Friday, February 15, 2013

It Should Be Easy to Move an Admitted Patient from the ED to a Floor Bed….Shouldn’t it?

This week a Team of GBMC people spent 5 days studying our system from when a patient is first seen by an Emergency Department physician until those that need to be admitted to the hospital are actually in an inpatient bed.

The Team was chartered because we identified this as a strategic opportunity for improvement when we created our operating plan for this fiscal year. We set a goal for ourselves to reduce the average time from when a patient arrives in the ED until they are in an inpatient bed from 8.5 to 6.8 hours… a reduction of 20 percent. 

GBMC HealthCare set this goal because our patients get very upset when they are still in the Emergency Department long after they have been told that they need to be admitted. This is no surprise. Almost every adult has accompanied at least one family member who has waited in some ED to be moved to an inpatient bed. If we don’t want this for our own loved one, no one should wait. Not to mention the cost to our system of extra staffing and foregone admissions when other people leave our ED and go somewhere else for care.

The Team included doctors and nurses from the ED, hospitalists and inpatient nurses, secretaries and people from many support services. Their mentor was Neil Crockett from Next Level Partners and they were aided by a number of our Performance Improvement Masters. After getting some training, the team set out to study the current processes. They went to the ED and the inpatient floors and watched them and documented the way they were doing things. The Team identified 89 sources of unnecessary variation and waste.

They were amazed that for almost every step that they studied, each person doing a task was doing it differently.  They then identified 56 actions that they could take to redesign the processes within the system.  The Team then divided these actions into things that they could change right away: “Just do it’s”, things that they could test immediately (trystorming), and more complicated things that could be changed over time. They immediately implemented the “just do it’s” and began implementing the things that seemed to work in the “trystorms”.

I went to the final Team report today and was amazed at how much they had accomplished. Every team member had a greater understanding of how the other team members were doing their job and how complex the system of admitting a patient from the ED actually is.

There is a lot of work to be done to redesign healthcare in our country and in the GBMC system. When we talk about delivering better health, better care, and lower cost, the uninitiated believe that this means more work for those providing the care. It is only when they develop the deeper knowledge of what is going on in our existing system that they see that a lot of what they are doing is not really benefiting anyone and if they do the work of redesign, they will accomplish better health and better care with less work.
It was really exciting to see that this was one of the learnings from the Team’s efforts this week. I am awed by what they accomplished and am more excited than ever about the transformation of the GBMC HealthCare system. 


  1. Its funny you wrote about this cause our hospital(on a much smaller scale)is in the process of looking into the same things and I have honestly learned a lot about other departments and their processes. I am a Financial Counselor and it was important for me ecspecially after they go to a bed because sometimes we have the problem of patients being obs to an inpatient and then back to an obs is very time consuming when calling to get the auths and then having to call insurance companies back to cancel the inpatient admission. So yes it affects every department in one way or another..Thanks for posting..Berlin, MD

  2. I am glad the hospital is concerned with getting patients into a bed from the ED in a timely manner, but we also need to be concerned about the inpatient units that are getting slammed with 5, 6, and 7 admissions from the ED, at, what always seems to be at the change of shift between 7-8am or 7p-8p. It is not only inconsiderate to the staff, but to the patient as well. The entire process, as it may be improving time wise, is not improving the care of the patient overall. Patients are thrown into inpatient units, soiled, with non working iv's, and diagnostic testing to be done. It's like starting all over and it is frustrating to the patient. There is no communication between the ED and inpatient units. It is unsafe! The system of "report is in the computer" has many downfalls, primarily because there is not one standardized report. Inpatient is doing bedside reporting, why can't the ED have a standardized information form, that they are required to discuss with the receiving nurse? The majoirty of the time, the person calling to say "report is in the computer" is not the nurse caring for the patient, if they are even a nurse at all. Patients are constantly being admitted to medical units, and being upgraded within hours, which is a waste of everyone's time and resources. The process may make the ED look like they are improving because they are getting the patients beds faster, but it is making the inpatient units look horrible.

    1. While the floors may be getting 5,6 or 7 admissions from the ED remember the ED can be getting at least that many patients or more. We in the ED can not say well that nurse is busy or she is at lunch we can't take a patient. Not to mention our patients can be coming by ambulance as well as through the front door. The patients we get are usually unstable and many times are soiled those that come through the front door do not come with an IV in place and do not arrive with all thier testing done. Even some of our ambulance patients do not arrive with working IV's and they definately do not arrive with thier testing already done for us. You may want to slam the ED but I can gaurantee you that the majority of your patients arrive to you with working IV's, tests done, foleys in place and stabalized. They do not come through our front door that way. I don't know where you work but the majority of our patient's do not get upgraded after arrival to the floor. Maybe your admitting doctors need to better evaluate and care for the patients. The ED does not chose thier room or care level. The ED summary is in our computer system and it has every bit of information we have on the patient. We do require the floor to read it and familiarize themselves with the patient and call with any questions. There is no need to receive a full report that is already available to them. We are happy to answer questions and clarify anything for you but there is no need for a full drawn out report. Maybe if the floors had not continually given excuses not to take report it wouldn't have come to a written report. As far as change of shift we can't control when our patients walk in, we can't say sorry we are changing shift can't come through the front door or hey you have to wait on the ramp with that ambulance it is change of shift. We can not control when the docotor writes the orders or when we get our room number from admissions. I worked on med surg for many years before going to the ED. You should try going to see what the other side looks like. I know I have missed a lot more meal breaks as an ER nurse then I ever did on med surg. As far as what is best for the patient try laying on our stretchers for hours on end and see how comfortable it is, esp if you have a broken hip. What if it were your family would you want them laying on an ER strethcer for hours on end?

    2. To the two "Anonymous" responders above:

      Thanks for taking the time to write. Both this blog, and the one on inpatient rounding are talking about our initiatives to design systems to get rid of wasteful steps that make it hard for our clinicians to care for patients.

      You are both frustrated because our processes are letting you down. What the physicians and nurses from both the ED and the floors learn at the Kaizens is how little they know about the others' work and how much extra work they create for the other even if their actions are well-intentioned. When we design the new processes collaboratively, it gets better for everyone.

      We want to get away from batching of all kinds. I agree that it is very hard for nurses to admit multiple patients at once. I also agree that "one way" report without the opportunity for dialogue between the sender and the receiver of the patient is not optimal. I also agree that it is unfair to leave the Emergency Department overwhelmed with patients.

      The Team is working to have patients come to the floor one at a time over the course of the day and to improve communication between caregivers. The new design must make it easier for both the Emergency Department and the floors to take care of the patients.

      Please avoid "blaming" the other side. What I see is very hard working people who are trying to do the right thing for the patient.

      If you have questions, please seek out someone who is on the redesign team. Thanks,


  3. Sounds like a great use of shared governance!

  4. As an ED RN, I can also say that I am frustrated with the way in which our calls to the admitted units are received. I am amazed that beds become available 30 minutes before change of shift, how long we have to wait at unit 38 for a RN or tech to come and take charge of the pt being transferred. Hearing from all units "I am in isolation. I will call you in 10 minutes", which actually ends up being more like 30. What the admitted units do not understand is that unlike them, we can't stop accepting pt's when our unit is full. We need to flex up when necessary. We work as a team.
    We as a whole need to understand that we all serve a purpose in the care of our pts. No one unit is more important than another. The flow from the ED to each following unit is a path in the care of our pts. The admitted units have to stop feeling that they are being "dumped on" when they get new pts and understand that our acuity is different. We can have any combination of MICU, CCU, TELE and Medical pts at one time all of which may have just come in at the same time. We all need to work as a team and only then can we increase pt and employee satisfaction.

  5. I don't think the intent of either writer was to "slam" anyone, but rather to point out the flaws and need for improvement from all areas. No one is perfect, and most of us have never "walked in the other's shoes." I work on a medical unit. I don't think the ED does a bad job, but I do think things could be improved, as I think the same about my unit. As medical professionals, we are all going to experience times when we are frustrated. We need to remember most of us are here for the patients, and we need to support eachother through the changes our professions are constantly experiencing.

  6. At the end of the day, just as someone stated above, it is EVERYONE'S job to care for patients. Not only does communication and flexibility need to improve between the ED and the floor(s), but we need to better communicate with our patients. That's what hourly rounding is all about. Our patients are usually satisfied with a reasonible explanation of their wait and a warm blanket. They care more about seeing our smiling faces and getting a little reassurance than anything else. Balancing the "waitress" stuff with the nurse stuff is often a challenge, but it isn't impossible.

    I also think it's important to improve the process of giving and receiving report. As an ED nurse, I am often frustrated when I don't receive a good story from EMS or a skilled facility. It's even tougher when patient's are poor historians or cognitively challenged. So I can imagine hearing "Report is in the computer" is maddening. Here's a tip, though, to my friends on the floors; take report the first time I call, if at all possible. Because in ten, twenty, or thirty minutes, I probably have a new ambo who is twice as sick as the patient you're receiving from the ED. In other facilities, you get an 'SBAR' sheet on your fax machine and fifteen minutes later your patient is at the door.

    Throughput is problematic everywhere, guys. Once again, at the end of the day, our jobs are to provide excellent care. That's why our patients bypass all the other hospitals to come to GBMC. If I have an empty bed in the ED, I KNOW it is going to get filled up quick, and I better be ready. Maybe the floors and units should have the same mindset.

  7. As a floor nurse l really appreciate this topic being addressed as l can actually see it affecting our patient satisfaction when they get to the floor.It took me a great effort to unwind the effects of one of my patient waiting in the ED for 12hrs!as she kept saying"is not your fault" and l kept saying is our fault.So,really both of us on the two ends really need to stop blaming each other because we really work hard but rather just be more tuned to how we can make things work better for our patient.

  8. As an ED nurse I pride myself in being able to be a "multidisciplined" employee. I not only care for critical ED patients,but also critical in-patients with their multitude of orders.And yes,I have chosen to do this--- because I love it.Not once in any of the previous comments did I here "I like my job",just blame and finger pointing. Shame on all of you!


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