Grand Rounds
Grand Rounds is a weekly round up of medical weblogs. I submitted an entry over the weekend, and just received notice that it was accepted. You can see my entry, along with many others, here.
ED Overcrowding and Diversions In Real Time
Two sites have come to my attention that indicate real time divert data.
The first is a site that covers an eight-county region in South Central Pennsylvania. The status of (17) hospitals is hosted at this site. You can visit the website at http://hospitals.ehsf.org/. The site is based on a package by Med Media, who has a number of EMS solutions. As I’m writing this one of the region’s three trauma centers is on divert (Lancaster General), and Gettysburg Hospital has overcrowding in Critical Care, General Medicine and General Surgery. Oh, and Memorial Hospital is on ED divert as well. And while I was adding links to this post, Good Sam also went on divert. That’s a total of one quarter of this regions hospitals on divert. Wait, there’s another one! Ephrata Community Hospital has joined the ranks of the diverted.
This link is to Credit Valley Hospital, a 365 bed hospital with 20,000 admissions annualy, in Mississauga, Ontario (a Toronto suburb). At the middle of their home page at the bottom, there’s a stylized picture of an ambulance. Below that it says, “Click here to view our ER admit status.” Here’s what the link says this evening:
At the present time we have 23 patients in the emergency department requiring admission to hospital. Because all of our inpatient beds are full, these patients will remain on stretchers in the emergency department until a bed can be found on a nursing unit.
The only way we can make room for these patients is to be diligent in discharging those patients on nursing units whose condition has improved to the point that their doctor feels they can safely recover at home.
We appreciate your cooperation and understanding.
They’re apparently boarding 23 patients in the ED awaiting admission to the hospital. I’m not sure what to make of the second paragraph.
I will continue to search for similar web sites. If you come across any, please let me know. In all, these two indicators of capacity are pretty cool. As the father of a seven year old, I would love to have similar feedback on potential emergency room overcrowding in the Portland area.
Bed Management Issues and Financial Impact
The other day I came across a Baltimore Business Journal article from late last year that describes patient flow experiences at Baltimore area hospitals.
There is some good background on the problem like the impact of capitated reimbursement and the rapid drop in LOS in the '90s. But the rapid drop in LOS started to level off in the late '90s because the easy fixes to patient flow problems, like optimizing individual departments, had been done. Impacting patient flow (and reducing LOS) today requires cross-silo organizational review and broad based solutions. The solution of final resort is adding capacity. At a cost of $1 million per new bed, building your way out of a capacity problem is an expensive proposition.
“The system doesn't like to pay a lot for standby capacity,” said Caroline Steinberg, vice president for trends analysis for the American Hospital Association in Washington. “It's a balance of extra capacity that the system is willing to pay for to make sure you only have gridlock a certain percentage of the time.”
Solutions discussed include:
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the addition of hospitalists
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acquiring capacity management software
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increasing hospital operating hours from 5 to 6 days per week
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optimizing diagnostic testing
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aggressive discharge management
Of course this is a partial list of fixes, and few of them are quick and easy. Johns Hopkins was the exception. Their secret was, “asking doctors where the problems were and fixing those problems.” I don't doubt that this quote was taken out of context – if improving patient flow was that easy, there would be no problem. But, there is some truth to the comment.
The people working in your hospitals (including the doctors) know the bottlenecks, and have good ideas how to fix them. Tapping this knowledge, with some process observation and analysis of data you already produce, is key to work flow optimization. This 20% of effort will get you 80% of the benefit. Stopwatches and time-in-motion studies are only required for that final 20%, if you want to up your effort considerably.
St. Joseph Medical Center in Towson increased admissions 7% from 2002 to 2003. Emergency room overcrowding resulting in ambulance diversions came down from several hundred hours a month to just ten hours. Improving lab results report turnaround times pulled ER wait times down 70% (a typical patient waits less than 30 minutes to see a doctor). The time required to admit an ER patient has come down 50 percent. Hopkins cut a half day off their average LOS and increased hospital admissions by 20 percent.
None of these Baltimore area hospitals appear to be using one of the most effective means to improving patient velocity, universal units. Emergency department overcrowding is typically the symptom of a lack of open ICU or Telemetry beds. The universal unit can handle a wider range of patient acuity, combining more aggressive therapies with a higher level of surveillance for safety. The end result is providing appropriate patient care in the lowest cost setting. This new care model reduces ICU and Telemetry utilization by reducing inappropriate admissions, reducing ICU/Telemetry LOS, reducing readmissions and reducing off-service admissions.
Bright Coop E-Z Catch Harvester Video
I know it is totally off topic, but I couldn't resist — the latest in chicken management technology. Bright Coop's web site has a link to the video on the right.
