Published in the April 2009 issue of Today’s Hospitalist
THE HOSPITALISTS AT University Hospital in San Antonio used to grapple with a familiar problem: constant bed crunch. The emergency department (ED) was often overrun with critically ill patients who had no beds to go to. Once patients were admitted, they remained in the hospital longer than necessary and the ED stayed on diversion much of the time.
That was the situation that confronted hospitalist Michael Johnson, MD, a few years ago when he began working with administration and staff to look for ways to improve the hospital’s bed management. Hospital administrators had asked him to attend an Institute for Healthcare Improvement (IHI) conference on hospital bedflow and to bring back a few ideas.
The experience was “eye-opening,” Dr. Johnson recalls, not because he heard all the answers, but because he learned which questions to ask. “We needed to figure out what the bottlenecks were at University Hospital,” he says, “because those would be completely different from bottlenecks occurring at another hospital.”
He quickly decided that the best place to start was to conduct an analysis of the hospital’s “wasted beds.” That analysis, he explains, “helped us identify problems that we didn’t realize were problems.”
Taking a broad view of wasted beds
The physician-nurse-administrator team in which Dr. Johnson participated started by adopting a broad definition of wasted beds. In addition to an empty bed, he says, the definition includes patients in beds “who are not receiving active medical care at the appropriate level that those beds are assigned to.”
Take the patient in a respiratory isolation bed who doesn’t need isolation, but is parked there because there was no other free bed when he was admitted. According to Dr. Johnson, that bed is being wasted even if there is no patient waiting for it.
“You can’t predict what is going to come through the ED next,” he explains. “If I don’t actively try to get him out of that bed, then in two hours when I have a patient who needs to be ruled out for tuberculosis, there will be no bed to give him.”
The team took wasted-bed “snapshots,” at first several times a week and then weekly. Along with a case manager and the head of nursing for each floor, Dr. Johnson walked past every room in the hospital and “made a quick assessment of whether this is a reasonable use of this particular bed.” The next step was to share that information with the hospital’s bed supervisor, an RN who oversees bed utilization throughout the hospital and acts as “bed czar,” making sure patients are moved to beds that better meet their needs.
That helped highlight what emerged as a major bottleneck: the fact that staff didn’t fully appreciate the need to move patients to lower levels of care when appropriate. To make that point, the RN bed supervisor and nursing floor supervisors began holding “bed meetings” every six hours.
“If there is no sense of urgency to get people out of a particular level of care they no longer need,” Dr. Johnson says, “then you won’t free up beds in the higher levels of care, which is what we always need.”
Showing just how much capacity was being wasted motivated physicians and nurses to pay attention during daily rounds not only to patients’ medical problems, but to whether those patients should move to a stepped-down level of care.
What causes wasted beds?
While wasted bed surveys can identify logjams, Dr. Johnson says they also make you think about why patients are in the wrong bed. Sometimes it’s due to a rare occurrence, such as a patient waiting for a surgical procedure that gets put off for another day. More frequently, it’s due to something that happens all the time.
Experts on bed management recommend ignoring one-time events, and Dr. Johnson found there was no lack of chronic problems. Along with a lack of urgency moving patients to lower levels of care, his team uncovered several other factors behind the gridlock.
Because University Hospital handles most indigent care for the University of Texas Health Science Center, for example, many patients have complicated social issues that can delay their discharge.
And the wasted-bed snapshots regularly included patients who should have been discharged, but had just been started on warfarin. Because many of these patients didn’t have a regular outpatient provider, they couldn’t get timely access to the hospital’s overburdened anticoagulation clinic.
“Many hospitalists felt they couldn’t discharge these patients until they got them therapeutic,” he says. “These patients would stay for several days just to get their Coumadin adjusted.”
That discovery led the team to approach several physicians who staff the hospital’s ExpressMed urgent care clinic. Those physicians agreed to treat these patients on an outpatient basis until they could get into the regular anticoagulation clinic.
“Now, you can discharge these patients on day 1 of anticoagulation therapy,” Dr. Johnson says. “It has worked really well, and it is continuing.”
Another change that came out of the wasted bed analysis, Dr. Johnson says, was fixing the hospital’s flawed transportation tracking system.
“We found many people in beds just because they were waiting to go to a procedure, to radiology or another floor, or to be discharged,” he says. “When we asked why patients were waiting, the answer that kept coming up was, ‘We called for transportation, but they still haven’t gotten here.’ ”
The team learned that each floor had its own archaic transportation system. A patient on the ninth floor, for instance, had to wait for the ninth-floor transporters, even if that group was busy and the eighth-floor transportation team was not.
The solution was a hospital-wide system where all transportation requests go to one central location that then dispatches transporters to wherever they are needed. “Waiting for transportation,” Dr. Johnson says, “just doesn’t happen any more.”
Over the course of 2007, the combined efforts to improve bedflow shaved about a day off the hospital’s monthly length of stay. To date, ED diversion time and wait times for ED patients have also significantly improved.
“Our ED still has a diversion level and a wait time that we want to decrease,” he says. But given the broad collaboration among inpatient, emergency, and outpatient physicians, as well as nurses, case managers, and administrators, “those are improving, and there is better communication throughout the hospital.”
Deborah Gesensway is a freelance health care writer based in Sierra Madre, Calif.