Delays In Patient Flow Research Articles

Tribalism in the workplace: Anesthesia providers and others differing perceptions on causes of scheduling delay

PurposeOperating an interventional radiology (IR) service takes the cooperation of a team of physicians, advanced practice providers, nurses, technologists, and anesthesia providers. Addressing delays in patient flow through IR takes the cooperation of all these groups. To measure the varying perceptions of the causes of these delays, IR team members were surveyed regarding the frequency and duration of potential sources of delay. MethodsA 13-question survey regarding perceived causes of potential delays was sent to all staff employed at a single academic center interventional radiology service. The survey responses were grouped by their role on the team: IR practitioners, technologists, nurses, and anesthesia providers. Intergroup rankings were compared using a Tau test. ResultsThere were 47 respondents out of a potential pool of 73 (64%). Significant differences were found between anesthesia providers and all three other groups regarding the most frequent and lengthy causes of pre-procedure and intra-procedure delays—the three other groups all perceived anesthesia delays as more common and severe (P values of 0.001, 0.001, and 0.009 for LIPs, nurses, and techs, respectively). Similarly, LIPs reported significantly different perceptions of the causes of most frequent delays against all 3 other groups (P values of 0.009, 0.009, and 0.001 for nurses, techs, and CRNAs respectively). Each group tended to rank their contributions to delays as less frequent and lengthy than all other groups, as evidenced by the fact that 8/12 pre-procedure rankings attributable to one group showed evidence of this pattern. ConclusionThis survey, at a single institution, revealed significant differences in opinion about the causes of procedure delays with individual groups tending to blame themselves much less for errors than others. Although not generalizable, these results suggest a source of inter-group stress that may be mitigated with improved communication, changes in education, and training in perspective-taking.

Implementing a Nurse-Driven Telemetry Discontinuation Protocol.

What is the best practice for implementing a nurse-driven telemetry discontinuation protocol?A Rayna Gorisek, MSN, RN, CCRN, CNL, replies:In the current climate of nurse staffing and supply shortages, nurses must take the lead in developing innovative ways to minimize waste and improve the quality of health care. Using a nurse-driven telemetry discontinuation protocol to optimize appropriate telemetry monitoring may decrease unnecessary monitoring, thereby reducing nurse workload, and it may promote patient flow through the hospital.The purpose of nursing protocols is to promote better patient outcomes, optimize patient safety, and improve quality of care. Nurse-driven protocols assist nurses in integrating evidence-based practices into patient settings, support nurses’ decision-making capacity, and increase their autonomy and accountability.1To begin developing a nurse-driven protocol for discontinuing telemetry, evaluate your organization’s existing process. Does a telemetry order set or protocol include steps to assess the need to continue telemetry? Next, conduct a comprehensive literature review, using more than one database to identify current evidence for developing a nurse-driven protocol for discontinuing telemetry. Also review any evidence-based guidelines for appropriate telemetry use, such as those from the American Heart Association, which identify 3 categories of patients and cardiac monitoring2: After reviewing the literature and guidelines, form an interdisciplinary task force that comprises all stakeholders—physicians, nurse managers, nurse directors, clinical nurse leaders, educators, risk management, and nursing staff—to produce a list of criteria for patients to be removed from telemetry. These criteria form the groundwork for developing the nurse-driven discontinuation protocol. As a team, the task force members develop a clinical research question using the PICOT (Patient, Intervention, Comparison, Outcome, and Time) method (see Table).3 Identify local problems specific to your unit or organization, such as delays in patient flow or limited availability of telemetry.Many organizations are challenged by transfer delays from emergency departments or intensive care units to acute care telemetry units. Specific metrics to consider evaluating include wait times for emergency department or intensive care unit patients to receive a bed on the telemetry unit and the total number of hours of telemetry monitoring. One opportunity for quality improvement is to assess alarm data on your unit. Nursing time and workload are impacted when nurses have to attend to unnecessary or nuisance telemetry alarms (eg, leads-off, poor connectivity, artifact, or battery failure alarms).4Initiating a 4-part iterative experiment by using the Plan-Do-Study-Act (PDSA) model offers a method of testing to achieve improvements on a small scale. With this model, a team performs a pilot to test a specific aim of improvement (see Figure).3 One of the benefits of using the PDSA model to test a nurse-driven protocol is that it does not require a lot of time or resources to fully execute the test for change. The PDSA model promotes simplicity by specifying who does what when and with what materials and supplies, ensuring that the stakeholders involved in the PDSA cycle have clear roles and responsibilities.4,5In the Plan phase of the PDSA cycle, the team establishes the specific aim or goal for change to be tested. Members of the interdisciplinary task force are assigned roles and responsibilities for the pilot, create a timetable for the pilot, and complete methods to measure and track data during the pilot. Frontline staff are given any necessary education or training during this phase. Consider ways to incorporate the nurse-driven protocol into nursing workflow, such as through the electronic health record or a checklist that would be used during nurse hand-offs or rounds.The Do phase of PDSA occurs when the pilot is implemented. Documentation is important in order to capture events—especially unanticipated ones—for future study. Listen to frontline staff and adjust the process on the basis of their feedback; making changes at this step reduces staff members’ anxiety and resistance to trying out a practice change.The Study phase is when data are analyzed. Ensure that an appropriate group and time interval are set for the comparison data that will be used to demonstrate the impact of the intervention or change. Evaluate and compare hypotheses and summarize the lessons learned.During the Act phase of PDSA, the task force decides, on the basis of the results, whether to implement, modify, or withdraw the change or idea. The team can continue the PDSA cycle if necessary.3–5Nurse-driven protocols can produce many positive outcomes. Implementing a protocol that decreases the amount of unnecessary telemetry monitoring may increase nurse autonomy, improve patient flow, and reduce costs. Using the PDSA cycle is one evidence-based way to systematically create improvement. Nurses need to be empowered and supported to lead in the development of innovations that improve processes and the outcomes of patients and the nursing profession.

Reduced isolation room turnover time using Lean methodology.

To prevent environmental transmission of pathogens, hospital rooms housing patients on transmission-based precautions are cleaned extensively and disinfected with ultraviolet (UV) light. To do so consistently requires time and coordination, and these procedures must avoid patient flow delays and associated safety risks. We sought to improve room turnover efficiency to allow for UV disinfection. A 60-day quality improvement and implementation project. A quaternary academic pediatric referral facility. A multidisciplinary healthcare team participated in a 60-day before-and-after trial that followed the Toyota Production System Lean methodology. We used value-stream mapping and manual time studies to identify areas for improvement. Areas addressed included room breakdown, room cleaning, and wait time between cleaning and disinfection. Room turnover was measured as the time in minutes from a discharged patient exiting an isolation room to UV disinfection completion. Impact was measured using postintervention manual time studies. Median room turnover decreased from 130 minutes (range, 93-294 minutes) to 65 minutes (range, 48-95 minutes; P < .0001). Other outcomes included decreased median time between room breakdown to cleaning start time (from 10 to 3 minutes; P = .004), room cleaning complete to UV disinfection start (from 36 to 8 minutes; P < .0001), and the duration of room cleaning and curtain changing (from 57 to 37 minutes; P < .0001). We decreased room turnover time by half in 60 days by decreasing times between and during routine tasks. Utilizing Lean methodology and manual time study can help teams understand and improve hospital processes and systems.

Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system

Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitiveand often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates. The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis. A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value(NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture). A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptomonset to ED presentation for patients with possible TT was 4h. After triage, a median of 79.8min was required for ED physician assessment and an additional 48min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration. Almost 4h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128min; Fig.1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS. Patient flow delays to surgical intervention for patients with TT representa preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.

Graphic facilitation as a novel approach to practice development.

The active participation of staff from the outset of any health service or practice improvement process ensures they are more likely to become engaged in the implementation phases that follow initial service analyses. Graphic facilitation is a way of getting participants to develop an understanding of complex systems and articulate solutions from within them. This article describes how a graphic facilitation process enabled the members of a multidisciplinary team at a specialist paediatric neurosurgery hospital in Uganda to understand how their system worked. The large graphic representation the team created helped each team member to visualise their day-to-day practice, understand each person's contribution, celebrate their triumphs and highlight opportunities for service improvement. The process highlighted three features of their practice: an authentic interdisciplinary team approach to care, admission of the primary carer with the child, and previously unrecognised delays in patient flow through the outpatients department. The team's active participation and ownership of the process resulted in sustainable improvements to clinical practice.

Examining the impact of health information systems on healthcare service improvement: The case of reducing in patient-flow delays in a U.S. hospital

The impact of Health Information Systems (HIS) on healthcare service improvement is well known; however, there has been a limited amount of research regarding the HIS payoff and how this has influenced the quality of patient care. By focusing on Kaizen, this study investigates the possibility of reducing patient-flow delays of outpatients using the HIS. By using a six-step Kaizen method, the root causes of patient-flow delays in the outpatient surgery process were first identified, followed by the development of potential solutions and implementation plans. Afterwards, the role the HIS has on the outpatient surgery process and the economic impact it can have on patient care operations were analyzed. The findings of this study indicate that the adoption of HIS has great potential to not only minimize the chaos and disorder in the outpatient surgery unit but also lead to a reduction of time and cost in relation to patient flow.

P005: Consultations in the emergency department: a systematic review

Introduction: Consultation in the emergency department (ED) is a common component of emergency health care. Consultation is defined as a case in which an ED physician (EP) requests the services of another physician (consultant) for an ED patient to assist, advise, and/or transfer care when the care required is beyond the expertise of the EP’s practice. While consultation is generally considered required and beneficial for patient care, consultation can also have a negative impact by incurring delays in patient flow and disposition. These delays contribute to ED crowding, patient dissatisfaction and, in some cases, worse health outcomes. Using an a priori protocol and accepted methodology, the aim of this systematic review was to update a previous review on the same topic and determine the proportion of 1) ED visits that involve consultation and 2) consultation cases that result in admission. PROPSPERO registration number: CRD42017054054. Methods: Literature search involved multiple electronic databases (e.g., MEDLINE and EMBASE) and grey literature (e.g., Google Scholar and conference abstracts). Study selection was conducted independently by two reviewers and determined by consensus among the two reviewers with disagreements resolved by a third party. Data extraction was conducted independently by two reviewers and determined by consensus among the two reviewers with disagreements resolved by a third party. A descriptive analysis was conducted. Outcome measure data were aggregated and reported with suitable descriptive statistics such as raw or weighted mean, median, or proportion with 95% confidence interval. Results: Literature search yielded 1,584 studies, of which 65 were included. Two-thirds of studies were conducted in USA or Canada. Of the 65, 54 were focused on a particular patient group or consulting specialty (e.g., psychiatry) while 11 considered the general ED population. Of these 11, the median proportion of ED visits involving consultation was 26%. The median proportion of cases with consultation that resulted in admission was 60%. Conclusion: Consultations in the ED are quite common and many of these cases result in admission. Given their frequency of occurrence and increasing ED crowding, efforts to reduce consult delays and expedite disposition appear warranted.

PTU-084 Decompensated Cirrhosis in the Acute Medical Unit – A Neglected Group?

Introduction Decompensated chronic liver disease (DCLD) is a medical emergency with high mortality, usually managed by non-specialists in emergency (ED) and acute medical (AMU) departments in critical early stages. A recently introduced BSG/BASL care bundle 1 (CB) highlights crucial investigations, which can influence outcome if performed early ( We audited performance against CB recommendations and impact on outcome. Methods Data was reviewed retrospectively using electronic records. Adherence to 4 key CB investigations (blood tests/cultures, ultrasound (US) and ascitic tap in Results All patients admitted over 3 months with DCLD were included (n = 25 patients/33 total AMU admissions). Ascites (51.5%) and jaundice (24.2%) were the commonest presenting complaints. Most (57.6%) had Childs C disease (Childs A 6%; B 36.4%). LOS was variable (mean 11 days; median 7 [1–60]), and 7 people were readmitted within 1 month. In-patient mortality was 16% (12.1% of admissions) in keeping with national data, and 80% were alive at 3 months. No-one had all 4 investigations performed within 6 hr of admission. 81.8% had routine blood tests performed (usually by ED), but only 15.1% had blood cultures, despite early identification of sepsis being a critical aspect of DCLD care. All cultures were taken for other reasons (e.g. cellulitis, pyrexia/rigour) suggesting sepsis risk in DCLD is under-appreciated by non-specialists. 39.4% had US requested within 6 hr and there was a lack of awareness of hepatoma/venous thrombosis as DCLD precipitants. Just 24.1% of those with ascites had a diagnostic tap within 6 hr, with most not performed until under gastroenterology care. Data suggests this was due to inexperience of the admitting doctor, both in understanding importance of excluding/treating sepsis early, and technical capability to perform the test. Slow patient flow added considerable delay to assessment/investigation, with 35% arriving in AMU > 6 hr post ED arrival (mean 4.5; median 5.5 [0.3–16 hr]), closing the window of opportunity for early intervention. There was a non-significant trend towards long waits in those who subsequently died (mean 7.5 hr; median 5.9 [3.6–14.5]), but no correlation between delay and LOS. Conclusion Patients with DCLD were under-investigated and experienced considerable delay in assessment and investigation, possibly impacting mortality. CB awareness was limited, and we identified failure of non-specialists to appreciate causes of DCLD and importance of rapid and robust assessment, compounded by delays in patient flow. We arranged talks for AMU staff on DCLD, and have commenced enhanced gastroenterology in-reach for ED/AMU, to identify and treat patients more rapidly. Reference 1 http://www.bsg.org.uk/images/stories/docs/decomp_cirrhosis_care_bundle.doc Disclosure of Interest None Declared

Using the Electronic Medical Record to Enhance Physician-Nurse Communication Regarding Patients' Discharge Status.

The fast-paced environment of hospitals contributes to communication failures between health care providers while impacting patient care and patient flow. An effective mechanism for sharing patients' discharge information with health care team members is required to improve patient throughput. The communication of a patient's discharge plan was identified as crucial in alleviating patient flow delays at a tertiary care, academic medical center. By identifying the patients who were expected to be discharged the following day, the health care team could initiate discharge preparations in advance to improve patient care and patient flow. The patients' electronic medical record served to convey dynamic information regarding the patients' discharge status to the health care team via conditional discharge orders. Two neurosciences units piloted a conditional discharge order initiative. Conditional discharge orders were designed in the electronic medical record so that the conditions for discharge were listed in a dropdown menu. The health care team was trained on the conditional discharge order protocol, including when to write them, how to find them in the patients' electronic medical record, and what actions should be prompted by these orders. On average, 24% of the patients discharged had conditional discharge orders written the day before discharge. The average discharge time for patients with conditional discharge orders decreased by 83 minutes (0.06 day) from baseline. Qualitatively, the health care team reported improved workflows with conditional orders. The conditional discharge orders allowed physicians to communicate pending discharges electronically to the multidisciplinary team. The initiative positively impacted patient discharge times and workflows.

Reducing Patient-Flow Delays in Outpatient Surgery Setting Through Kaizen Methods

Healthcare organizations are looking for new opportunities to reduce the costs of healthcare without sacrificing the quality of patient care. Particularly, outpatient surgery has a very large share of healthcare service categories as well as remains the highest cost in overall outpatient visit service. Thus, the aim of this study is to demonstrate a case study that how to reduce outpatient patient-flow delays in a large U.S. Southeastern University Health Sciences Center by using a six-step kaizen framework. Through this framework, we identified the patient-flow delay problems in outpatient surgery process, organized the potential solutions and plans, provided several empirical measures to improve the efficient of in the surgery process, and subsequently introduced a healthcare information system for addressing the delay issues in the admitting process, patient late to the outpatient surgical units, and incomplete paperwork. Finally, this case indicated that by implementing kaizen methods to improve patient-flow delays not only saved a large amount of cost (a yearly estimated savings of $256,800), but patient care efficiency, process feasibility, and patient satisfactions were increased.

Breaking down the silos to decrease internal diversions and patient flow delays.

Hospitals strive to admit patients to the units where caregiver competencies align with the patient's condition. When the hospital's census peaks, internal diversions and the associated risks increase, which are intensified when silos exist, as segregated care negatively impacts collaboration and patient safety. In this study, a 600+-bed academic, tertiary care specialty hospital experienced an increase in internal diversions. Within the neuroscience service line, emergent neuroscience transfers from outside hospitals had been declined or internally diverted because of capacity limitations. Formalized processes for improving collaboration between health care providers related to capacity issues were required to decrease internal diversions and improve patient flow and patient safety. A pilot project was conducted on neuroscience units during a process improvement initiative. A hospital-wide internal diversion plan was developed, identifying primary and secondary placement options for all patients requiring hospitalization to support patient flow and patient safety. Forecasting tools were developed to provide units' leadership with current information on expected admissions. Daily capacity huddles were instituted to increase collaboration between patient care units. The interventions trialed during the pilot decreased internal diversions and improved patient flow. The improved collaboration resulted in an 80% decrease in declinations of emergent intensive care unit transfers from outside hospitals due to capacity limitations and a 50% decrease in the number of these patients being internally diverted to alternate intensive care units. The interventions implemented minimized internal diversions and improved patient flow. The transparency of the patient placement process led to an increased collaboration between all participants.

Reducing patient-flow delays in surgical suites through determining start-times of surgical cases

A scheduling strategy to determine starting times of surgeries in multiple operating rooms (OR) is presented. The constraints are resource limit of a downstream facility, post-anesthesia care unit (PACU), and the service time uncertainties. Given sets of surgeries that need to be done on a day, this problem is formulated as a flexible job shop model with fuzzy sets. Patient-waitings in the process flow, clinical resource idling, and total completion times are considered for evaluation. This multi-objective problem is solved by a two-stage decision process. A genetic algorithm is used for determining relative order of surgeries in the first stage and definite starting times for all the surgical cases are obtained by a decision-heuristic in the second stage. The resultant schedule is evaluated by a Monte-Carlo simulation. The performance is shown to be better than our previous approach, a simulation based scheduling which already outperforms simple scheduling rules in regional hospitals. Additionally, the ratio of PACU to OR is examined using the proposed scheduling strategy.

Consultations in the emergency department: a systematic review of the literature

Objectives:Consultation is a common and important aspect of emergency department (ED) practice which can lead to delays in patient flow. Little is known about ED consultations and this review systematically...

Mixing methodologies to enhance the implementation of healthcare operational research

Healthcare Operational Research (OR) has had limited success in achieving a sufficient level of stakeholder acceptance to lead to implementation of results. This research study is aimed at combining OR methodologies to achieve greater acceptance of results for organizational change. Patient flow delays in the Paediatric intensive care unit (PICU) at Children's Hospital of Wisconsin were identified using case studies. Patient flow was modelled using hard OR (simulation) using case study findings, with active stakeholder participation, and enhanced with outcomes research. Outcomes research allowed achieving greater clinical relevance of OR findings. Results from hard OR, particularly for politically sensitive issues, were persuasive but inadequate to result in change. Soft OR (cognitive mapping) was used to identify new issues and enhance results. Consequently, the planned PICU expansion was deferred, and resources focused on improving staffing strategies identified independently from both hard and soft OR. These findings suggest that: (1) Outcomes research can play a unique role to enhance results in healthcare OR. (2) After obtaining a holistic understanding of the system using hard and soft OR, stakeholders are willing to implement results from each independently, supporting the development of a common form of knowledge, which is consistent with Mixed-Mode Modelling. (3) Hard OR, enhanced with outcomes research, with active stakeholder participation, and combined with soft OR, results in greater acceptance and sustained organizational change.

Using statistical process control to demonstrate the effect of operational interventions on quality indicators in the emergency department.

When our emergency department (ED) initiated a continuous quality improvement (CQI) program, we selected as a quality indicator the percentage of patients leaving without being seen (LWBS) by a physician. Because the primary reason for LWBS patients was determined to be dissatisfaction with waiting time, we devised four interventions in clinical operations to decrease delays in patient flow through the ED. Statistical process control (SPC) methodology was then used to assess the effect of these interventions. Because baseline data were available, we constructed control charts of the percentage of LWBS patients versus consecutive months beginning in January 1990 with the mean percentage of LWBS patients and upper and lower control limits. Postintervention data, plotted using control statistics from the baseline period, demonstrated sustained special-cause variation, indicating a fundamental change in the overall system. A new control chart was then constructed using postintervention data. A significantly lowered mean percentage LWBS and a narrowed control limit range were observed, leading to the conclusion that the interventions improved the quality of care as measured by a reduction in percentage LWBS.