Patient Flow Madness

Hospital nurses have a voice-- to a certain extent. At the end of the day, your shift is truly formed by that of the nursing supervisor and the patient flow coordinators. Your moments tick away following the drive that holds all afloat, the BIG green, aka money. But, is money killing us? Is it killing the nursing spirit? Is it leading to mistakes, low satisfaction scores and a general displeasure with the health care community as a whole? Nurses Announcements Archive Article

Patient Flow Madness

In recent weeks while talking with friends that are nurses, as well as fellow co-workers, I find myself hearing the same sort of worries and complaints that seem to be focused on patient flow (admission to discharge). The drive for patient flow has been affecting the moods and minds of CNAs, MDs, dieticians, physical therapists, respiratory therapists, nurses, educators, lab workers, pharmacists and many, many more. The pains and frustrations are not only shared by nurses but the ENTIRE care staff of hospitals (I'm sure clinics, free-standing emergency departments and more can vouch for the same emotions on the subject). But all emotions aside, let's talk about the mechanics of the situation...

In a basic hospital setting, you find two types of patient groups. Inpatient. Observation patients have no more than a set amount of time to be treated and thus having coverage from their insurance companies under that label. If treatments are incomplete, or illnesses take a route that needs further care, these individuals need to be changed to inpatient status. This must be done in order that billing and insurance are correct for reimbursement and that the patient receives the care they need with the ultimate discharge plan to encourage autonomy and wellness post hospital stay. There is a situation threatening this seemingly fool-proof flow. In unpredictable waves, the current population is utilizing emergency rooms at a rate that causes longer wait times and patient holds in the (supposed to be) short stay rooms. The sick populations established in beds outside of the ER are needing more case management consults, multiple therapy plans when considering discharge and having issues obtaining rehab or skilled nursing placement for discharge. All of these situations have a synergistic effect concerning patient flow. At the end of the day (leaving many details out, mind you) often the pressure falls onto the bedside staff because it is their duty to ensure admission and discharges. These things occur as the nurse becomes available to perform these duties. With the growing expectations for nurses, often admissions and discharges do not occur within the "timeliness" deemed by patient flow supervisors, and thus the pressure ensues.

All of the fancy speak aside, here is where health care can buckle down and dig deep. This is where we need to fix or educate the flow coordinators idea of how quickly patients "need" to be moving.

For example, I was charge nurse and the unit was full. I was working on a step-down unit of high acuity (of which we had a symptomatic septic patient and symptomatic hypovolemic shock patient transferred to the ICU first thing in the morning). I was called by the supervisor of the hospital deeming that I was not moving patients fast enough to assist appropriate hospital flow. To be honest with you, from her point of view, it may have looked that way. From my point of view, I was perplexed to find that our careful attention to patients saved their lives, even if possible discharges were not being addressed as quickly, and I was being chastised for it.

Unfortunately, this type of thing has happened to me more than once, and it has happened to fellow friends that are charge nurses in the same hospital as me, as well as other hospitals in the area.

The pressure on nurses is great, it is amazing even. At the root of our practice, we all want to be amazing nurses, catching problems to save patients pain, and seeing an issue before it's a code blue. These are amazing wins for nurses and the patients they care for. This is why we work so hard. We want to make an impact that can heal and lead to less pain if at all possible. It is a nurse's greatest contribution to their care, to be the best they can in every way they can to help their patients in whatever way they may need.

Patient flow is extremely important, money is important (I have not forgotten that healthcare is a business), and getting patients out of the ED to a bed (if it's warranted) is SUPER important. BUT (that this is a big but)... There has to be a safe and effective flow. Back to back admissions on units with stat room cleaning isn't the safest situation when nurses don't have time to round on their group due to multiple admits (of which many can be unstable). It's a difficult situation and balance.

This may be one of the most important situations in the hospital that needs to be refined. We can't push patients out the door that aren't ready to go, even if the bed is needed (and yes, as ugly as it sounds, it happens). Readmissions are a thing, and sometimes this is the reason for it. Admissions need to be appropriate to the appropriate specialty. In a perfect world, a bed would always be available and there would always be ample staff... We all know that this isn't the case.

How to fix flow and promote safety is a big task to take on. How does your hospital operate? Does your machine need fixing? I know that where I provide care could use a massive face-lift.

In what way can we fix this to promote patient flow, safe admissions, appropriate discharges, all the while allowing nurses to provide the best care possible (with the capability to have ample time with patients to tend to their needs)?

It's a big ugly monster to fix, but nevertheless, a task worth taking on.

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Jacqueline.Damm

About Jacqueline.Damm

Molded and formed by a drive to live up to her own expectations, Jacquie ultimately thrives on creativity. Dreams, testing her limits, and traveling all fuel the fire, thus leading to adventures of the past and yet to be: http://misadventuresofanurse.blogspot.com/

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The biggest obstacle at the 700+ bed facility I'm familiar with are these:

1. Morning labs. MDs ask for morning labs to be drawn at 0500 so they are available when they come in; our phlebs don't even start rounds until 0530 as they arrive at 0500. Sometimes though, our phlebs and lab gets so backed up that morning labs aren't completely finished and available for review until 0900-1000. By that time, the hospitalist has already done morning rounds and won't be back until 1500 to do afternoon rounds. Wouldn't it make more sense to do discharge anticipation labs at 0200 so they are available first thing in the morning? Our patients are awake all night most of the time anyway, and the lab is staffed all night.

2. "Mass dump of patients" - everyone knows what I mean - you get the call, get them out, the 80+ bed ER is backed up. 8-10 discharges are written (usually all between 1500-1700), which results in 8-10 new patients arriving to the floor between 1800-2100. This is a 40 bed floor. THIS IS DANGEROUS! You get 8-10 new admissions/transfers for 6-7 nurses during a high flow time with staff that's already stretched thin.

3. Bed placement that doesn't read orders/talk with physicians clearly on where patient should be placed. A person with a BP of 220/140, chest pain, headache, and a Hgb of 5.6 should not be placed on a general med tele floor where each nurse has 6 patients. That person is going to need close tele/BP monitoring, blood transfusion, and frequent neuro checks. It's better to hold them in the ER where the ratio is 4:1 until an appropriate bed is available rather than dump them in the first open bed (see #2 - the person ends up on this floor). A patient who has admission orders for stroke or progressive care being placed on med tele with a "do the admission and we'll move them once a bed opens up." NO - that is NOT good patient care; not unless you are going to give that nurse a patient ratio that is similar to what those specialty floors have.

4. MDs writing discharge orders during high shift change/stress times, i.e. 1845 or 0730. On top of that, telling patients - you'll be able to leave soon. No, it won't be soon - please don't tell a patient that. We are in the middle of shift report which takes the entire 30 minutes on our high acuity, each person has 6 patients floor. It is going to be 1930-2000 (0800-0900) before I can get all the paperwork printed and go over it with you.

5. Poor communication as to "the discharge plan" - we have people who are "pending discharge" for 4-7 days at times. It's hard to prep someone's paperwork for discharge, go over the education needed, etc if you aren't sure they are going to be discharged as the plans change. We have a ridiculous number of 90 minutes from the time the order is written to get someone discharged. It's not realistic, even with preplanning. JUST GENERAL POOR COMMUNICATION! MD walking in to tell a patient "you are going home" and getting them all set to go in 90 minutes is TOUGH even when the patient is prepared. The MD writes the CPOE but doesn't tell anyone - it sits on the printer for 15 minutes before the secretary sees it. Then the RN/secretary needs to print all the discharge instructions/med rec/paperwork that goes with it. If it's days, we need to call and confirm all appointments that are scheduled/schedule new ones. We have to go over it with patients and get them to sign all the paperwork. Get IVs out, dressed, bags packed, etc. People have to wait for rides - we can't just discharge the patient, an NA or RN has to walk them to the car picking them up at the front door to "verify" they were still stable when they left. Oh, and, I'm still taking care of the 5 other patients I have, and did I mentioned, this all happened at shift change so I'm not even familiar with this patient I'm discharging.

6. Transfer patients not having meds given before transfer. If you know you moving people around during high flow times, it's common courtesy to give the patient the meds before you send them. Why - because I have to review orders, wait on the pharmacy to put the meds in, and verify them all before they can be given if it's a step up/down transfer. It's going to be 30-60 minutes before that all falls into place.

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Specializes in Step Down, Cath Lab, Health Coach, Education.

You just described the last hospital I worked for, is it all hospitals????? Ugh!!!!

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I am 62, so almost ready to retire. I have been a nurse for 35 years. I am ready to leave. Mostly because of the 'problems' you are describing. Healthcare is presently a business, but if you read the history of nurses and related healthcare you find it was a philanthropic, caring institution. The Mayo Brothers started by giving free care to those who could not afford it, often using the bartering system as payment.

It was around 1984 that the tiered system of nursing changed to 'one nurse does it all'. I have worked in both systems, and I can tell you that the best nursing is realizing that one person can not be the 'all in all'. Nurses can not be doctors, pharmacist, rt, and pt. They can not have 13 patients and be secretary, staff nurse and charge nurse. The tier system, or some form of it, is a viable way to assure better patient care and safety. Charge nurse, secretary, med nurse [so the nurse is not interrupted during the med pass], staff nurse.

Who is the god who says that 10 patients deserve 2 nurses but 7 patients deserve 1. If I was one of those 7, I would get good care on day one and be practically ignored on day 2.

Yes, the health care needs reformation, but maybe we need to look backwards a little. Sure, not everything done in the past was best, but when it comes to patient care, we just cannot put money first. BTW, progress can be negative as well as positive. So if someone tries to down you by saying you are against progress, or some such nonsense, remember that you may have good reason to be.

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Specializes in Med/Surg, Onc., Palliative/Hospice, CPU.

I love that you mentioned the past D Lam-Ham! It's very true how far we've come, and yet have taken so many steps back. We have so far to go in terms of technology, etc. But what I feel really and truly matters is how our patients feel.. Safe, secure, able to trust, etc. As a profession we have a lot of work to do to get back to a time where the patients come first and the money (is obviously there, otherwise we won't be supported) isn't our first and foremost focus.

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