I have worked with many hospitals concerning patient throughput – it’s one of those issues that every hospital struggles with. A common barrier of efficient patient throughput is moving ED-admitted patients safely and quickly to inpatient nursing units. There are likely many barriers to this process and a process improvement event or A3 problem-solving team should be utilized to identify all the issues and direct the improvement team to action.
Let’s start with the one barrier that is top of the list in many organizations – an effective handoff of patient conditions from ED nurse to floor nurse.
There are three prominent ways to facilitate handoff communications:
- Assigned ED nurse calls floor nurse and gives verbal report
- Assigned ED nurse transmits a patient situation, background, assessment, recommendation (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 nurse or tech moves patient to the floor
- Transport moves ED patient to the floor
- Floor nurse retrieves patient from ED and moves patient to floor
I recently helped a hospital problem solve and develop a process to overcome this challenge that worked best for its environment. Let’s recap how they looked at the problem through Lean eyes:
On transport, best practice dictates a face-to-face communication whenever the ED moves a patient to the floor and gives 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 removes their critical resource (ED nurse or floor nurse) 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 a nurse to accompany them if patient is monitored). This minimized a key waste: the time nurses are off their units; but the problem of handoffs still existed. Their existing process required verbal reports between nurses. They observed a significant time waste with staff playing telephone tag; the measured average was 50 to 60 minutes for the ED nurse and floor nurse 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 is made and a bed is assigned within 10 minutes (if a clean and staffed bed is available).
- The assigned ED nurse would then ready the patient for transport, 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 contact transport with a request for response in 10 minutes or less.
- If transport has to wait for more than seven minutes while a patient is being readied, they would not be required to stay and a new transport would be requested.
- The floor units would have 15 minutes to respond to the sent SBAR and at that time, the patient is moved to the floor unit.
- Transport contacts the floor to indicate they are in route with the patient.
This process requires vigilance by all parties but ensures safe and efficient patient movement.
About the author. Bob Watson leads Lean health care transformations for Vizient and provides consulting services in a variety of areas within health care. He has developed training for Lean, Six Sigma and DFSS. He has also spoken at several health care, APICS and ASQ functions.