MMHA 6000 Week 9 Patient Flow Case Example

Week 9 Discussion: Patient Flow Case

The Emergency Department Is Where the Wait Shows, Not Where It Starts: Tracing Calder Ridge's Boarding Problem Back to Discharge Timing and Skilled Nursing Placement

Symptom

In the case, admitted patients at Calder Ridge Community Hospital, our invented 118-bed hospital, waited a median of 5.2 hours between the admission decision and leaving the emergency department, and some waited overnight. The emergency department went on ambulance diversion for 31 hours last month, and 4.1 percent of patients left before being seen. Boarding is not only an inconvenience: a study of over 41,000 admissions found in-hospital deaths climbing from 2.5 percent for boarding under 2 hours to 4.5 percent for boarding of 12 hours or longer, with longer stays as well (Singer et al., 2011).

Trace

The obvious diagnosis is an understaffed emergency department, and the case notes that the emergency director has asked for two more nurses. I do not think that is the cause, because the patients waiting are already treated and admitted. They are waiting for something outside the department. Following the chain:

Admitted patients wait in the emergency department because no inpatient beds are open. Inpatient beds are full because most discharges happen late: in the case data, 62 percent of discharges leave after 2 p.m., while emergency admissions peak from late morning through the afternoon. Discharges are late because discharge orders are written after hospitalist rounds, which finish between 11 a.m. and 1 p.m. Patients cannot leave as soon as the order is written because transport and the pharmacy's bedside medication delivery are scheduled only after the order exists, adding about two hours. And on a typical day nine patients are medically ready but cannot leave at all, because a skilled nursing facility bed has not been arranged; they wait an average of 3.4 days.

Constraint

In theory of constraints terms, the slowest step sets the pace for the whole system, and speeding up any other step adds little (Goldratt & Cox, 1984). Here the binding constraint is discharge, with two parts: the time of day discharges happen and the days lost waiting for skilled nursing placement. Nine beds held for placement is roughly a full nursing unit's worth of capacity in a hospital this size. A review of crowding studies found that access block, when admitted patients cannot get to a ward bed, is among the most consistently reported causes of emergency department crowding (Morley et al., 2018). Adding emergency nurses would treat new arrivals faster and move them into the same queue.

Ownership

The emergency director does not own this constraint. Discharge timing belongs to the hospitalist program and the nursing units, which answer to the vice president of medical affairs and the chief nursing officer. Skilled nursing placement belongs to case management, and partly to the facilities in the region, which the hospital does not control. The person feeling the pain is not the person who can relieve it, which explains why the request in the case is for emergency nurses.

Question

Each department involved is measured on its own goals: hospitalists on length of stay and patient load, nursing on staffing ratios, case management on readmissions. None is measured on emergency boarding time. How would you align incentives across these departments so that discharging before noon is in each one's interest, and not only the emergency department's?

Reply to Theresa

Theresa, you argued the binding constraint is the hospitalists' rounding schedule, and that moving rounds earlier would solve it. I agree rounds are part of it, but I think skilled nursing placement is the larger piece. Earlier rounds would move today's discharges to the morning; they would not free the nine beds held by patients waiting for placement. The Institute for Healthcare Improvement's work on flow suggested that hospitals look at the whole system, including the transitions out of the hospital (Institute for Healthcare Improvement, 2003). Would you test both changes together, or rounds first?

Reply to Omar

Omar, you raised a fair objection to my post: the emergency department may also have its own slow steps, such as waiting for consultants, so adding nurses is not useless. I accept that. My disagreement is about how large the effect is. The case data show that boarding time, not time to be seen, makes up most of the length of stay for admitted patients. Could you look at whether the department's own delays affect patients who are discharged home, rather than those admitted?

References

Goldratt, E. M., & Cox, J. (1984). The goal: Excellence in manufacturing. North River Press.

Institute for Healthcare Improvement. (2003). Optimizing patient flow: Moving patients smoothly through acute care settings. Institute for Healthcare Improvement.

Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: A systematic review of causes, consequences and solutions. PLOS ONE, 13(8), e0203316. https://doi.org/10.1371/journal.pone.0203316

Singer, A. J., Thode, H. C., Jr., Viccellio, P., & Pines, J. M. (2011). The association between length of emergency department boarding and mortality. Academic Emergency Medicine, 18(12), 1324-1329. https://doi.org/10.1111/j.1553-2712.2011.01236.x