The outflow (from the ED) of admitted patients is complex and incorporates elements of the nursing handoff, the physician handoff and inpatient bed (and hospital flow) management. Successful management of these elements is critical to moving the patient to inpatient units efficiently and effectively. Aligning all of these key variables requires relentless attention by senior leadership and engagement of frontline staff and middle management
The nursing handoff is frequently plagued with politics, incentive misalignment, and resource constraints, and the process is often complex, with a number of failure points and bottlenecks. The increasing financial constraints placed on systems has caused many institutions to utilize “core staffing” to reduce inpatient staffing or use real-time demand capacity techniques to “right-size” staffing based on current rather than anticipated demand. This approach can result in a lack of staffed inpatient beds causing the delay of patient transfers to and from critical care units and from the ED to inpatient units. Further, overwhelmed staff may by necessity delay
- Taking report
- Receiving bed assignments
- Discharging patients
To better utilize current inpatient resources, inpatient nursing incentives can be structured to be similar to those in the ED. As in the ED, the inpatient nurses have a significant amount of work required to discharge a patient and a discharge means another patient “queued up” will take the place of the recently discharged patient. The new patient will also require a significant amount of work to assess and treat. Placing even more pressure on the inpatient nurses, many of the discharges and admissions occur as staff conclude or attempt to take scheduled breaks from their shifts, that is, between noon (lunch) and the 3 pm shift change and between 5 pm (dinner) and the 7 pm shift change. These breaks in care further limit the time periods during which nursing reports can be given/taken.
In an attempt to address these problems, some facilities have formal “no admit zones” (ie, the time of shift change), during which the ED cannot transfer patients to the units. This attempt to protect the nurses whose shifts are ending only increases the pressure on the nurses whose shifts are beginning. While the hazards associated with nursing change of shift are well documented in the literature,17 many of these are linked to communication breakdowns for which there are few proven solutions.18 There are no studies linking patient safety and transfer of patients between areas of the hospital during shift change. Many ED staffs argue that their patients never stop coming, so others should be continuously open to accept the same constant flow of patients.
However, it should be noted that the ED providers and nursing staff also participate in this uneven flow of admissions. Examples include
- Emergency physicians, who continue to see new patients during their shifts and near the end of their shifts, attempt to admit several patients at once.
- Emergency nurses, who at the end of their shifts admit several patients at once, or because of prolonged sign-outs (handoffs) do not admit patients for significant periods of time.
The current best practice is “call and send”:
The transferring ED nurse calls report to the inpatient unit.
If the floor nurse is unavailable, then the charge nurse takes report and the patient is sent upstairs.
If the charge nurse is unavailable, then the floor has 15 minutes to call back.
If there is no call back, then the report is faxed or the floor alerted that the EMR report has been entered and the patient is moved.
While this “fax and go” system is widely used, direct nursing handoffs are preferred, when possible.
Another recent trend involves the ED nurse directly transporting all of the patients to the floor. While this is resource intensive, it does obviate the need to discuss clinical issues over the phone and allows report to be given face to face at the bedside. Other hospitals have the inpatient nurses come to the ED to retrieve their patients and receive report at the bedside. However, while this practice does provide direct transfer of care, it does not overcome the motivational issues delaying patient receipt.
Another emerging practice hands off admitted patients to an ED flow coordinator, who acts as a bridge between the ED and the nursing units. The flow coordinator packages the patient, transports, provides bedside review of the ED nursing summary, and assists the nursing floor with settling the patient into that floor. In this approach, the patient needs are met and the nurses on the floor have support for inpatient paperwork during the times of high transition volumes.
An effective physician handoff is essential to ensure efficient patient movement. In some academic centers, physician delays often exceed the time of nursing delays. This occurs in those centers because, after the decision to admit, members (sometimes multiple) of the admitting physician team are required by policy to evaluate the patient before the bed can be formally requested. This reevaluation process inserts a queue for the additional evaluation that usually occurs prior to (rather than simultaneous with) the bed request. Even worse, there can be multiple queues in the inpatient physician evaluation, from intern, to junior to senior resident and finally to the attending all requiring approval for admission.
As academic medical centers increasingly face competitive financial and service pressures, it is unlikely that these traditional non-value-added processes can be allowed to continue, since there is limited to no value-added benefit to these processes, even from an educational and training perspective.2-5
As a best practice in some academic centers, attending-to-attending conversations begin the admission and bed request processes, allowing the resident assessments to occur in parallel with the bed placement process. This parallel process significantly reduces the delays typically due to queuing and communication breakdowns.
In community hospitals, PCPs have increasingly chosen to focus their work in their offices in order to improve efficiency. As a result, the use of hospitalists has increased dramatically. This specialty has substantially changed the workflow for the physician handoff. In the past, the ED physician called the primary care doctor who, once contacted, provided admitting orders by phone to the ED nurse or inpatient nurse with the only delay related to contacting the primary care doctor. Now, there are frequent queues in the ED for Hospitalist evaluation as it is difficult to match hospitalist staffing with the peak demand for admissions. As such, admitted patients residing in the ED or on the inpatient unit can wait several hours for a hospitalist evaluation. As the relationship between emergency physicians and specialists in hospital medicine evolve, many hospitals are developing processes which allow for much faster and more efficient communication between these groups. This in turn, allows for faster movement to the inpatient environment. (See Chapter 48.)
Bridging or Transitional Orders
In the past, it was considered unacceptable (by many) for ED physicians to write bridging or transitional orders. The practice was frowned upon as writing inpatient orders may increase malpractice risk, and inpatient management is not a competency of emergency physicians. However, in order to facilitate flow, many ED physicians are choosing to write transitional orders, or continuation of care orders that are timed and limited to facilitate safe and effective patient movement from the ED to the inpatient units. This practice has recently been endorsed by the American College of Emergency Physicians19 and The American Academy of Emergency Medicine.20
It is now considered a “best practice” to write brief, time-limited bridging orders when patient evaluation is not immediately obtainable by the accepting physician. This practice allows queues (bed assignment and inpatient physician assessment) to occur in parallel rather than in series.
The third key element in the admission transition is bed management, requiring leadership at the highest levels of the hospital and healthcare system to address several critical elements to ensure bed availability. This starts with timely decision to discharge and then efficient discharge. It requires timely reporting of dirty beds, efficient EVS services, effective bed management from the individual units and the nursing supervisor, and the optimization of short stay strategies such as observation and clinical decision units.
Timely inpatient discharges are usually a significant issue in both community hospitals and academic institutions. This process is quite complicated as efficiency requires
- A focused, efficient physician and nursing workforce
- Sufficient nursing resources
- A commitment to organizational goals
Executing early discharges is more difficult in academic centers due to teaching obligations and their interference with flow. Many academic centers have predictable patterns of rounding and discharge. As an example, teaching rounds consume most of the morning and may continue until the beginning of didactic conferences. Interns and residents may not be able to get to several competing responsibilities of reevaluations, new admissions, and discharges until later in the afternoon, even though the discharge decision may have been made hours before. Best practice discharges require a specific team focus on timely inpatient discharges, including rounding with case management and nursing leadership, and predicting and preparing for the discharge 24 to 48 hours ahead of time.
For over 10 years, some hospitals have used an evidence-based approach to identifying and assigning beds, based on the principles of demand-capacity management.2-4 These programs use statistical process methodologies to predict the time, acuity, and level of service needed for patients needing beds from all areas of the institution, including the ED, transfers within the institution, transfers from other hospitals, and admissions from the operating rooms (ORs). Instead of waiting until the bed request is made, Be-A-Bed-Ahead programs prospectively identify where the next patients will be assigned their bed and the charge nurse on those units are advised in advance that the next patient will be assigned to them. These programs have dramatically improved hospitals' ability to more efficiently and proactively utilize their resources21 (Table 38-2).
Table 38‐2 Comparison of Traditional and Be‐A-Bed-Ahead Programs |Favorite Table|Download (.pdf)
Table 38‐2 Comparison of Traditional and Be‐A-Bed-Ahead Programs
- ED calls for an inpatient bed
- Bed board begins to “search” for a bed
- Multiple calls to multiple floors
- “Bed hiding”
- Bed located
- Environmental services cleans the bed
- Bed in service
- Bed available
- Beds identified as available only when clean, unoccupied, and staffed
- Bed board prospectively identifies beds by type (Med-Surg, ICU, Telemetry, etc)
- Bed board informs unit of “next up” status
- Charge nurse informs nurse of “next up” status
- Bed assigned when requested
Optimized Rounding Practice
Another practice that contributes to optimal bed availability during high census is reverse-order rounding. Historically rounding begins with ICU, then moves to progressive care units, and finally to medical and surgical floors. In reverse order rounding, practitioners begin with patients requiring the lowest level of care (resources) and work toward to highest level of care. In this manner, inter-facility movement is optimized as filled or overutilized high-resource units (telemetry, ICU) can offload patients as beds become available. This practice is often adopted by hospitalist working closely with EDs, postanesthesia care units (PACUs), and other hospital areas routinely requiring access to patient beds.
Once the patient is discharged, some institutions tolerate “bed hiding,” which is nonreporting of “dirty” rooms (the patient has been discharged from the room, but the room has not been cleaned and put back in service on the bed board). This slow reporting delays room cleaning by EVS, and consequently, the transfer of a patient from the ED to the inpatient unit. To counter this practice, some institutions have adopted one of several best practices, such as
- Unit manager or charge nurse is held accountable for managing bed flow and ensuring rapid turnaround of beds.
- Nonclinical staff (volunteers, transporters, or other staff) are responsible to report the newly evacuated bed as dirty.
- Order to discharge creates an automatic electronic alert to EVS and the nursing supervisor.
To create rapid bed turnover and availability, it is necessary to reduce “batching” and ensure availability of key resources. Many hospitals have implemented discharge lounges to vacate the patient room earlier. In concept, this transfer of the patient from the clinical space allows it to be cleaned more efficiently for the next admission. Anecdotally, these discharge lounges have not proven to expedite patient flow or free inpatient resources and there are no published data supporting the routine use of this strategy.
The hospital's strategy of bed resource management has significant implications for bed availability. Some hospitals allow
- Charge nurses or unit managers to assign beds on their units
- Nursing supervisors handle the entire process
- Hybrid systems, in which the nursing supervisor assigns the unit and the unit charge nurse assigns the bed
Unit-level control creates greater potential for delaying notification of a potentially available bed unless specific accountability mechanisms exist.
Managers responsible for inpatient bed availability must vigilantly address admissions and manage beds real time to ensure capacity. Hospitals that actively address demand-capacity consistently conduct daily huddles to predict the likely admissions from all sources and the anticipated discharges. This information is used to determine the net surplus or deficit of beds, which then triggers specific responses from the individual floors to facilitate off-loading of critical care beds and early discharges, when necessary. This data can also be used to predict staffing and right-size nursing capacity. However, this staffing practice should be used with great caution as unanticipated ED census and acuity lead to ED congestion because empty beds on the units may not be adequately staffed.
Generally, the simplest process with the fewest number of steps and people and the most accountability results in the best performance. The best outcomes occur when there is a “Bed Czar” (a role often assumed by the nursing supervisor). To be effective, they should immediately be aware of admission needs, consistently assess the inpatient resources, and have the authority to independently assign the bed. While, this loss of control is often unsettling at the unit level, it significantly decreases the potential to “game the system” and promotes more efficient patient flow.
During high-census periods, a best practice employs 2 (or more) nursing huddles—1 in the morning and 1 in the evening. Some best practice hospitals are also moving toward “no meeting periods,” with the goal of having all managers on the floors to expedite patient discharges. Depending on the frequency of demand-capacity mismatches, no meeting periods result in either:
- Routinely no meetings are scheduled during certain hours, for example, 9 am to 11 am
- All meetings are cancelled during high-census low-capacity periods.
Senior Management Responsibility
All successful hospital and bed flow systems have support from executive teams, with institutional leaders holding managers accountable for recognizing and addressing the queues of patients heading to individual units. There are many competing demands for the inpatient beds, particularly from units that are not open 24 hours per day and 7 days a week, that is, PACU, cath lab, and so on. However, it is imperative that ED patients continue to move to inpatient units with the same priority as other patients from other areas of the hospital.
Any hospital patient being held in an area or bed that is not that patient's final inpatient destination poses safety and risk issues for the patients as well as the hospital leaders. Executive teams must be fully engaged in problem solving and own strategic process changes to mitigate holding patients in any area of the facility. Robust hospital throughput measures should be developed and routinely monitored to ensure optimal performance.
Clinical Decision Units and Observation Units
Another important strategy that enhances inpatient capacity is the use of low-acuity admission pathways, that is, clinical decision units (CDUs) and observation units. This alternative to inpatient placement is equivalent to developing an ED fast track that facilitates the flow of low-acuity patients, increasing bed availability for higher-acuity patients.
The most successful observation units are administered by or in collaboration with the ED leadership and may be run either by the emergency physicians or the hospitalists. Further, they are “closed” units with admissions initiated only by the emergency physicians and hospitalists, regardless of the patient's attending physician. The most successful units have well-defined evidence-based and protocol-driven patient care pathways and admit patients whose workups are generally predictable and exclude patients with complicating factors.
The observation unit staff should be staffed by a committed team that possesses a working knowledge of clinical observation medicine as well as a clear understanding of the observation versus admission criteria. The units may limit consultations, which often prolong the patients' LOS. Patients requiring multiple consultations are more appropriately admitted to inpatient units. Ideally, the observation units are located in or near the ED, allowing rapid and efficient access to providers (24 × 7), radiology, cardiac stress testing, and echocardiography. Most hospitals that implement decentralized observation units without a dedicated location find it difficult to maintain standard patient diagnostic and treatment pathways and, as a result, longer average LOS.