily going to fix everything. “Clear communication is really the key,” says Jacobsen. “Technology can help facilitate better communication by providing clear visuals. It can show you where the available beds are and where the demands are coming from, but it’s just one piece of the overall process.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.

 

Study: Electronic Data Improve Operating Room Scheduling
In the current economic climate, using electronic medical records (EMRs) to lower healthcare costs is receiving a great deal of attention. For some specialties, however, EMRs may not be beneficial in the way most people imagine, according to Franklin Dexter, MD, PhD, a University of Iowa professor and the director of operations research.

Dexter and colleagues have devised a way to use electronic medical data to make inroads into one area of medicine in which it has been notoriously difficult to control costs—operating room (OR) and anesthesia scheduling. The changes help OR managers better estimate how long a particular case will last, making it easier and more cost-efficient to schedule subsequent cases in the same room.

“It isn’t having electronic medical records that reduces costs but rather how the information from electronic medical records is used,” says Dexter, a professor of anesthesia at the University of Iowa Roy J. and Lucille A. Carver College of Medicine. “In practice, much of the cost reduction is from using electronic medical record data for managerial purposes.”

The new system, which Dexter described in the March issue of Anesthesia and Analgesia, combines information about a patient’s vital signs in the OR with historical data about how long cases typically last and applies statistical mathematics to provide realistic estimates of the remaining time needed for an ongoing OR case. This information is updated continuously as the case continues—a process that is currently done manually.

“We have figured out how to do this updating accurately, automatically, and electronically without any human input and display that information throughout the surgical suite,” Dexter says. “This application can completely change the day-to-day jobs of people who run OR desks.”

The data crunching performed by the system can be augmented by a real-time estimate from the surgical team on the time remaining for the case. The OR staff provide this information in response to an instant message sent by the system that essentially asks, “How much longer?” The response is automatically plugged back into the calculation to improve the accuracy of the time-remaining estimate.

Because every hospital has patient monitoring equipment and an electronic system for tracking historical case-duration information, Dexter suggests that the system could be easily implemented in any other hospital.

He notes that an important feature of his research, which has spanned more than one decade, has been understanding why it is so difficult to accurately predict how long a surgical case will last and thus why it is so difficult to efficiently schedule multiple surgeries.

As Dexter explains, the “average” time a case may take is not a useful number for OR management when scheduling several cases in one OR. At that point, as with a double header in a sports stadium, it is important to know the longest and the shortest time the first case may run and the probabilities associated with the possible case-duration estimates.

“We have figured out how to do this math, and we can do this with only the information in electronic medical records. It’s not just that we can say, on average, how long a case will take; we can say there is a 90% chance that it will take two hours, for example,” Dexter says.

— Source: University of Iowa Health Sciences