Improving Patient Flow

I hope there is some relief in the activity at your institution now that we have made it through another heavy viral season. Not that there really is a slow season in health care anymore, just a less busy one. So, welcome to the less busy season, when there is time to think and plan.

Environmental services departments are pivotal in the “flow” process, but it must be balanced with proper infection control practices. The challenge is timely, thorough communication—getting and giving good information.

Let’s imagine the emergency room waiting area is filled to capacity and census is at 99 percent. The health care institution has a patient throughput initiative and, hopefully, all of you have been involved in this initiative.

Here is the scenario:

The emergency room has just informed Patient A that he will be admitted. Bed management then scurries to see where the patient can be placed. For purposes of this scenario, we will assume Patient A is a cardiac patient and will need to be admitted into the cardiac intensive care unit, which is currently full. This means the patient shuffle will now occur.

This pending admittance is happening after 7 p.m., when staffing is at a lower level. The most stable patient, Patient S in the cardiac intensive care unit, will move to the step-down unit. But Patient O, who is currently in the step-down unit, needs to be relocated since there is now no need for monitoring this patient, but he is still not ready for discharge. We will now have to move multiple patients to get emergency room Patient A into a necessary room, but the only data that will be looked at is the time it takes to get Patient A to his room, although this is not the only process that is occurring.

The race is on to get Patient A into an intensive care unit room within a certain time frame. Patient S, who is in an intensive care unit room, has to move to the step-down unit room occupied by Patient C. Patient C is stable enough to move to Patient H’s room, which was discharged earlier in the day during the shift change.

This means either there was a lack of communication or miscommunication both from human beings and/or from the “fail-safe” electronic system to notify the incoming environmental services shift of the discharge. The room now resides in “neitherland”; hopefully, it will be discovered and cleaning completed within the required amount of time of the patient flow initiative. If not, we just encountered our first “dam” in the flow.

The current status for environmental services is one critical patient in the emergency room, two patients needing relocating, four rooms counting the ER exam room needing to be cleaned, with the emergency room waiting area overflowing and the health care institution on the verge of going into divert. Contact time to properly disinfect surfaces is 10 minutes, and two of the three rooms are in the same cleaning zone of one person. Patient C needs to go into Patient H’s room, which is the empty discharge room that is lost in the communication process. Patient A, who will move when Patient O moves, can go into Patient S’s room. What does all this mean for the hospital’s environmental services department?

Well if you played along with my little word game, the answer is “chaos”! Most hospitals spend from November to April in this type of scenario. Though the patient flow initiative may not have been accomplished, patients are treated in a timely, effective and safe manner with positive outcomes.

Now, when things are calmer, evaluate your turnaround times, your communication methods and your systems and start to develop process improvement initiatives. Use this time to document, evaluate your data and present this information to your administrator with improvement suggestions. This will assist you and your staff to develop, acquire or change initiatives that will lessen the burden next viral season.

On the road to excellence!

Tina L. Cermignano, CHESP
Operations Manager
Children’s Hospital of Philadelphia
Philadelphia

This article first appeared in the June 2008 issue of HFM Magazine.

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