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How to streamline discharges

A medical center eliminates discharge bottlenecks in the pharmacy

October 2018
green light for hospital discharges

WHEN IT CAME TIME to streamline workflow around discharges, Kelley Barry, senior clinical applications analyst at VCU Medical Center, VCU Health’s Level 1 trauma center in downtown Richmond, knew the solution could be pushing the functionality of software the medical center already had.

That software was TeleTracking’s Capacity Management Suite. (TeleTracking is an operations platform that works in conjunction with VCU Health’s Cerner EHR.) As Ms. Barry explains, the medical center had used a “rudimentary” TeleTracking platform for many years, one that notified environmental services when a bed went dirty and let patient transportation know when a transport was needed.

But in 2014, VCU Health upgraded to a much more robust TeleTracking system to help manage patient flow from admission to discharge.

That upgrade included what TeleTracking calls “care progression indicators,” icons that can light up in various colors on the 55-inch screens that were installed in the nursing stations. Ms. Barry realized that various service lines—nursing and physical and occupational therapy, for instance— could use those icons in red/yellow/green to communicate when each of those services had completed its portion of a discharge or had run into a barrier.

“Pharmacists were being distracted by phone calls, and the whole process was being delayed.”

~ Kelley Barry
VCU Medical Center

But implementing that solution didn’t come easily at first. “We didn’t have buy-in,” she points out. “TeleTracking wasn’t being utilized enough for clinicians to know about it or want to rely on it.”

In 2017, she got the representatives of several services together. “I said, ‘How do you want this to look, and what information would be meaningful to you? What will bring you to use this tool to get information—and push you to put in information for others to consume?’ ”

She quickly realized, however, that one key party that represented a lot of discharge bottlenecks wasn’t at the table yet, and that was pharmacy.

Prioritizing discharges
The initiative Ms. Barry helped launched in 2017 was designed to streamline the workflow processes of ancillary services and improve communication around— and prioritization of—patients close to discharge.

That effort quickly became part of a larger initiative to improve throughput in a system that, Ms. Barry says, was “at 95% capacity and above on a daily basis.”

Why wasn’t pharmacy, which fills and delivers discharge medications, initially pulled in? “People don’t realize how many service lines have an impact on the progression to discharge,” she says. It was the nurses who pointed out that knowing the real-time status of discharge medications would be a big improvement.

“They said it takes a lot of effort to call and see when those prescriptions will be ready,” Ms. Barry notes. “Fortunately, one pharmacist came to one of our capacity huddles and confirmed that it was a problem.” When she met with that pharmacist, Ms. Barry found that paper prescriptions for discharge medications were sent to the pharmacy through the pneumatic tube system. Instead of being marked with an estimated time of discharge, “team members wrote ASAP on a lot of them, indicating that they needed them right away.”

But when the pharmacist showed her one ASAP prescription as an example, Ms. Barry looked that patient up in TeleTracking (the pharmacy at that time couldn’t access that software), and found that the patient didn’t even have a discharge order yet and still had to go to dialysis. “So it was at least six hours until discharge,” she says. With ASAP marked on all the orders, “the pharmacists had no way to prioritize the discharge prescriptions they needed to fill first.”

Providers grew impatient waiting for medications and kept calling the pharmacy for updates. “The pharmacists would have to stop what they were doing, find the prescriptions and say where they were in the process,” Ms. Barry says. “Pharmacists were being distracted by phone calls, and the whole process was being delayed.”

Communicating order status
The first fix: giving pharmacists access to TeleTracking, allowing them to at least see when a discharge order has actually been filed.

The next fix was to incorporate discharge pharmacy into the TeleTracking platform. Ms. Barry adapted the system—she says it took her and her colleagues about a month—to give the pharmacy a pill icon on the TeleTracking boards that would light up as red, yellow or green, depending on the status of a particular patient’s discharge prescriptions.

A red pill on the board indicates that while pharmacy has received the prescriptions, it hasn’t started filling them.

“There was confusion on the units waiting for discharge medications: Were they waiting for the physician to provide the prescription or for the pharmacy to fill it?” Ms. Barry says. “A red pill indicates that the prescription is at least in the pharmacy.”

When a pharmacist updates that icon to yellow, that means he or she is working on filling that patient’s medications. “The button that turns the icon yellow also provides a time and user stamp, so you can see who’s filling the prescription and when.”

Once the prescriptions are filled, the pharmacist clicks the icon again to turn it to green on the boards, indicating that the prescriptions are done and being tubed or couriered to the unit. In deciding how to prioritize the discharge prescriptions they receive, pharmacists give top priority to medications needed for patients who already have a discharge order in the system.

“We also have a TeleTracking indicator to identify patients who can leave by noon that day,” Ms. Barry explains. When the pharmacists no longer see more discharge orders in TeleTracking or patients identified as a discharge by noon, they then move to fill prescription orders for patients identified as being discharged sometime later that day or the next.

More discharges by noon
Because changing the discharge-medication process in the pharmacy was part of larger initiatives, Ms. Barry can’t quantify how much that specific effort contributed to more streamlined discharges and increased throughput. She notes, however, that since the capacity initiatives were rolled out, “we’ve seen a 20% increase in our discharges by noon,” as well as $23.6 million in increased revenue and savings in terms of capacity management.

And using the pill icons with different colors on the TeleTracking boards has eliminated most of the unnecessary phone calls down to the pharmacy. Now, when team members call just to check up on the progress of discharge medications without any kind of clarifying question, “the pharmacy will simply say, ‘We’ve updated TeleTracking, so please check that,’ ” says Ms. Barry. “It’s teaching them not to call.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the October 2018 issue of Today’s Hospitalist
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