Executive summary

One of the greatest challenges facing healthcare today is capacity management and patient throughput. Ensuring patients receive the right care, at the right time, in the right location is paramount. Although healthcare leaders realise prioritisation of patient throughput correlates with an organisation's overall operational performance, capacity breaches still occur. Capacity breaches such as emergency department overcrowding and acute care overcapacity impact patient throughput.

The problem

An emergency department (ED) can become overcrowded in the blink of an eye. Overcrowding is the result of variability in patient volume, acuity, and holding admitted patients in the ED until a bed is available. Holding, or boarding, is a critical healthcare situation facing national and global acute care facilities. Boarding inpatients in the ED is often due to inpatient capacity exceeding 90%, creating overcapacity.¹ In acute care facilities, overcapacity results from delays in discharges.

Delayed discharges create stagnant patient flow, leading to delays in care, risks to safety, overloading the care team and reducing quality of care and sustainability.² The effect of stagnant patient flow creates an upstream impact to patients awaiting care in the ED, arriving by emergency services personal or boarding in the ED. Stagnant patient flow further compounds patient throughput and breaches in capacity management.

Patient throughput

Often used interchangeably in healthcare, patient throughput and patient flow refer to the movement of patients from one location to another. Patient throughput starts from the time a patient is discharged until the time the next patient is placed in the appropriate location.³ Impacts to throughput occur from mismatching beds, insufficient resource utilisation to meet variability of demand, long waits to transfer patients to post-acute locations and disconnected mental health, community, and social care services, or facilities within the community.⁴ Patient throughput is not a project or initiative.

Instead, it is a system-level opportunity requiring an effective team approach to improve capacity allowing hospitals to safely provide the right level of care, at the right time, the first time. Optimum patient throughput is critical to patient care delivery.

Patients seeking care expect it to be available when they need it. At times, patients may use the ED for low acuity visits and primary care needs. ED utilisation has become the first line of treatment for unscheduled care and a primary entry point for patients requiring inpatient hospitalisation.^{2 4} Patients expect timeliness in care delivery within all venues of care and, when necessary, expect that an inpatient bed is ready and available to begin care, rather than waiting in the ED. When delays occur, the main culprit is delayed discharges, which impacts the patient's emotional state creating anxiety, disengaging from discharge planning and negatively influencing the patient experience.⁵

Overcapacity and stagnant patient throughput create additional stress for the care team due to pressures from other patients awaiting discharge or admission, and from an organisational commitment to improving throughput. When capacity is breached and throughput stagnates, interventions and resources are unable to meet the demands of patients. Without available inpatient bed capacity, patient care delays and suboptimal outcomes, such as higher mortality rates, longer length of stay (LOS) and higher risk for hospital acquired infections loom.⁶

The demand for patient access and efficient patient throughput is critical even as organisations challenge healthcare leaders to stretch resources. Organisations continue to experience operational and financial stress from capacity breaches and diversion.⁴ Organisational delays in accepting patients due to overcapacity impact the ability to offload ambulances from the community. The results are inefficiencies, care delays, additional costs and an inability to meet the local population’s needs. Reducing diversion enables organisations to rebuild relationships with patients, families, general practitioners (GPs), neighbouring healthcare organisations, and the community.

Decisions regarding ambulance diversion place patients at risk in the community and within the ED; thus, diverting is never an easy decision and often avoided.

The economic impact from overcapacity is also evident in lack of reimbursement, volume loss, cancelled surgical procedures, additional outlay for staff and higher administrative costs.⁷ Improving the bottom line depends upon the local contexts and organisation's payment model. In a value-based model, organisation can improve the bottom line by reducing length of stay, complications, avoidable ED visits, hospitalisations and readmissions.⁴ Ultimately, the patient experience will likely improve, so healthcare leaders must direct attention to improving patient throughput efficiencies while maintaining safety and quality care delivery.

The pulse of hospital patient throughput processes can be felt within the ED. However, patient throughput constraints and overcapacity are not a single department’s problem. They are symptoms of broken processes linked to the admission, discharge and transition of care across the organisation. Patient throughput is a complex process involving the entire care team across every area of the hospital. Organisations must evaluate variation in throughput processes by looking at the whole system of care versus silos of operations by keeping a near-real-time, patient-centred organisational approach. The key to impacting throughput lies in decreasing variation impeding throughput, plus actionable data and monitoring through measurement.

The key metrics for measuring and monitoring patient throughput involve reducing wait times. The metrics enable transparency of operations and measurement for the care team across the organisation. The key metrics for throughput include:⁴

Key throughput metrics

Recommended patient throughput strategies

The three strategies to decrease variation in patient throughput are near-real-time clinical decision support (technology), care coordination (people) and discharge processes (process). Near-real-time clinical decision support lies within the patient placement technology. Optimal patient placement technology displays near-real-time needs integrated into an operationally aware electronic health record (EHR), providing seamless and transparent placement information. Hospital-specific protocols guide the determination of proper patient placement for admitted patients, augmented through the patient's clinical attributes from the medical record. By using clinical decision support tools such as patient placement technology, patient placement staff can successfully determine the proper patient placement to transition from the ED or post-anaesthesia care unit (PACU) to inpatient care.

Near-real-time patient placement technology enables care team communication between healthcare providers and administrative staff to decrease assignment errors. Communication failures result in improper patient placement that can negatively impact the patient experience and lead to unnecessary costs. Transparent, clinically relevant, near-real-time data automates and streamlines clinical placement, assists in decreasing the number of avoidable hospital days, and reducing these risks.²

Near-real-time clinical decision support of patient placement technology focuses on the key steps of the placement process to enable seamless patient throughput to guide efficiencies. Capturing and sharing clinical attributes from the EHR enables transparency of admission, discharge and transfer processes. The implementation of a bed management system tracks the status of beds and communicates vital information to environmental services (EVS), patient transportation, admissions and nursing. The transparency of information communicated via mobile devices to a mobile care team provides a connection of key clinical attributes driven from an operationally aware EHR to the hands of the care team.

Easy-to-read mobile screen displays provide support to the extended care team (transportation and EVS). Displays include accurate, transparent information, status, alerts, job acceptance and delay notifications. A key benefit to near-real-time clinical decision support for patient placement is instant discharge notification, with zero lag time between a patient vacating a bed and the EVS notification. Additionally, sending notification of infection control indicators seamlessly to EVS mobile devices expedites readiness to clean when the bed is vacated.

The second key strategy is care coordination from admission through discharge. Care coordination involves how patients are placed and cared for within the organisation, geographical assignments, automation, and access to near-real-time data.

Communication is essential in care coordination. When coordination and communication struggle, delays create barriers to patient placement. Poor communication causes delays due to insufficient information, lack of a discharge plan on admission, resource constraints (staff, beds, supplies), turnaround times for testing, and delays with transportation and bed cleans. Efficient patient throughput requires care team coordination and communication centred on the patient experience.

The bed huddle is an effective communication and patient placement coordination strategy. Bed huddles involve key stakeholders, such as clinicians, bed control, EVS, case management, and staffing meeting twice daily to review the current organisational picture. Bed huddles review the current inpatient census, ED census, admissions and discharges to develop a plan for decompression and throughput. It also includes a review of the operative schedule, case progression and projected inpatient bed needs to support surgical flow and decompress the PACU. Stakeholders discuss resource management needs across the organisation aligning variability of demand requirements with staffing resources to the workload of patient care needs. Patient-centred decisions focus on ensuring safety, efficiency and care delivery by reviewing obstacles to patient placement, discharges and transitions of care.

Care coordination tactics are directly linked to the third strategy of discharge processes. Specifically, focusing on ‘discharge begins on admission’, through early identification of the discharge date and time upon admission. Timeliness is essential for patients ready for discharge requiring effective interprofessional care team coordination within and between health systems. The identification of key barriers to discharge and managing those barriers through care coordination and communication facilitates a readiness for discharge.

To prevent patients from occupying inpatient beds when they are ready for discharge, some hospitals implement a discharge lounge with technology. Using RTLS combined with a discharge lounge mitigates the nurses’ tasks in the discharge process, and shortens both patient wait and bed occupancy times, therefore improving the patient discharge process.⁸ Improving the discharge processes has an upstream impact to improve patient throughput and ED congestion, including boarders.

Once a patient has been discharged, if discharge notifications are delayed, hiding beds occurs. This also delays notification for EVS to clean and prepare for the next admission. It artificially inflates occupancy, creating more delays for patients awaiting acute care needs. The impact causes patients from the community to be diverted and other hospitals are unable to accept direct admissions or transfers from other organisations requiring specialised services.

How Cerner is helping

CareAware Capacity Management^® solutions provide visibility and transparency to throughput operations, enhanced productivity, and the ability for facilities to capture data that can be used to continually improve operations.

CareAware Capacity Management solutions include:

• CareAware Patient Flow: Patient throughput is a combination of clinical workflows, bed management, environmental services and transportation services. Transparency and visibility allow for efficient operations through use of CareAware Patient Flow.
• CareAware CareView: A customisable, digital dashboard that provides the interdisciplinary team with visibility over patients, care team assignments and clinical patient care notifications, including indicators for new orders, results, and barriers to discharge.
• CareAware Transfer Centre: Supports the management of cases for patients requiring a direct admission to an inpatient bed. This helps reduce unnecessary emergency department visits for direct admissions while helping streamline the direct admission process.
• CareAware Tracking: Near-real-time visibility of patients, assets, and health and care providers creates efficiencies in daily workflows. Automation of certain workflows provide real-time and historical throughput metrics.

Centralised operations

A centralised Command Centre brings the three strategies together to create operational efficiency. Situational awareness, actionable data and co-locating key stakeholders establish an organisational approach to patient throughput.⁷ Key stakeholders leverage near-real-time clinical decision support to take action with capacity and workforce to measure workload, throughput and operational metrics. The synergies established enable organisations to find solutions to address barriers to capacity breaches and stagnant patient throughput. Improving patient throughput does not necessarily involve bricks and mortar or hiring more staff. Instead, it is about patient-centred care using near-real-time data.

Conclusion

Capacity breaches, overcrowding, and delayed discharges are widespread concerns across the healthcare sector. The daily management of capacity and patient throughput cannot be achieved in a vacuum or silos of operations, and it must be patient-centred.

Healthcare leaders acknowledge capacity breaches impact the quality, safety, finances, and patient/staff satisfaction of their organisation. The first step to managing capacity and patient throughput is leveraging an operationally aware EHR through integration. Leaders evaluate bottlenecks and are working diligently to address barriers through key strategies: near-real-time decision support (technology), care coordination (people), and discharge processes (people). Ultimately, leveraging situational awareness, actionable data, and co-locating key stakeholders establishes an organisational approach providing transparency of operations.

When creating a business case for capacity management and patient throughput, Cerner’s CareAware Capacity Management suite is designed to improve operations through visibility and transparency to all patient throughput activities. Patient throughput and capacity management are system-wide processes ensuring patients receive the right care, at the right time, in the right location using integrated solutions.

Further reading

A pair of Yorkshire Foundation Trusts have worked together to manage the flow of patients that visit their sites to allow better communication, greater efficiency and an improved experience for both staff and parents. Read more about how Calderdale and Huddersfield worked with Bradford Teaching Hospitals in Client achievements.

References

¹Walker, C., Kappus, K., & Hall, N. (2016). Strategies for improving patient throughput in an acute care setting resulting in improved outcomes: A systematic review. Nursing Economics, 34(6), 277-288.

²Kreindler, S. A. (2017). The three paradoxes of patient flow: an explanatory case study. BMC Health Services Research, 17(1), 1-15. doi: 10.1186/s12913-017-2416-8

³Tortorella, F., Ukanowic, D., Douglas-Ntagha, P., Rya, R., & Triller, M. (2013). Improving bed turnover time with a bed management system. The Journal of Nursing Administration, 43(1), 37-43. doi: 10.1097/NNA.0b013e3182785fe7

⁴Rutherford, P.A., Provost, L.P., Kotagal, U.R., Luther, K., & Anderson, A. (2017). Achieving Hospital-wide Patient Flow. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement. Retrieved from www.ihi.org

⁵Rojas-Garcia, A., Turner, S., Pizzo, E., Hudson, E., Thomas, J., & Raine, R. (2017). Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expectations, 21(1), 41-56. doi: 10.1111/hex.12619

⁶Lateef, A., Lee, S. H., Fisher, D. A., Goh, W., Han, H. F., Segara, U. C.,Sim, T. B., Mahadehvan, M., Goh, K. T., Cheah, N., Lim, A. Y., Phan, P. H., & Merchant, R. A. (2017). Impact of inpatient care in Emergency department on outcomes: A quasi-experimental cohort study. BMC Health Services Research, 17(1), 1-8. doi: 10.1186/s12913-017-2491-x

⁷Davenport, P. B., Carter, K. F., Echternach, J. M., & Tuck C. R. (2018). Integrating high-reliability principles to transform access and throughput by creating a centralized operations center. The Journal of Nursing Administration, 48(2), 93-99. doi: 10.1097/NNA.0000000000000579

⁸Shim, S. J., Kumer, A., & Jiao, R. (2016). Using a radiofrequency identification system for improving the patient discharge process: A simulation study. The Journal of Medical Practice Management: MPM, 31(6), 383-387. Retrieved from https://greenbranch.com