The dynamics of patient flow are an important component in the overall success of any inpatient or outpatient unit. Patient safety, hospital revenue, staff satisfaction, and patient satisfaction are all negatively impacted when patient flow is stagnated or interrupted. Variables that are taken into account when looking at the dynamics of patient flow in an inpatient or outpatient setting include: the patient census, a staff nurse, a technician, and physician support. Also, the physical layout of the unit can inhibit efficient flow.
On Aug. 23-24, 2007, the new endoscopy lab opened at the Tennessee Valley Healthcare System in Nashville, Tenn. When the lab was designed years ago, patient flow and efficiency was a big factor in the equation. Our new lab is both patient- and staff-friendly, and includes four endoscopy suites and six recovery rooms. Each room is stocked to service virtually any type of case, with the exception of the moderate sedation medications, which are kept in our Pyxis in a centralized location.
The plans included individual workstations for the nurses, GI technicians, and the physicians. A supply storage area was also placed between the endo suites for easy access. A set of patient bathrooms are located between the endo suites and the recovery room areas. Finally, when a patient has been fully recovered, he or she is escorted back to the reception area through a side door. These plans were designed with efficient patient flow in mind.
As the nurse manager of the gastroenterology and bronchoscopy labs at the Tennessee Valley Healthcare System in Nashville, Tenn., I realize that the dynamics of patient flow are integral when staffing nurses and technicians for our unit. Nurses and technicians are staffed Monday through Friday from 7:00 a.m. to 4:00 p.m. to support patient needs during their procedures. Patient census must be considered when staffing nurses. On a high-volume day, six to seven nurses are staffed in our GI lab. The seventh nurse serves as a "flow" to the bronchoscopy lab and assists in endoscopic retrograde cholangiopancreatographies (ERCPs). The charge nurse directs the flow of patient care in the unit in most cases. He or she keeps abreast of add-ons and cancellations and assigns staff to cover specific areas in the labs as needed. All staff must take an active part from the moment the consult is written by the nurse practitioner or physician to the moment when the patient is being scheduled by the clerk. We see an average of 20 patients each day. Of course, there are variables that may cause this census to fluctuate. Adequate staff support is just one variable.
The efficiency of patient flow does not start when the patient arrives on the date of his/her procedure, but at the time the consult is written. If the patient is an outpatient, which accounts for approximately 85 percent of the patients we see in the GI lab, the clerk mails the scheduled appointment date and time. The instructions that are mailed to the outpatients include a hospital policy regarding the requirement that a driver consent to transporting the patient following the procedure if he or she has received medication for sedation. By including this information, all parties are aware of what is expected on the day of the procedure. This also aids in effective patient flow. Effective communication from our department to the patient and family is very important when moving the patient through this process, especially if it is his or her first encounter.
Strategies for Effective Patient Flow – Inpatient and Outpatient Resources
Having sufficient resources is a key element is keeping the flow constant. The staff must have all of the supplies for patient care on hand. For instance, in the endo suites, we have storage carts on wheels that the nurses keep stocked with IV start kits, IV catheters, saline flushes, standard 2 x 2s, tape, etc. C-lockers are located in each endo suite to house a moderate supply of linen. Each endo suite and recovery room has needle and glove boxes strategically placed so that they are easily accessed by the nurses and technicians.
The physical layout of the work area can increase productivity or hamper patient flow. Patient prep areas and procedure rooms should be easily accessible to patients from the reception area. For the patient’s convenience, bathrooms are available in the endoscopy lab and in the general reception area.
In our GI lab, a prep station was initiated by one of the nurses in the lab. The nurse uses a room in the recovery area to bring the patient back into the lab, take an initial assessment, give them instructions as to where to place their clothing and personal items, and gain IV access. Once the preliminaries are done, the patient is ready to be seen by the physician. The next step is the signing of the electronic consent. During this time, the physician explains in detail the procedure that is to be done and gives the patient an idea of expected outcomes following the procedure.
The technicians play a major role in the entire process. Prior to each procedure, the technician sets up the scopes and lays out supplies that are essential to the completion of the various procedures. When all of the medical professionals are in place, the paperwork has been done, and the endo suite has been set up, everything is ready. This preparation helps to ensure a smooth flow during the procedure.
Once the case is completed, the turnover of the endo suite is crucial to continued patient flow. The nurse then takes the patient to the recovery area, where he or she is monitored and stabilized for an additional 20-30 minutes. Once the patient is stable, discharge instructions are given and the patient is discharged home or back to the appropriate inpatient area. The flow continues from one patient to the next, until all the patients on the schedule have been seen. This method of processing patients has proven to be very effective in keeping the patients flowing through the GI lab in a timely manner.
Effective case management is also a key component in moving the patient through his or her inpatient hospitalization course of stay. Transfer coordinators assist in the determination of patient placement within the medical center. Each case must be handled differently, taking into consideration what is actually going on with the patient. Discharge planning begins at admission. Once the determination has been made that the patient is appropriate for admission and has been placed, the assumption as to outpatient care needs are made by the designated social worker, nurse, or medical affiliate.
Several things may be taken into consideration during this process
- the patient’s past medical history
- socio-economic status, and
- estimated length of stay based on the hospital Quality Management Department’s certifying criteria, for example, Milliman and Robertson1 or InterQual®2.
Once the patient has a plan for care that has been established, he or she must be reviewed for continued inpatient stay. The case reviewer must be comfortable making recommendations to the interdisciplinary team regarding the patient’s care. These recommendations become key in moving the patient along his or her hospital course. In order to keep patient flow moving and turn the beds over in an appropriate amount of time, the reviewer must determine whether the patient meets continued stay guidelines. Continued stay guidelines may differ depending upon the criteria used, for example, Milliman and Robertson, InterQual® or independent criteria. The nurse must keep in mind that these are only guidelines and that they do not substitute or supplement sound clinical judgment. Each case must be reviewed individually with the patient’s current, past, and present medical history taken into consideration. Not only is patient flow and efficiency important for patient satisfaction, it is also cost effective for the hospital. Inpatient bed days are viewed in days per $1,000. The goal is to keep the inpatient days as low as possible, and by doing so, the hospital is losing less revenue. However, when the utilization review nurse is evaluating a length of stay, he or she must be careful to assure that the patient’s medical needs are being addressed and met.
Communications among the patients, nurses, technicians, physicians, and clerks is important in moving the patient forward through procedures and to recovery. Patient compliance with taking preparations for endoscopy procedures and following through with recommended diets helps to ensure visualization and, in most cases, completing the procedure in a timely manner. Patient teaching is needed in virtually every case regarding the procedure and what is to be expected during the recovery process. Some barriers in communication in this setting may include sensory or cognitive deficits or the patient’s lack of a telephone or valid address. The latter barrier may even result in a delay in a patient receiving care. Among staff and physicians, communications prior to and during a procedure set the tone for timely case completion. Physicians communicate the drug and dosage to be administered for the patient to the nurse when starting the moderate sedation process and during the procedure. The case then moves right along. Once the procedure is completed, the patient is taken to the recovery room and a belief report is given to the receiving nurse. The endoscopy suite is then prepared for the next case.
At times when the patient wait times become extensive in the GI lab, patients and their drivers may become disgruntled. In most cases, a patient waiting for an endoscopy procedure has had nothing by mouth, and may have been on a special diet for a couple of days. There is a prep required for the colonoscopies. In many cases, the patients whom we see travel long distances ranging from 30-250 miles. Under these circumstances, anxiety may even start to set in, especially if this is his or her first procedure of this type. All of these elements prompt unpleasant events when the wait times are prolonged. It has been my personal experience that if someone talks to the patients and their drivers, they have an appreciation that an effort is being made to deliver the best possible care, and they generally calm down. If the patient can not be appeased, they are given a chance to reschedule their appointment. It is very important to keep the lines of communication open with all parties involved in the care of patients.
In conclusion, patient flow and efficiency plays a major role in patient satisfaction. One of the National Performance Measures when looking at quality of care is the assessment of patient satisfaction. When patients are seen in a timely manner and they feel that they have been handled with care, they report back in a positive way, regardless of the results of their test or procedure.
Key components in efficient patient flow include the physical layout of the hospital or unit, staff support, availability of resources and supplies, movement through the inpatient hospital course in a timely fashion, and effective communication by all parties involved. Whether the setting is an outpatient clinic or inpatient stay, patient flow is of great importance. From the moment of the outpatient appointment to admission to an inpatient unit, patient flow affects various facets of the healthcare system. When an appointment is cancelled or the patient does not show up, lost man-hours spent on the case can be calculated. From an inpatient perspective, patient flow is very important for the patient and the facility. The patient becomes at risk for exposure to nosocomial infections when stays are extended; this may prolong their hospital stay even further.
Another consideration is that the hospital risks the loss of revenue due to the inability to turn the bed over, according to the Diagnostic Related Groups3 (DRG) system. Ultimately, we are looking at patient satisfaction. In the long run, the effectiveness of patient flow and other efficiencies yields quality patient outcomes. No matter the stakeholder—be it local, state or federal government, or private healthcare system—they can all benefit from the strategies of effective patient flow.
Phyllis Ogbode, RN, MSN, is the nurse manager of the GI and bronchoscopy labs at Tennessee Valley Healthcare System in Nashville, Tenn.