Publication Year: 2008 REASSESSING THE BED COORDINATOR S ROLE SHADY GROVE ADVENTIST HOSPITAL Summary: Creation of Bed Coordinator position to improve patient flow throughout the entire hospital Hospital: Shady Grove Adventist Hospital Location: 9901 Medical Center Drive Rockville, MD 20850 Category: E: Exit from ED Key Words: Ambulance Diversion Communication Crowding ED Boarding Information Systems Patient Volume Queuing Wait Times Hospital Metrics: (Taken from FY2005 AHA Annual Survey) Annual ED Volume: 24,712 Hospital Beds: 239 Ownership: Not-for-profit Trauma Level: 2 Teaching Status: No Tools Provided: Census Report Form A single page form for recording patient census and staffing from all hospital departments. This form is used by the Bed Coordinator to help manage patient flow. Patient Throughput Committee Presentation A three-slide presentation containing the outcomes of the new Bed Coordinator role, including diversion hours and the number and length of stay of boarders for 2007 and 2008. Clinical Areas Affected: Emergency Department Inpatient Units Registration Staff Involved: Communications ED Staff Nurses Physicians Copyright 2002 2012 Urgent Matters 1
Innovation By the end of 2003 Shady Grove Adventist Hospital had earned the dubious distinction of having the most ambulance diversions a total of more than 2300 hours for the year-- of the five hospitals located in Montgomery County, a suburban county just outside of Washington D.C. Patient satisfaction was at an all-time low with more than 50 percent of patients surveyed saying the wait times in the ED were too long. In addition, the average length of stay in the ED for patients admitted to the hospital was nearly 450 minutes. What s more, the number of ED Boarders patients who were admitted to the hospital but had to wait in the ED for an in-patient bed had grown to alarming numbers. Shady Grove administrators knew something had to be done. Over the next couple of years the hospital had organized a major patient flow initiative, complete with organized teams to address the problems of diversions and throughput, bed huddles were held daily to go over the hospital census, a new clinical bed coordinator position was created and soon the problems of 2003 started to improve. By 2004, ambulance diversions had decreased to 655 hours. The problem was the improvements didn t stick. By the middle of 2007 ambulance diversions began to spike again. As a result of that decreased performance, we re-energized our patient flow initiative and changed our approach to a few things, Foshee said. We found some of the things that had worked in past were no longer effective or relevant. There were things that needed to be revived. Shady Grove folded its Bed Coordinator position into the Nursing Supervisor s duties. A high ambulance diversion rate and alarming number of boarders in the Emergency Department (ED) in 2003 led an advisory committee at Shady Grove Adventist Hospital to create a new Clinical Bed Coordinator Position. The purpose of the Bed Coordinator position was to improve patient flow throughout the entire hospital, decrease the number of ED boarders and help the ED avoid ambulance diversions. Although the newly created position helped the hospital reach its initial goals, overall progress at the suburban Washington D.C. facility began losing ground in 2006 and 2007. The committee reassessed the role of the Bed Coordinator and decided the position s duties would be better carried out by the Nursing Supervisor. While the job description remains the same, the goal of this personnel change is to ensure that the person overseeing bed turnover also has a clear understanding and involvement in staffing levels, which the previous Bed Coordinator did not have. Results Hospital administrators credit folding the Bed Coordinator Position into the administrative supervisor s duties for helping to decrease ambulance diversions. (See Patient Throughput Committee Presentation) The move was just one part of an overall new strategy the hospital has adopted to improve patient care in the ED and throughout Shady Grove. Between January and May 2008, the most recent figures available, the total ambulance diversion hours at Shady Grove Adventist Hospital have decreased nearly 95 percent from 288 hours in January to 14.79 hours in May. The average number of ED Boarders in the first five months of this year has increased from 246 to 358; however, the average duration for the boarder patients is steadily decreasing, Leyba said. Innovation Implementation From 2006 to 2007 the number of ED Boarders grew from 1,178 to 2,547, a 116 percent increase. The bottleneck in the ED led a hospital advisory committee to reassess many of the strategies it had previously adopted, including the role of the Bed Coordinator position. We had a very high rate of boarders who required admission but were sitting in ED waiting for beds, said Shelly Leyba, Vice President of Operations at Shady Grove. That is not optimal care for patients. It clearly meant we were not meeting our mission. Leyba said often hospitals think the easiest way to solve a problem is to create a new position and hire someone to manage the problem. By doing this, hospitals sometimes run up against creating a job that is too person-specific, Leyba said, adding that the system often shuts down if the Bed Coordinator, for example, calls in sick or goes on vacation. Because the administrative supervisor job is covered 24 hours a day, seven days a week, folding the bed coordinator duties into that job made sense, Leyba said. In addition the previous Bed Coordinator worked in admissions and did not have a clear understanding of staffing levels, which Leyba points out can have a critical impact on patient flow. The nursing administrative supervisor also reports directly to the Chief Nursing Executive, which eliminates one level of management compared to how the bed coordinator position was structured The hospital obtained the necessary buy-in to implement this personnel change because staff realized it was a more efficient way to oversee bed turnover. The administrative supervisor also leads the twice daily Bed Huddle meetings to report on patient census figures, anticipated admissions and discharges. (See Census Report Form) Leyba said this allows Copyright 2002 2012 Urgent Matters 2
other units to gain a big picture of hospital operations. For example, if the ED is in need of an ICU bed, the administrative supervisor will organize a patient transfer from the ICU to the Post anesthesia care unit (PACU). This will allow the ICU to admit the ED patient and avoid the need to go on divert. In addition, the administrative supervisor sends a shift report at 7 a.m. and 7 p.m. to the executive team to increase the awareness of throughput issues. Advice and Lessons Learned Leyba said the key to reaching goals lies beyond creating new positions or adopting best practices. She has worked with Shady Grove to adopt foundational principals that can withstand the test of time. When Leyba began working at Shady Grove in 2007 she began laying the ground work for strong foundations to address the hospital s biggest challenges: ambulance diversions, ED wait times and patient flow. Building Awareness. Many hospital staff members outside of the ED did not know why or when the ED needed to go on diversion. By informing the entire hospital when diversion is a threat other units can often come up with solutions to help the ED avoid turning ambulances such as finding available beds for ED Boarders. Accountability. What broke down in the system to cause a backlog of patients in the ED, for example, ultimately leading to diversions. Know the data. Using hospital census figures to forecast when diversions are likely can help units take the necessary steps to avoid turning ambulances away and better manage patient flow. Communication. Building communication between different departments allows key stakeholders to see the big picture. I guarantee you if we don t do this piece of it we re not going to see what we are looking for, said Leyba. Tools to Download Census Report Form A single page form for recording patient census and staffing from all hospital departments. This form is used by the Bed Coordinator to help manage patient flow. Patient Throughput Committee Presentation A three-slide presentation containing the outcomes of the new Bed Coordinator role, including diversion hours and the number and length of stay of boarders for 2007 and 2008. Copyright 2002 2012 Urgent Matters 3
400 380 360 340 320 300 280 260 240 220 200 180 160 140 120 100 80 60 40 20 0 SGAH Divert Outcomes 220 282.53 225 369.45 209 47.67 226 226 25.70 Total Divert Hours - 2008 14.79 Shady Grove Holy Cross Jan Feb M ar Apr M ay Jun Jul Aug Sep Oct Nov Dec WAH Suburban Montgomery General SGAH SGAH Avg Avg Dly Dly Census Adults & Peds SGAH Emergency Department ED Boarders - Number & LOS 500 450 400 Average Boarders Per Month (Jan Apr) 2007 246 2008 358 2007 2008 740 720 700 Number of Boarders 350 300 250 200 150 LOS 680 660 640 620 Avg LOS Minutes 100 600 50 580 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 560 1
SGAH Administrative Supervisor s Report Date: June 15, 2008 Time: 16:30 hrs Census at time of report: Adults: 259 Peds/PICU: 8/4 NICU/WBN: 21/26 Births in last 24 hours: 12 since midnight Throughput: ED Census: Main: 44 GEC: 20 Patients Boarding: ED: 0 PACU: 0 Diversion Hours: none Red on: off: Yellow on: off: Rapid Response Events: none Codes: none Facility/Environmental/Equipment Issues: none Staffing: To current guide hours Contact with AOC regarding Critical Issues: Morgue-Bed-ICE Report prepared by: Jill Johnson RN Admin. Sup. 2