"It’s the most invigorating thing I’ve ever done in my career," says Linda Caissie, RN. "If this is my legacy to health care, I will be very happy."
Caissie, director of emergency care services at Bon Secours Venice Hospital in Venice, Florida, USA, radiates the kind of zeal that seems in short supply in health care today. The rewards of caring for patients can sometimes be overshadowed by the frustrations of working in a system that makes delivering care harder than it ought to be.
Caissie’s professional life has been invigorated by her hospital’s commitment to widescale improvement, and its success in a number of areas, including improving the flow of patients between and among departments. Improvements in patient flow have led to greater efficiency and higher patient and staff satisfaction, as well as cost savings for the hospital.
Caissie says that one of the first challenges for the Flow Team at Bon Secours, which she leads, was to change the perception that flow problems begin and end in the emergency room. "People associate flow with the Emergency Room," she says. "But we could fix everything in the ER and still not move patients through quicker. We had to help people understand that improving flow involves not just the ER, but the entire organization."
Embracing this notion, Bon Secours has attacked its flow problems with a multi-faceted approach that includes:
- Compressing the ER, including reducing the nurse/patient ratio
- Faxing patient reports to med/surg floors on admission
- Reassigning responsibility for PACU transport
- Organizing (linking) discharges
Compressing the ER
As a member of the Institute for Healthcare Improvement’s (IHI's) IMPACT network, Bon Secours is ambitiously pursuing improvements in all five IMPACT domains, including Office Practices and Outpatient Settings; Critical Care Settings; Workforce Development; Improving Flow Through Acute Care Settings; and Patient Safety.
Through this work, Bon Secours’ Flow Team learned an IHI concept that seemed counterintuitive to some, but that resonated with Caissie. "IHI taught us about the concept of compression in the ER, and it just hit home with me," recalls Caissie.
While Emergency Departments nationwide are expanding in attempts to ease overcrowding and reduce the need to divert ambulances to other hospitals, Bon Secours did just the opposite. "We closed some rooms, and reduced our nurse/patient ratio from 1:4 (and sometimes 1:5) to 1:3," says Caissie.
"The nurses were about evenly split on whether or not they thought this would work," recalls Jean Reschenthaler, RN, a staff nurse in Bon Secours’ Emergency Care Center (ECC) and a member of the Flow Team. "Many nurses thought, 'We can't get to everyone fast enough now. How are we going to get patients in and out faster by seeing fewer patients each?’"
In part, the answer lies in working more efficiently, which is made easier when the space is smaller and the responsibilities are fewer. "With four or more patients, the nurses were just enough overloaded that they couldn’t manage to move patients out quickly enough. It is an interesting phenomenon that seeing fewer patients each, allows us to see more overall. On our first night of trialing the new ratio, we cut our patient turnaround times completely in half," says Caissie. This was done without adding any additional staff.
"With three patients, we have more time to talk with patients and educate them," says Reschenthaler. "We can also enlist their help in keeping things moving. If I know a patient’s cardiac enzyme test results are due at 2:00, I’ll tell him, and ask him to remind me if I am busy."
Reschenthaler says that having fewer patients also allows the nurses to work more closely with the physicians, guiding them toward the most acutely emergent patients first, and helping them with the prompt disposition of patients. Cassie adds that one of the keys to their success has been giving clinical managers responsibility for overall flow in the ECC.
The new ratio has dramatically improved patient satisfaction, patient safety, as well as nurse retention. "Before, nurses didn’t always feel they had the time to give the best care. Now they do," says Reschenthaler.
But as anyone knows who’s been involved in improvement projects, solving one problem often highlights or even creates another.
"When we began to move patients faster through the ER," says Caissie, "we ran into bed crunch issues upstairs." They couldn’t place patients in med/surg or ICU beds as fast as they needed to. "We had solved things in the ER, but now we had to look upstream at the next blockage."
When the Flow Team looked into the steps involved in transferring patients to a med/surg bed from the ER or the OR recovery room, they found one part of the process was rather consistently blocking patients’ ability to move forward in a timely manner.
"Before a patient was transferred, the ER or recovery room nurse would call the nurse on the admitting floor to give a report about the patient," explains Caissie. "If the nurse wasn’t available to come to the phone, the patient would wait until the nurses were able to talk to each other."
So they created a very simple form and a new process. "The nurse writes a brief summary of the diagnosis on the form and fax it, along with the nurse’s notes, to the admitting floor," says Caissie. "The nurse calls the floor to let them know the fax is coming. The protocol is that the patient leaves the ER or recovery room 15 minutes after the report is faxed. That gives the floor nurse time to review it and call before the patient leaves if there are any questions."
Faxing reports has had a hugely beneficial impact on patient turnaround time, says Caissie, but was not initially ideal from everyone’s perspective. "The floor nurses felt like they lost some control. In the ECC, we don’t necessarily know what they are dealing with. We’ve spoken with other hospitals that have put this protocol in place, and they say it takes about a year to iron out the wrinkles," says Caissie. "We are continuing to refine the process."
Caissie says the team is now working on creating a computer-based "real-time assessment tool" that will allow all nurses in the hospital to view the "big picture" of patient volume and acuity on any given unit. "If an ER nurse sees that a floor nurse just received three patients from the OR, we know we can’t send her a patient from the ER just then," says Caissie. "It will return some control to the inpatient side."
The clinical manager in Bon Secours’ post-anesthesia care unit (PACU) was also a member of the Flow Team. She knew first-hand that the OR would grind to a halt when patients weren’t transferred out of the PACU on schedule. Having PACU nurses responsible for transporting patients to the floors turned out to be part of the problem. "The nurses were taken away from the PACU to transport patients, and it was a very inefficient use of their time," says Reschenthaler.
So they arranged to share a transporter with two other units, says Reschenthaler, and saved five PACU nursing hours a day. This enabled them to transfer one FTE RN from the PACU to another unit, saving an estimated $31,500 per year. Not to mention, adds Reschenthaler, that "the PACU nurses are thrilled."
A smooth and predictable discharge schedule is another element that helps improve overall patient flow. Caissie says that Bon Secours’ efforts in this area have so far been very promising.
Discharge linking works like this: on a daily basis, physicians are asked to identify patients they think will be ready for discharge the following day. This sets in motion a series of steps. "We notify the family that tomorrow is the likely discharge day, and agree on a time for them to take the patient home," says Caissie. "This gives the nurses 24 hours to prepare for discharge, get the paperwork, do the patient education, arrange for visits from rehab, arrange ahead of time for any special transportation the patient may need at discharge." Housekeeping is also notified so they can plan to clean and prepare the room for the next patient.
The physician still must approve the discharge in the end. "We are not trying to control what the physicians do with their patients," says Caissie. "We are just trying to make it all work better." She says the physicians involved in testing discharge linking have been enthusiastic about it.
Discharge linking has also helped smooth some bumps when patients are transferred internally, says Caissie. "We found that a lot of orthopedic patients were transferred to our Transitional Care Unit (TCU) in the early evening, when they do not have as many resources available." So they worked with physicians to discharge patients earlier in the day, and communicated discharge plans to the TCU. "We let them know 24 hours in advance they would get a patient at 10 pm, and they could plan for it. It gave organization to what was once chaos."
Caissie says the team tested discharge linking in orthopedics because it is easier to predict the average length of stay for orthopedic patients. Spreading it to other units, especially med/surg patients, will be more challenging, she acknowledges, "but I think it will be a successful challenge."
Caissie has good reason to be optimistic. As an IMPACT member, Bon Secours has committed to making dramatic change throughout its systems. Caissie says that all the improvement work currently underway is intertwined. "Each domain impacts the others. The flow improvements are helping with workforce issues and patient safety. Improvements in the critical care domain — enabling patients to move out of the ICU faster — help relieve pressure on our ER."
It is the convergence of all these improvement efforts that is both demanding and energizing for staff, says Reschenthaler. "Sometimes our tests of change succeed, and sometimes they fail," she says. "But the improvements we’ve made in patient flow have truly empowered our nurses. The bottom line is that we are giving better care."