Maximizing Hospital Capacity – Critical Now, More Than Ever
Capacity management has challenged hospital leaders for many years, as success, or lack thereof, significantly impacts financial strength, quality outcomes, reputation in the community, and satisfaction for patients, staff, and physicians. Now, more than ever, this core competency requires laser precision to maximize appropriate utilization of beds, staff, and services. Opportunities to improve capacity management can be identified by monitoring Emergency Department admit holds (boarding hours), PACU hold hours, bed request to patient in bed turn-around times, and incoming transfer patients declined due to beds unavailable. Hospital management teams who view capacity management as a hospital wide issue, rather than an issue isolated to the Emergency Department alone, see significantly better results. This is because all departments impact hospital capacity, so the best results are achieved when all department leaders are keenly aware of how their decisions impact patient throughput.
Understanding industry best practices for each department can make a big difference in supporting the overall goal to improve hospital throughput. Whether you are working to create capacity in your ICU, reduce OR cancellations, or impact the number of patients who leave without being seen in your Emergency Department, these best practices can drive significant capacity improvement results in your hospital.
Nursing – Leveraging Care Team Relationships
Discharge planning should begin the moment the patient is admitted. Upon admission, the nurse provides the patient and family with key information about the expected duration of hospital stay and milestones the patient must achieve to be discharged. After admission, discussions about estimated length of stay and goals, whether lab values, ambulation, or tolerating food must be disseminated upon admission and discussed daily with the patient and their family. Updating Care Boards, or white boards, daily with estimated discharge dates and plans to remove barriers to patient discharge are essential parts of the primary nurse’s responsibilities. Nurses play a key part in coordinating care between hospitalists, specialists, respiratory and physical therapists, pharmacists, and many other members of the healthcare team throughout the stay and regularly communicate anticipated discharge. Prioritizing discharges on each nursing unit helps to increase capacity and ensures new patients receive the appropriate level of care quickly. This makes a big difference for ER patients waiting hours or days for an inpatient bed. The night shift team can support discharge planning by preparing medication reconciliation and completing patient education before discharge.
Case managers provide information to the healthcare team through their utilization review, care coordination, and discharge placement. Case managers often perform a preliminary utilization review on all patients, however their primary focus for discharge planning is on patients who require transfer to a more appropriate level of care, or have complex placement issues such as nursing home, rehabilitation, behavioral health, or homelessness. Several states now require hospitals to provide specific placement for homeless patients upon discharge. This is very challenging, as it requires the case manager to coordinate with community resources, assuring appropriate placement for homeless patients after they leave the hospital or ER. The nurse and the case manager are key partners in this effort and must stay in constant communication regarding the barriers to discharge and progress toward patient goals. A best practice that drives great results is multidisciplinary “Barrier Rounds,” lead by Case Management and Nursing. These interdisciplinary rounds focus the care team on resolving barriers to discharge. Maintaining a 24-48-hour Discharge Dashboard through the hospital’s bed management software helps to keep all team members aware of anticipated discharges.
Top Tip: Multidisciplinary “Barrier Rounds,” lead by Case Management and Nursing keep the care team focused on resolving barriers to discharge.
Bed Management – A Coordinated Interdisciplinary Process
Capacity management requires leaders to view the hospital bed as a key hospital resource. Utilization Management should be a focus for this resource, similar to the processes leaders use to manage capacity for imaging equipment and operating rooms. Appropriate and timely use of the hospital bed drives financial and quality results. Below are some key Bed Management tactics that drive success.
Bed Manager or Bed Czar - Identify one Registered Nurse (RN) on each shift who will be assigned oversight of bed control for the entire facility. This RN may have other duties, depending on the size of the facility, but must have authority to make key decisions about bed placement during the shift. This Bed Manager RN leads daily Bed Huddles and rounds on nursing departments at least every 4 hours to help Charge Nurses assess and manage bed capacity and resolve barriers. This position is also key in working with physicians as they admit patients to the hospital and actively partners with them to address holds between different levels of care (ER, ICU, PACU, etc.). Establishing clearly defined admission and discharge guidelines for every unit assists the Bed Manager in swiftly supporting patient transfer to the appropriate level of care and assists physicians in determining appropriate admission units. Adhering to the admission and discharge criteria supports bed availability in key units such as ICU, Step Down, and Telemetry.
Bed Huddles – A morning huddle, held before 0900 for best results, is essential for bed management. Additionally, most facilities find it beneficial to hold a late afternoon huddle to support follow up for discussion items from the morning meeting. These huddles have multidisciplinary participation with a representative attending from each nursing unit, ER, OR, Lab, Radiology, EVS, Case Management, CV Services, and Administration. The meeting should be highly structured and last no more than 15-20 minutes with a focus on creating a plan for patient flow by identifying admissions, discharges, and transfers within the hospital. Specific “hot spots” are identified during the huddle and an action plan is made between the disciplines present to address the bottleneck quickly. Ancillary departments may prioritize testing and services for patients ready to be discharged. Lab, Radiology and CV Services may also prioritize test results to expedite discharges. The most important thing to remember about Bed Huddles is that each meeting MUST have actionable outcomes to be successful.
Environmental Services (EVS) – When considering the hospital bed as a key hospital resource, the ability to maximize utilization of each bed becomes critical to success. Understanding the flow of patient admissions and discharges throughout the 24-hour period can help the hospital appropriately staff the EVS department for the patient needs. For example, three 8-hour shifts with a change in staff at 1500 may not align well with room cleaning workload for EVS. Some large hospitals dedicate a bed cleaning team during peak patient discharge hours to achieve minimal downtime for each hospital bed. The use of Ultraviolet (UV) light for terminal cleaning by robot or wand has also positively impacted the time necessary for terminal cleaning. Ensuring the appropriate number of robots is critical to success.
Successfully Managing Capacity – High Effort, but High Impact
Engaging multiple disciplines in a single effort is incredibly challenging, however managing utilization and capacity in a hospital can have a profound effect on the hospital’s ability to manage expenses, quality, satisfaction, and reputation in the community. Literature shows that assigning patients to the level of care they need quickly reduces the chance of complications from hospitalization. The high effort needed to implement these best practices can produce results that are incredibly rewarding for operations and finances, but also for patients and the healthcare team.