Avoidable Admissions Impact Patient Flow
Every hospital has them. Frequent fliers. These are the patients with chronic disease (not the one's looking for pain medication) who are admitted once, twice, or more often a year. They come in, get a tune up and go back home until the next tune up. The patients I'm referring to are not ER frequent fliers (although they can be a problem too), but folks who come and stay a few days. Some hospitals create special frequent flier services to shorten their stay. These admissions are potentially avoidable, and avoidable admissions represent over 10 percent of hospital admissions.
Here is a story of a new effort to improve chronic disease management and avoid those frequent flyer admissions. While the “wireless body vest” from Medify sounds a bit Buck Rogers, remote disease management along with some monitoring (or self monitoring) technology can make a big difference.
Improving Patient Flow with an Acute Medical Admission Unit
There are many methods for improving patient flow. One broad category represents organizational and procedural changes that can streamline care. One common approach is to create a holding area for patients awaiting admission as an alternative to boarding patients in hall ways. Called by various names (I like Express Admissions Unit myself), these areas complete all admitting paperwork, assessment and initial orders. Patients are housed (and cared for) here until a bed is available on the appropriate unit. This approach relieves unit nurses the time consuming work required by newly admitted patients. They also provide a safe patient care alternative to boarding.
Here are the results from a study at St. James' Hospital, Dublin:
For all physician teams, median LOS shortened significantly from 2002 to 2003 (6 vs. 5 days, p<0.0001). Overall, patients seen by general physicians had a shorter LOS (5 days) than that of those seen by sub-specialists (6 days) (p<0.0001). The number of patients waiting in the ED for a hospital bed was reduced by 30% from 2002 to 2003 (p<0.001). Extrapolated cost savings for the hospital with the introduction of the AMAU were estimated at approximately 4039 bed-days and
1,714,152.
An alternative to a dedicated unit is a roving admitting nurse who goes with the admitted patient to their unit, relieving staff nurses from this time consuming process. Other functions can be assigned to pre admissions units that improve patient flow, for example, medical observation and evaluation units or clinical decision units. Of course, based on need and situation, effectiveness can vary.
Patient flow initiatives frequently result in seven figure annual savings. Compared to all the hubub about questionable HIT ROIs (here and here) it's no wonder more and more hospitals are looking at many ways to improve patient flow.
Hospital Bed Management — One Hospital's Experience
Here's a nice story that describes how Seton Medical Center in Austin improved their patient flow. They were experiencing the usual problems, ED diverts, boarding patients overnight because rooms were unavailable, and admitting physician compaints about delays and unavailable beds.
To improve patient flow, the hospital staff divided into several teams, focusingon four key areas: ED diversion, post-anestesia care unit (PACU) holding, patient access to the facility, and in-house and out-of-house transfers. Ultimately, these teams merged to form the patient throughput department.
The results are impressive:
Before the initiative was begun, the average holding time in the PACU was 120 minutes per patient. In the last three months of 2004, the average total hold time per month was just 180 minutes for all patients.
In 2003, the hospital had to divert patients brought by emergency medical services a total of 458.24 hours because there were no beds. In 2004, the time dropped to 49.57 hours. In December 2003, the average patient stayed in the ED for 296.26 minutes before admission. In November 2004, the time had dropped to 190.22 minutes.
They created a Throughput department, managed by Pat Ramming, RN. The team includes house supervisors (RNs who coordinate house-wide patient flow 24/7), bed board staff (non-clinical staff that coordinates and tracks bed assignments), and express admissions nurses (nurses who off-load patient admitting from unit staff). The use of admissions nurses contrasts nicely with this approach at a Dublin hospital, where patients go to a special admitting unit (where they are of course admitted) before being transferred to the floor.
This article (requires registration) from January 2002 describes the ED divert situation in Austin that partially prompted Seton's patient flow improvement efforts.
Emergency Room Overcrowding Online
In a continuation of a previous post, I've found 2 more sites that reflect emergency department overcrowding and diversions in real or near-real time. The first is MIEMSS, the Maryland Institute for Emergency Medical Services Systems. The far left column on the bottom half of their site has a section titled CHATS (for County Hospital Alerts Tracking System). Below CHATS are links to three different regions of the state, listing all the hospitals in that region and color coded status for various degrees of overcrowding and bypass.
This Friday shows 13 out of 58 hospitals showing some sort of divert status (that's 22 percent). The MIEMSS Annual Report notes (page 15) that emergency room overcrowding has gotten more acute in the current reporting period (2003-2004) than in previous years, with record peaks during the flu and respiratory season. While not as cool as the Med Media website that the Emergency Health Services Federation in Pennsylvania has, the MIEMSS site is informative and updated regularly.
Our second status site covers 17 Montreal area hospitals. This site is updated at 8 am daily. For each hospital the site shows “stretcher capacity”, i.e., beds, occupied stretchers and stretchers occupied for more than 48 hours (yikes!). As of 8am this morning (Friday, March 18, 2005), capacity was at 120 percent, and 79 patients had been boarded more than 48 hours waiting for a hospital room.
Siemens First to Offer Virus Protection for Medical Devices
This is a huge step in medical device security, and the first of its kind. Read about it here, and if you’re asking, “what’s the big deal,” read on…
Many medical devices are built on general purpose computing platforms. Holter systems, PACS, and central stations are obvious examples, but many seemingly “embedded systems” are also using general purpose computing platforms. The most common general purpose computing platform is Windows running on Intel microprocessors. There are several flavors of Windows used: XP, 2000, NT, and CE. Susceptibility to malicious code like viruses and worms is more dependent on the operating system than the microprocessor. And since more and more medical devices are getting networked, more devices are getting infected with malicious code. (Here is a good explanation of different types of malicious code.) Unfortunately, due to Windows overwhelming market dominance, the vast majority of malicious code is written to target Windows computers. Solaris, Unix and Linux are also used in medical devices — the good news is that few hackers target these platforms due to their small market share, the bad news is that there are few protective software tools available for the same reason.
How big is the threat? At HIMSS last month, John Glaser, CIO at Partners Healthcare, reported that they receive 500,000 emails per day from the Internet, of which 7 percent carry malicious code (that’s 35,000 infected emails). He also mentioned that their network is probed 20,000 a day by would be hackers looking for vulnerabilities. To make matters worse, hacker programs called scripts can be easily found and downloaded from the Internet. The hackers who use these programs are called script kiddies and use these scripts to search for and exploit computers accessible from the Internet, usually with little regard or even understanding of the potential harmful consequences.
Very few medical devices contain any software to actively protect them from malicious code. I know of only a few very recent products that include software based firewalls. Hospitals must rely on general IT security products and methods to protect their IT networks and medical device networks. When devices get infected, they frequently become inoperable.
Vendors must “repair” infected devices or systems. Repair includes “patching” the operating system to remove the vulnerability exploited by the malicious code, and removing malicious code from infected devices. One method of repair is to “remanufacture” the product by reloading the operating system and application software — this is easy for the vendor because it uses existing processes. Remanufacturing is less attractive for hospitals because it means shipping the product back to the manufacturer. Remanufacturing may simply remove the malicious code and not fix the operating vulnerability, leaving the device open to infection. Alternatively, vendors may release a software patch. Software patches usually only close the vulnerability, leaving infected devices broken. (Click here to see the current list of Microsoft patches, and here is a good introduction to patch management.)
Software patch procedures at most vendors are somewhat undeveloped and hospitals can find themselves without the use of a device for some time. You can read more about patching medical device software here. You can learn more about medical device security at the HIMSS Medical Device Security web site.
The bottom line is that vendors must provide better protection against malicious code, and develop the processes and tools to respond to attacks in a much more timely and effective manner. Siemens has thrown down the gauntlet — it will be fun to watch the responses.
