Inpatient Capacity Research Articles

LO18: How big is emergency access block in Canadian hospitals?

Introduction: Emergency department (ED) access block is the #1 safety concern in Canadian EDs. Its main cause is hospital access block, manifested by prolonged boarding of inpatients in EDs. Hospital administrators often believe this problem is too big to be solved and would require large increases in hospital capacity. Our objective was to quantify ED access gap by estimating the cumulative hours that CTAS 1-3 patients are blocked in waiting areas. This value, expressed as a proportion of inpatient care capacity, is an estimate of the bed hours a hospital would have to find in order to resolve ED access. Methods: A convenience sample of urban Canadian ED directors were asked to provide data summarizing their CTAS 1-3 inflow, the proportion triaged to nursed stretchers vs. RAZ or Intake areas, and time to care space. Total ED access gap was calculated by multiplying the number of CTAS 1-3 patients by their average delay to care space. Time to stretcher was captured electronically at participating sites, but time to RAZ or intake spaces was often not. In such cases, respondents provided time from triage to first RN or MD assessment in these areas. The primary outcome was total annual ED access block hours for emergent-urgent patients, expressed as a proportion of funded inpatient bed hours. Results: Directors of 40 EDs were queried. Six sites did not gather the data elements required. Of 34 remaining, 29 (85.3%) provided data, including 15 tertiary (T), 10 community (C) and 2 pediatric (P) sites in 12 cities. Mean census for the 3 ED types was 72,308 (T), 58,849 C) and 61,050 (P) visits per year. CTAS 1-3 patients accounted for 73.4% (T), 67.7% (C) and 66.2% (P) of visits in the 3 groups, and 34% (T), 46% (C) and 44% (P) of these patients were treated in RAZ or intake areas rather than staffed ED stretchers. Mean time to stretcher/RAZ care was 50/71 min (T), 46/62 min (C), and 37/59 min (P). Average ED access gap was 47,564 hrs (T), 37,222 hrs (C) and 35,407 hrs (P), while average inpatient bed capacity was 599 beds (5,243,486 hrs), 291 beds (2,545,875 hrs) and 150 beds (1,314,000 hrs) respectively. ED access gap as a proportion of inpatient care capacity was 0.93% for tertiary, 1.46% for community and 2.69% for pediatric centres. Conclusion: ED access gap is very large in Canadian EDs, but small compared to hospital operating capacity. Hospital capacity or efficiency improvements in the range of 1-3% could profoundly mitigate ED access block.

"Byoin" in Modern Japan: Focusing on the Terminological Introduction of "Hospital" and the Complex Formation of Its Concept.

This paper aims to clarify when the term of Byoin (hospital) was introduced and how its concept was developed in modern Japan. The word "Byoin" was introduced in Japan in 1787 for the first time, but it had not been in use until early 1860s. Instead, various medical institutions performing the functions of modern medical facilities, such as Yojosho (A place for preserving health), Shijuku (private school), called by traditional names as ever. Japanese intellectuals already adopted the word Byoin and the concept of western hospital in early 1860s when their national delegates were dispatched to Europe to revise the treaties forged with western powers. Japanese translations of hospital appeared in English-Japanese/Japanese-English dictionaries published in the 1860s. For instance, the word Byoin (hospital in Japanese) was first published in a dictionary published in 1867 and unclearly connected to the words, hospital, infirmary. This paper will argue that the concept of Byoin was sophisticated through Meiji government's efforts to implement reforms distinguishing medical facilities based on their capacity of inpatients and quality. The first medical law (Isei) proclaimed by the Meiji government in 1874 articulated regulations for a hospital in eight different articles. The government established hospitals in various parts of the country, following its newly established modern medical care policies. However, in this process, Iin (hospital/clinic), another term for "hospital" appeared. Regional differences and financial issues made standardizing the concept of a hospital even more difficult. In response to the widely embedded confusion, the Japanese government made an effort to clarify the concept of a hospital, setting up provisions regarding the size of medical facilities. As a result, the word Byoin finally came to be used for a hospital with more than ten beds, while a clinic with beds below ten was called Shinryojo (clinic). On the other hand, Iin meant a medical facility less qualified than a hospital since 1933 when Japanese government made a harder restriction on the usage of Byoin.

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department.

IntroductionEmergency department (ED) crowding is widespread, and can result in care delays, medical errors, increased costs, and decreased patient satisfaction. Simultaneously, while capacity constraints on EDs are worsening, contributing factors such as patient volume and inpatient bed capacity are often outside the influence of ED administrators. Therefore, systems engineering approaches that improve throughput and reduce waste may hold the most readily available gains. Decreasing radiology turnaround times improves ED patient throughput and decreases patient waiting time. We sought to investigate the impact of systems engineering science targeting ED radiology transport delays and determine the most effective techniques.MethodsThis prospective, before-and-after analysis of radiology process flow improvements in an academic hospital ED was exempt from institutional review board review as a quality improvement initiative. We hypothesized that reorganization of radiology transport would improve radiology cycle time and reduce waste. The intervention included systems engineering science-based reorganization of ED radiology transport processes, largely using Lean methodologies, and adding no resources. The primary outcome was average transport time between study order and complete time. All patients presenting between 8/2013–3/2016 and requiring plain film imaging were included. We analyzed electronic medical record data using Microsoft Excel and SAS version 9.4, and we used a two-sample t-test to compare data from the pre- and post-intervention periods.ResultsFollowing the intervention, average transport time decreased significantly and sustainably. Average radiology transport time was 28.7 ± 4.2 minutes during the three months pre-intervention. It was reduced by 15% in the first three months (4.4 minutes [95% confidence interval [CI] 1.5–7.3]; to 24.3 ± 3.3 min, P=0.021), 19% in the following six months (5.4 minutes, 95% CI [2.7–8.2]; to 23.3 ± 3.5 min, P=0.003), and 26% one year following the intervention (7.4 minutes, 95% CI [4.8–9.9]; to 21.3 ± 3.1 min, P=0.0001). This result was achieved without any additional resources, and demonstrated a continual trend towards improvement. This innovation demonstrates the value of systems engineering science to increase efficiency in ED radiology processes.ConclusionIn this study, reorganization of the ED radiology transport process using systems engineering science significantly increased process efficiency without additional resource use.

Management of pharmaceutical waste in hospitals in Serbia – challenges and the potential for improvement

Abstract: Background: Left over medication widely used in hospitals for the treatment of various diseases including malignant illnesses, stand to represent a hazardous form of healthcare waste. According to regulations in the Republic of Serbia dating back to 2009, all healthcare facilities are obligated to separate, label and safely put away said leftover medication, i.e. forward it to authorised operators in order to be securely shipped and properly taken care of abroad. Pharmaceutical waste can lead to dire consequences on a patient’s or medical employee’s health, as well as cause simultaneous damage to the environment, both work and not. The main aim of this research is the assessment of the state of Serbian hospitals as is, from the perspective of dealing with pharmaceutical waste. Also, the research’s objective is to examine the factors that affect the way healthcare waste is handled and the respectful aftermath of their alterations in healthcare institutions. Methods: For the realization of this survey, a special questionnaire was developed, concocted with regard to the margins set out by WHO, in order to promptly assess the management of healthcare waste in hospitals, which had beforehand been pretested. The research was carried out as a cross-sectional study of the representative hospital sample of the secondary and tertiary level of healthcare facilities in the public domain, in November 2014. Results: The questionnaire was completed by 60 hospitals, which typifies a representative number of said facilities in the Republic of Serbia and which covers more than 85% of inpatient capacity within the public sector’s network of healthcare hospitals defined by the Bylaw (referred to as the Network of healthcare facilities in Serbia). Conclusion: Tertiary level hospitals, meaning clinical centres, clinical-medical centres and institutes that offer highly specialized healthcare services and have an admittedly larger number of hospital beds, have a more evolved system of sorting pharmaceutical waste and do away with grander amounts of it on a yearly basis. Establishing a safe and lawabiding management of pharmaceutical waste in hospitals will come to wholly enhance the management of hazardous waste in the healthcare system. Key words: Healthcare waste management, factors, pharmaceutical waste, training, hospital

The estimated hospital-wide financial impact of a comprehensive inpatient palliative care (PC) program.

173 Background: Inpatient PC improves quality of care, patient and family satisfaction, and lowers costs. PC consultation during a cancer hospital stay led to a 14 (if by day 6) to 24% (by day 2) reduction in direct cost, and especially when people had comorbidities. (May, JCO 2015; Health Affairs 2016). We attempted to discern the financial impact of both a PC inpatient unit (PCU) and PC consultations on patients in other inpatient units for a large academic medical center, the Johns Hopkins Hospital (JHH), as we prepared to expand the PCU from 6 to11 beds and increased inpatient PC consultation capacity. Methods: We estimated the savings for an 11 bed PCU based on cost per day from FY 2015 with a 6 bed unit ($444 lower costs per PCU day compared to inpatient stay prior to transfer to the PCU). We then calculated the cost savings for an 11 bed unit operating at 80% occupancy. We estimated the direct cost savings of consultations by adjusting the $/discharge saved (Morrison, Arch Int Med 2008) to 2014 $ (by multiplying the $/discharge saved by 1.4 to adjust for medical inflation). Results: The PCU inpatient stays resulted in projected lower costs of $6.7M over 5 years ($444/day x 3009 days/year, or $~1.3M yearly). IP revenue and margins were small (data not shown). For PC consults of 785 alive discharges ($2197/case) and 97 decedent discharges ($6357/case), total estimated savings in direct costs per case are $2,530,000/year. The PCU allows for additional benefits not calculated in this analysis, including inpatient backfill opportunities, more appropriate ICU bed use, savings from increased referral to hospice (hospice referrals increased 340% in 3 years), and reduced readmission rates from increased PC and hospice use. Conclusions: In addition to improving quality of care and patient satisfaction, the combined IP and consult PC programs contribute to substantially lower charges and costs per day. Backfill revenue, the opportunity for increased revenue from improved patient satisfaction (HCAHPS) scores, and reduced readmission rates will increase this financial impact. [Table: see text]

Reverse triage: more than just another method.

Reverse triage is a way to rapidly create inpatient surge capacity by identifying hospitalized patients who do not require major medical assistance for at least 96 h and who only have a small risk for serious complications resulting from early discharge. Electronic searches were conducted in the MEDLINE, TRIP, Cochrane Library, CINAHL, EMBASE, Web of Science, and SCOPUS databases to identify relevant publications published from 2004 to 2014. The reference lists of all relevant articles were screened for additional relevant studies that might have been missed in the primary searches. There will always be small individual differences in the reverse triage decision process, influencing the potential effect on surge capacity, but at most, 10-20% of hospital total bed capacity can be made available within a few hours. Reverse triage could be a response to Emergency Department (ED) crowding, as it gives priority to ED patients with urgent needs over inpatients who can be discharged with little to no health risks. The early discharge of inpatients entails negative consequences. They often return to the ED for further assessment, treatment, and even readmission. When time to a medical referral or bed is less than 4-6 h, 100 additional lives per annum are predicted to be potentially saved. The results of our systematic review identified only a small number of publications addressing reverse triage, indicating that reverse triage and surge capacity are relatively new subjects of research within the medical field. Not all research questions could be fully answered.

Online Module to Improve Emergency Department Observation Unit Practice.

The emergency department (ED) observation unit has become a unique practice opportunity to liberate inpatient capacity in the United States. Substantial variations in clinical practice and level of comfort among ED providers existed in a large health care system. We aimed to study the effectiveness of an educational module targeted for emergency medicine providers. We developed a 20-minute online module including pretest, learning module, and posttest. The format consisted of Likert-scale (1 = least comfortable, 5 = most comfortable), true-or-false, and multiple-choice questions. The learning module contained slides, script, and figures describing management strategy for commonly encountered conditions in the observation unit. The institutional review board granted exempted review. Pre- and posttest scores were evaluated with the Wilcoxon rank-sum test, and a p value of less than .05 was considered significant. Twenty-one participants completed the pretest, with a mean score of 63.8 (SD = 19.3), and 14 participants completed the posttest, with a mean score of 87.9 (SD = 9.7; p = .0001). Eight participants responded to a follow-up survey, a response rate of 57%. Responses demonstrated that levels of provider comfort in selection of observation (M = 4.3, SD = 1.5), choice of stress test for chest pain (M = 4.3, SD = 1.0), asthma management (M = 4.1, SD = 1.0), anaphylaxis care (M = 4.1, SD = 1.4), and documentation (M = 4.3, SD = 0.9) were high. An online learning module can be useful to enhance the knowledge of observation medicine among emergency medicine providers.

Clinical Manual of Emergency Psychiatry, Second Edition

Back to table of contents Previous article Next article Book ForumFull AccessClinical Manual of Emergency Psychiatry, Second EditionScott A. Simpson, M.D., M.P.H.Scott A. SimpsonSearch for more papers by this author, M.D., M.P.H.Published Online:1 Jun 2016https://doi.org/10.1176/appi.ajp.2016.16040381AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail edited by Michelle B. Riba, M.D., M.S., Divy Ravindranath, M.D., M.S., and Gerald Scott Winder, M.D. Washington, D.C., American Psychiatric Association Publishing, 2016, 375 pp., $70.00 (paperback).More than 12% of emergency department visits are for behavioral health emergencies, a large number resulting from inadequate outpatient resources and shrinking inpatient psychiatric bed capacity (1). To meet this demand, psychiatrists may consult in emergency departments, practice telepsychiatry, or manage psychiatric emergency services. Psychiatric emergencies are also being treated through free-standing crisis centers and regional referral centers (2). More providers are practicing emergency psychiatry in its different forms, and there is a need for research and education specific to this subspecialty. The Clinical Manual of Emergency Psychiatry offers a solid first step into the field of emergency psychiatry.The book is “not meant to be a textbook” for “first-year and second-year psychiatry residents” but is designed to introduce them to clinical management in “busy psychiatric emergency services”—where, for the first time, they face the combination of acute psychopathology, uncertainties of diagnosis, time pressures, medical comorbidity, and team management unique to emergency psychiatry (p. xxiii). Many trainees are intimidated by this environment, and this text makes the field feel accessible and manageable. The authors organize chapters by chief complaint in order to assist in the assessment and treatment of common presentations. The authors’ explicit goal is to help trainees to “review the key points, as needed, just before seeing a patient” (p. xxiv).How well, then, does this book achieve this goal? I brought the Clinical Manual to work in my urban psychiatric emergency service center to find out. There are immediate limitations to the chief-complaint-oriented approach: for example, when a hyperactive patient was brought in involuntarily by police, I was uncertain whether to start with the chapter on psychosis (chapter 5), agitation (chapter 7), substance-related emergencies (chapter 9), or even seclusion and restraint (chapter 11).The agitation chapter proved the right choice. I found a helpful differential of medical etiologies followed by a description of verbal de-escalation strategies espoused by Project BETA (3). As I began considering medication options, the authors provided a helpful table to summarize the dosing and pharmacokinetics of commonly used medications. However, understanding which medication was indicated required me to read 11 pages, which was not conducive to rapid decision making. The authors again use Project BETA’s approach to medication selection, although they do not build on those guidelines by introducing trainees to novel mechanisms of delivery (e.g., inhaled medications) or action (e.g., intramuscular ketamine, increasingly popular among our colleagues in emergency medicine).The not-a-textbook middle ground is frustrating. The text does not work well as a bedside reference because many of the clinical gems and decision-making advice are embedded in the text and are not presented visually. Such reading makes it difficult to do a quick review when busy. Although the authors do not intend to offer an encyclopedic text, the level of detail can be insufficient; for example, the authors rightfully recommend antiparkinsonian agents or benzodiazepines with intramuscular typical antipsychotics but do not provide dosing instructions. A differential of medical etiologies for acute agitation is emphasized, but no clear guidance is offered as to how extensive a workup is warranted. Perhaps it would have been helpful to describe several short scales validated for delirium screening in the emergency department.It speaks to the enjoyable writing, and maybe to the dearth of literature in emergency psychiatry, that I was left wanting more on contemporary topics, including managing boarding patients, identifying malingering (barely mentioned), and developing quality improvement metrics.But that is not the detailed textbook that the authors envisaged. Instead, they deliver a strong, if at times incomplete, introduction to emergency psychiatry for advanced medical students and junior residents. Most situations encountered in my psychiatric emergency service shifts were well-covered. My own copy will rest on the psychiatric emergency service center’s bookshelf to await anxious residents in need of a quick primer. And if trainees remain sufficiently interested to outgrow its scope, the Clinical Manual of Emergency Psychiatry should be considered a success.Dr. Simpson is an Assistant Professor in the Department of Psychiatry at the University of Colorado Denver School of Medicine and an emergency psychiatrist at Denver Health Medical Center.The author reports no financial relationships with commercial interests.

Exercise therapy improves aerobic capacity of inpatients with major depressive disorder.

BackgroundUnipolar depression is one of the most common diseases worldwide and is associated with a higher cardiovascular risk partly due to reduced aerobic capacity.ObjectivesTherefore, the aim of our study was to examine whether a structured aerobic training program can improve aerobic capacity in inpatients with MDD (major depressive disorder).MethodsOverall, 25 patients (13 women, 12 men) diagnosed with MDD were included in the study. Parameters of aerobic capacity, such as maximum performance, maximum oxygen consumption, and VAT (ventilatory anaerobic threshold), were assessed on a bicycle ergometer before and 6 weeks after a training period (three times per week for 45 min on two endurance machines). In addition, a constant load test was carried out at 50% of the maximum performance prior to and after the training period. The performance data were compared with 25 healthy controls matched for sex, age, and body mass index before and after the training period.ResultsCompared to controls, patients with MDD had significantly lower aerobic capacity. After training, there was a significant improvement in their performance data. A significant difference remained only for VAT between patients with MDD and healthy controls.ConclusionWith regard to the coincidence of MDD with cardiovascular and cardiometabolic disorders, a structured supervised exercise program carried out during hospitalization is a useful supplement for patients with MDD.

Implementation Analysis of a Nurse-Led Observation Unit.

This implementation analysis of a nurse-led observation unit describes the development process and analyzes patients' characteristics, patient satisfaction, and provider perceptions. A nurse-led observation unit was developed to create more inpatient bed capacity and place patients in the clinical area best suited to their needs. Descriptive statistics and content analysis were used for analysis. The average length of stay of 467 patients was 1.1 days; 68.1% (n = 318) were female. Elective surgery was the most frequent reason for admission. All of the patients rated the observation unit patient feedback survey factors favorably except for noise. All healthcare providers (n = 64) reported that they communicated well with each other and had resources to provide quality care but rated the environment less favorably. A nurse-led observation unit was found to be an effective and efficient approach to providing postoperative and postprocedure care, which was generally well received by patients and healthcare providers.

Time-Series Approaches for Forecasting the Number of Hospital Daily Discharged Inpatients.

For hospitals where decisions regarding acceptable rates of elective admissions are made in advance based on expected available bed capacity and emergency requests, accurate predictions of inpatient bed capacity are especially useful for capacity reservation purposes. As given, the remaining unoccupied beds at the end of each day, bed capacity of the next day can be obtained by examining the forecasts of the number of discharged patients during the next day. The features of fluctuations in daily discharges like trend, seasonal cycles, special-day effects, and autocorrelation complicate decision optimizing, while time-series models can capture these features well. This research compares three models: a model combining seasonal regression and ARIMA, a multiplicative seasonal ARIMA (MSARIMA) model, and a combinatorial model based on MSARIMA and weighted Markov Chain models in generating forecasts of daily discharges. The models are applied to three years of discharge data of an entire hospital. Several performance measures like the direction of the symmetry value, normalized mean squared error, and mean absolute percentage error are utilized to capture the under- and overprediction in model selection. The findings indicate that daily discharges can be forecast by using the proposed models. A number of important practical implications are discussed, such as the use of accurate forecasts in discharge planning, admission scheduling, and capacity reservation.

Increasing Access to State Psychiatric Hospital Beds: Exploring Supply-Side Solutions

The objective of this study was to identify supply-side interventions to reduce state psychiatric hospital admission delays. Healthcare Enterprise Accounts Receivable Tracking System (HEARTS) data were collected for all patients admitted between July 1, 2010, and July 31, 2012, to one of North Carolina's three state-operated psychiatric hospitals (N=3,156). Additional information on hospital use was collected at nine meetings with hospital administrators and other local stakeholders. A discrete-event simulation model was built to simulate the flow of adult nonforensic patients through the hospital. Hypothetical scenarios were used to evaluate the effects of varying levels of increased capacity on annual number of admissions and average patient wait time prior to admission. In the base case, the model closely approximated actual state hospital utilization, with an average of 1,251±65 annual admissions and a preadmission wait time of 3.3±.1 days across 50 simulations. Results from simulated expansion scenarios highlighted substantial capacity shortfalls in the current system. For example, opening an additional 24-bed unit was projected to decrease average wait time by only 6%. Capacity would need to be increased by 165% (356 beds) to reduce average wait time below 24 hours. Without more robust community-based hospital and residential capacity, major increases in state psychiatric hospital inpatient capacity are necessary to ensure timely admission of people in crisis.

Analysis of inpatient specialist capacity of a hospital using DRGs method

Objective To analyze the inpatient specialist capacity of a hospital during 2013-2014 in Beijing for its specialists development, based on relevant local specialist development. Methods Analyzing the inpatient specialist capacity using case mix index (CMI) and DRG numbers according to BJ-DRG grouping method. Each MDC of the hospital is divided into four types according to the status and development of inpatient specialist capacity. Results Of the 19 MDCs, 2 (such as nervous system disease) fall into type 1, 6 MDCs (such as neck, ears, nose, mouth, pharynx disease and dysfunction) into type 2, while 5 MDCs (such as female reproductive system diseases and dysfunction) into type 3, and 6 MDCs (such as pregnancy, childbirth and postpartum) into type 4. Conclusion Most of the MDC inpatient specialist capacities of the hospital in question are at ranking high in Beijing, and such capacities for various MDC can be improved by all means. Key words: Clinical specialties; Medical capacity; DRGs

Use of a capacity audit tool in a mental health setting.

This paper reports on a pilot applying the capacity audit tool (CAT) in a mental health environment and what the tool reveals regarding mental health in-patient capacity issues. The CAT was modified to create an electronic mental health-relevant tool to audit acute in-patient capacity. This tool was then piloted across nine bedded units, within a single Local Health Network, covering a total of 153 mental health beds. The application of the mental health CAT resulted in 100% compliance in completion. The findings revealed that 16% (25 beds) of the 153 beds surveyed were occupied by patients who did not need to occupy the bed or the bed was vacant. Of these 25 beds, 10 had patients awaiting transfer to another facility or service, nine were empty and six were occupied by patients ready for discharge but for whom there were delays. The CAT was successfully applied to the mental health setting and identified a set of opportunities to improve processes and practices to reduce the identified delays or barriers in order to improve patient flow.

"Boarding" Psychiatric Patients in Emergency Rooms: One Court Says "No More".

"Boarding" involuntary psychiatric patients in medical emergency rooms is common in many parts of the United States. The practice, driven by a shortage of alternative resources, including limited inpatient capacity, can result in patients' being held for days without treatment or a hospital room, often in busy corridors or treatment rooms. A recent challenge to this practice led the Washington Supreme Court to declare it illegal and resulted in the appropriation of substantial funding to create new psychiatric beds. Centralized psychiatric crisis services, with appropriate payment models, may offer another approach to reducing the need for holding patients awaiting inpatient admission.

Is “boarding” appropriate to help reduce crowding in emergency departments?

Moving patients from full emergency departments to corridors outside full wards is safe and necessary when accommodating new emergencies, say Adrian Boyle and Peter Viccellio . But Chris Whale warns...

A study of New York City obstetrics units demonstrates the potential for reducing hospital inpatient capacity.

Hospitals are under significant pressure from payers to reduce costs. The single largest fixed cost for a hospital is inpatient beds, yet there is significant variation in hospital capacity utilization. We study bed capacity in New York City hospital obstetrics units and find that while many hospitals have an insufficient number of beds to provide timely access to care, overall there is significant excess capacity. Our findings, coupled with current demographic and clinical practice trends, indicate that a large fraction of obstetrics units nationwide could likely reduce their bed capacity while assuring timely access to care, resulting in large savings in capital and staffing costs. Given emerging health care delivery and payment models that will likely decrease demand for other types of hospital beds, our study suggests that data-based methodologies should be used by hospitals and policy makers to identify opportunities for reducing excess bed capacity in other inpatient units as well.

A Multidisciplinary Care Pathway Significantly Increases the Number of Early Morning Discharges in a Large Academic Medical Center

In an environment where there is increased demand for hospital beds, it is important that inpatient flow from admission to treatment to discharge is optimized. Among the many drivers that impact efficient patient throughput is an effective and timely discharge process. Early morning discharge helps align inpatient capacity with clinical demand, thereby avoiding gridlock that adversely affects scheduled surgical procedures, diagnostic procedures, and therapies. At our large, academic medical center, we hypothesized that an interdisciplinary approach to scheduled discharge order entry would increase the percentage of discharges occurring before 11:00 AM and improve overall discharge time. The pilot study involved moving rate-limiting steps to earlier in the discharge process, specifically medication reconciliation to the night before discharge and "discharge to home" order entry before 9:00 AM the morning of discharge. The baseline rate of discharges before 11:00 AM was 8% and significantly increased to 11% after the intervention (P = .02). Moreover, in the subset of patients (21%) for whom early medication reconciliation and discharge to home order entry were both executed, the percentage of patient discharges occurring before 11:00 AM increased to 29.7%, with an associated average discharge time of more than 3 hours earlier. No patient harm events were associated with this pilot project. There was no significant change in length of stay, and 30-day readmission rate improved significantly from 13.8% to 10.3% (P = .002). Our study demonstrates that a multidisciplinary approach using prescribed order entry and medication reconciliation is a low cost, safe, and effective way to increase early morning discharges and improve patient flow for large hospitals with high volumes of scheduled patient admissions.

Whiteboards and discharge traffic lights: visual management in acute care.

Flinders Medical Centre was experiencing issues with timely discharge and knowing the potential discharges and in-patient bed capacity for the next day. This case study describes the application of 'visual management' theory to discharge processes. The solutions developed were 'patient journey boards' and 'discharge traffic lights'. The implementation of these visual management systems has enabled the hospital to improve its discharge processes.

Optimization of ambulatory monitoring of patients with heart failure using telecardiology (OSICAT)

Summary Background The prevalence of heart failure has been steadily increasing over the past twenty years. It is the first cause of unplanned hospitalizations for patients aged 60 years and older in France, and contributes to the congestion of emergency departments. The economic burden of heart failure is increasing, emphasizing the importance of developing ambulatory care and prevention strategies. Methods OSICAT is a prospective, randomized, controlled, multicenter trial for patients with chronic heart failure, developed in the South of France. The telecardiology program involves a daily scale assessment, a device asking the patients daily questions on the symptoms associated with their heart failure, and regular telephone calls made by nurses. All-cause mortality and hospitalization will be assessed at six, 12 and 18 months in the two groups. A cost-utility study will be performed. The economic analysis will adopt the healthcare payer's perspective and will take into account direct costs, indirect costs and informal care costs. The study will evaluate social and organizational acceptability. Results The first results of the OSICAT trial are expected in 2015. Discussion A combination of both the constant increase in heart failure prevalence and the downsizing of acute hospital inpatient capacity requires the development of outpatient support programs. More and more evidence emphasizes the effectiveness of comprehensive, multidisciplinary, coordinated heart failure patient care, including patient education. This can reduce mortality and incidence of all-cause hospitalizations. However, recent data from the literature shows conflicting results. A new trial is therefore required to provide consistent answers. Conclusion OSICAT hopes to clarify these uncertainties. The project will facilitate home stay for patients with guarantees of care quality and security, prevent isolation, and widespread education of heart failure patients.