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Go With The Flow

By Michael Donoghue

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It's early afternoon and the ED is starting to fill up. Bed Management has become very good at determining if the daily supply of beds can accommodate the anticipated demand. With the expected discharges today, it has been determined that there are enough beds for expected admissions. Then why the daily bed crunch?

I believe it is most often the timing. Admissions can happen anytime however, the activities involved in discharging a patient can be difficult to coordinate and often lend themselves to "batching". We often see 60-70% of discharges occurring between 2PM and 6PM. This leads to 60-70% of patients needing transport and 60-70% of rooms being cleaned soon after.

The ripple effect on patient flow is felt daily. When admitted patients get into their bed, it may be too late to start the patients care plan and LOS may be extended. The answer seems simple, discharge patients earlier! The reality is, a hospital is not a hotel and 11AM discharge initiatives are seldom successful. The reasons are plentiful: physicians round late, transportation home cannot be arranged; critical test results are pending etc. The impossible task of discharging every patient by a certain time only leads to staff frustration. Check out this funny video that provides a little levity to an often difficult issue.

Rather than move the discharge bubble to 11AM, we like to break the bubble and move the right amount of discharges to earlier in the day.  By "right amount", I mean each unit should have a specific daily target for early discharges. Lower acuity units will have higher targets to allow patients to step down from the higher acuity units. Simple discrete event simulation models can be used to set the targets.

Planning of the early discharges can begin 24-36 hours ahead of time. This allows for scheduling transportation home or expediting critical test results. It also helps nursing staff plan their day. For a nurse, a batch of discharges also means a batch of admissions. Smoothing this flow can give nurses more time to spend with patients and give proper patient education during a discharge. Doing these things helps align discharges to admissions... and that goes a long way to alleviating the daily bed crunch.

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