Case Study - Patient Flow at Brigham and Women's Hospital

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Summary

This case study focuses on improving patient flow from the hospital’s emergency department (ED) and its floors to its intensive care units (ICUs) by decreasing the time that is required to transfer patients.

Brigham and Women’s Hospital (BWH) is one of the best and busiest hospitals in the United States which is located in Boston, MA. The hospital has an average occupancy rate of ninety percent with an average length of stay of five days and a net income of $75 million.

The admission to medical and surgical ICUs impacts the patient flow in the ED hugely. The ICU admission delay causes overcrowding of patients treated in the ED, staffing shortage to take care of these patients, longer wait times for patients to be seen, walk-outs and ambulance diversions.

The patient flow from the ED/the floor to an ICU is complicated by multiple factors. These factors include availability of an empty and clean bed in the ICU that is suitable for the patient’s illness, the availability of an ICU nurse, a complex communication protocol among the health care providers which required multiple pages and calls.

Key Analysis

There are several significant issues affecting the flow of patients from the ED to one of the 8 ICU’s. The complicated and inefficient process itself of admitting a patient to the ICU from the ED lacks transparency, communication and results in significant issues. These issues result in disruptions in communication of bed availability, frustration of staff, delays in patient admission to ICU.

 Significant Issues:

• The communication process involves many parties, i.e. the attending, nurse administrator, residents in each ICU that the patient may or may not ultimately be transferred to which takes up an unnecessary amount of time. Clinicians are relegated to the administrative tasks of figuring out if there is an available bed in the ICU instead of focusing on patient care. There are too many parties to keep informed at every step of the process.
• Workaround and lack of protocol adherence affects the admission of patients. Workarounds is the result of staff not knowing and therefore not adhering to the existing protocol of admitting and transferring patients to the ICU from the ED. For example, the ED physicians searching for an open bed directly calls the attending physician of the secondary ICU, working around the existing protocol.
• The eight ICUs function from a position of constantly being over capacity. Each ICU has a designated secondary ICU where the patient can be rerouted in the event that the primary ICU is at capacity. When the secondary ICU is at capacity, the attending ED physician needs to check with all the other ICUs to confirm if there is an available bed. The primary ICU receives reimbursement, even if the patient received care from any of the other ICUs.
• The empty ICU beds are not being identified and prepared immediately to be able to receive a patient from the ED. ICU beds often showed up as available on the computer, while in fact they weren't.

Less Significant Issues:

• There is an existing culture in the hospital that involve conflicting incentives that need to be dispelled and to unite the staff under a few incentives. As seen from the response to Rogers email, physicians reacted emotionally instead of working to improve the current situation and when presented with the correct procedure, find that the current hospital culture of workarounds and ignoring protocol work to their benefit.
• The ICU nurses are already stretched thin as the ICU requires a nurse-to-patient ratio of 1:1 or 1:2 which the hospital cannot fulfill when they are at over capacity. Trauma patients needed immediate care in the ED or on the floor, which drew the nurse's' attention to care for the trauma patients immediately.
• There is a delay in the notification of transferring ICU eligible patients that caused an extra boarding time.
• Overcrowding of ED leading to long wait hours is causing high rate of walkouts and turning away of incoming ambulance patients (diversion). In the year 2006-2007 Brigham and Women’s hospital had 1,876 walk outs causing $1,457,652 of lost revenue and 3,937 cases of diversion because of no bed availability.

Recommendations

After analyzing this case our team suggests the following recommendations for maximizing efficiency and improving patient flow. The admitting process should be simpler and more transparent than the one in effect.

1. An admitting coordinator should be hired as mentioned by Dr. Krishna Dugar. They would be the authoritative figure responsible for receiving notification of available beds from housekeeping and communicating with ICU and ED physicians and nurses when an available bed is needed. This individual would also be able to audit the ED and ICUs to make sure protocol is being followed by staff. This will streamline the process, facilitating efficient communication among physicians from different units while saving critical time in the both the ED and ICU.
2. Empty beds need to be identified when is a patient is going to be discharged so that housekeeping is informed to prepare the bed. We suggest training the discharging nurse or resident to notify housekeeping that the bed needs changing, training the housekeeping staff that once a room has been turned over to notify the coordinator, and updating the computer systems so that it reflects accurate records. Early notification would prevent any unnecessary delays in beds not being changed. An accurate count of available beds and would prevent patients from being moved to the secondary or “tertiary” ICUs.
3. Staff trainings of new protocol that will avoid workarounds. The admissions coordinator will check-in with the staff to provide adjustments in the current protocol. During staff training, there should be an emphasis that the admitting coordinator will take on responsibilities that will free up time for the attending physicians, nurses and residents. This is especially important for the nurses as they are often at a maximum capacity. Being able to focus on patient care and less administrative work is an incentive that would encourage the staff of the independent ICUs to follow the protocol.
4. Secondary ICUs should receive a percentage of the reimbursement since they are decreasing their available bed capacity but are not required the use of their attending physician. They lose reimbursements to the primary ICU and also lose reimbursements because of reduced bed capacity to accept ED patients. This would encourage ICUs to make sure they have an accurate bed availability count with the admitting coordinator to ensure they retain the majority of reimbursements and also provide an incentive for secondary ICUs to accept patients from ED.
5. The capacity of the MICU should be increased. According to Appendix A below, the hospital lost nearly two million dollars in a year. Those two million dollars were calculated only from the wasted time in the ED, while patients waited to be boarded, walked out, or diverted to another department. The hospital can invest in hiring ten new nurses at the ED, a new coordinator to find exactly the empty bed to which the patient needs to be transferred, expand the ED with new beds, and establish a new secondary ICU to reduce the capacity. As a result, the hospital will be able to earn the money spent in the following year.
6. The profit yielded from the investment done in the previous step can be used in hiring more staff to increase the proportion of nurses to patients. When the proportion becomes 1:2, nurses will be able to take care of the details of the discharge. Also, they will be able to alert the housekeeping staff whenever a bed is emptied to get it ready for the following patient. Additionally, it will be easy to allocate one nurse in the case of a very sick patient, and it won’t create a huge burden,

Appendix A