Bed Assigning Program Improves ED-to-Inpatient Process

Decreasing door-to-floor time in the ED

More than a year ago, Cleveland Clinic challenged the Emergency Departments at its main campus and eight regional hospitals to strive for a door-to-floor time of less than 175 minutes for each patient admitted: Within that time, patients should receive a workup in the Emergency Department (ED) and be admitted as an inpatient. South Pointe Hospital, a 173-bed regional hospital southeast of Cleveland, instituted a new program called “Who’s on Deck” last March to help meet the goal. The program identifies available beds in advance to speed up the bed request process.

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Multidisciplinary group examines ED process

In 2012, South Pointe’s door-to-floor time hovered at around 240 minutes. The hospital put together a multidisciplinary team to review the process. “This is not just a function of the ED,” says Erica Shields, BSN, RN, Nurse Manager for the South Pointe Emergency Department. “There are a lot of other departments in play when moving a patient through the hospital.” The team includes members from the ED, environmental services, lab, radiology, patient access and quality as well as the nursing director and nurse managers from inpatient units.

The group dug into what South Pointe does well when patients are admitted through the ED and what areas need improvement. They divided the process into three parts and drew these conclusions:

  1. The “door-to-doc” front end—South Pointe excels in this area, with patients waiting an average of 11 to 14 minutes to see a physician.
  2. Testing and observation—The team concluded this would be the hardest area to tackle because it’s contingent on how individual physician’s practice, what tests they order, how long they decide to observe patients, etc.
  3. The back end once a decision has been made to admit a patient—“Once a doctor orders a bed, we were still taking an hour to an hour-and-a-half to move that patient upstairs,” says Shields. “What took so long? What could the nurses do to move things along?”

The multidisciplinary team decided to begin its work by improving this last part and created the Who’s on Deck initiative.

How the bed assigning system works

At the beginning of each 7 a.m. and 7 p.m. shift, the nursing operations manager asks each unit to provide a list of the next three available beds on their floor. That information is relayed to the bed booker. When ED places a request, the bed booker has the authority to make a decision based on the list and patient needs. For example, if a patient requires isolation or a bed near the nurse’s station, the bed booker scans the list for an appropriate room. Then the bed booker informs the floor that a new patient will be arriving.

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While the system works well, it’s not without hitches. Sometimes circumstances change with beds provided at the start of a shift. “The challenge is getting the floor to tell us we can’t use 315 bed 2 anymore because they’re swabbing the patient in bed 1 for flu or the patient is in C-diff isolation,” says Sandra Smith, BSN, RN, Nursing Operations Manager at South Pointe.

Smith encourages floors to update their available bed list throughout the day and explains to nurses the importance of reaching the 175-minute door-to-floor objective. She also chips in whenever necessary, even cleaning and prepping beds herself on occasion or reassuring patients in the ED that she is working hard to get their bed ready. “It’s a matter of us all working together because there are going to be some snags,” she says. “But when we’re not rushed for beds on the average day, Who’s on Deck works well.”

Metrics confirm the program’s success

Shields says the initiative improves patient safety. “We never know who’s going to walk through the ED doors,” she says, “Our focus tends to be on the more acute patients, so we need to get others up to the floor where the proper level of care can be initiated.” This is especially important considering that the Emergency Department is the primary entry point for more than 70 percent of inpatient admissions to the hospital.

The initiative also increases patient satisfaction. “No one wants to go to the emergency department because of the wait,” says Smith. “Who’s on Deck decreases that wait time.”

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Finally, the program benefits the ED staff by lessening their patient load. “It helps ensure we decompress the ED as quickly as possible so when an emergency walks in, the floor can give it all our attention and not be focused on patients who are already worked up and waiting for rooms,” says Shields.

Less than a year into the Who’s on Deck bed assigning initiative, the metrics point to its success. South Pointe had its best door-to-floor months in October (225 minutes) and November (215 minutes). While the time increased in December and January, so too did visits to the Emergency Department and in-house census. February numbers trended back down.

Who’s on Deck is one component of a broader initiative to reduce door-to-floor time in South Pointe’s Emergency Department. The nurses have also cut eight to 10 minutes off their nurse-to-nurse report time. Reducing both report time and bed assignment time has led to a 20 percent reduction in overall decision-to-departure time, according to James Bryant, MSN, BSN, RN, CEN, CPEN, CCRN, NEA-BC, Associate Chief Nursing Officer of Emergency Medicine at Cleveland Clinic.

Although South Pointe hasn’t hit the 175-minute goal yet, the regional hospital is the best in the Cleveland Clinic healthcare system and it continues to make great strides.