NR 532 Week 3 Patient Flow Analysis Example

Patient Flow Analysis: Four Weeks of Timestamps on a Spine Unit, the Hours Between a Discharge Order and an Empty Bed, and the Arithmetic That Turns Two Earlier Hours Into Room for the Afternoon's Surgical Arrivals

Student Name

College of Nursing, Chamberlain University

NR 532: Healthcare Operational Planning and Management

Instructor Name

Month Day, Year

Patient Flow Analysis: Four Weeks of Timestamps on a Spine Unit, the Hours Between a Discharge Order and an Empty Bed, and the Arithmetic That Turns Two Earlier Hours Into Room for the Afternoon's Surgical Arrivals

Question

On Tuesday through Thursday afternoons, patients finishing elective spine surgery wait in the recovery unit for a bed on our spine and neurosurgery floor. Over the last quarter, an average of 1.8 patients a day on those days waited more than an hour, with a median wait of 2.3 hours. At the same time, the unit's midnight census on those days averaged about 20, which suggests spare beds. This analysis asks where the beds were when those patients needed them. It follows each bed through discharge, cleaning and the next arrival, using timestamps rather than impressions.

Data

For four weeks, I collected five timestamps for every discharge from the unit: the discharge order, the patient's departure, the bed marked clean, the next patient assigned and the next patient's arrival. The electronic record supplied all but one of these; the bed-cleaned time came from the environmental services tracking system. There were 128 discharges. For departures, I also recorded the main reason for any wait of more than two hours after the order, taken from nursing notes and a short question to the discharging nurse.

What the Timestamps Show

Table 1 summarizes the timings, split into midweek and the rest of the week, because the unit behaves differently in each.

Table 1

Discharge and Bed Turnaround Timings, Four Weeks, 128 Discharges

Reading the Midweek Pattern

The midweek problem is timing, not supply. Discharge orders are written by about 1030, but patients leave at a median of 1520. Most surgical arrivals come from recovery between 1300 and 1900. For the first two to three hours of each midweek afternoon, therefore, the unit has beds that are occupied by patients who are medically ready to leave, while new patients wait in recovery. The beds do turn over, with a median empty time of 2 hours and 40 minutes, but they turn over too late in the day.

The reasons for waits longer than two hours after the order, for the 61 midweek discharges that had them, were a ride not yet available (38%), a physical therapy clearance visit not yet done (22%), discharge medications from the outpatient pharmacy not yet delivered (18%), discharge paperwork incomplete (12%) and other reasons (10%). Three of these are within the hospital's control: therapy timing, pharmacy delivery and paperwork together account for 52% of long waits. Rides are harder, but not beyond reach. Many of our patients are driven by a working family member who cannot leave before the end of a shift. When the pickup time is agreed before surgery rather than on the morning of discharge, families can arrange it, and nurses can plan teaching around it instead of rushing it at the door. The other 10% included patients who became unwell after the order was written, which is appropriate and should not be counted as delay.

Reading the Weekend Pattern

From Friday through Monday the pattern reverses. Beds empty earlier, but there are few elective arrivals to fill them, so the median bed stays empty for about fifteen hours. A bed that empties at 1600 on Friday may not receive a patient until Monday afternoon. These are the idle hours no report shows, and they explain why the midnight census looks spare. They are not wasted by the unit. They are created by the operating room schedule, which concentrates elective surgery midweek, a source of artificial variability that hospitals can reduce by smoothing the elective schedule (Litvak & Fineberg, 2013).

Turning Hours Into Capacity

The arithmetic for the midweek afternoon is straightforward. The unit has about 20 midweek discharges a week. If the median time from order to departure fell by two hours, from 1520 to about 1320, the unit would gain about 40 bed-hours a week, all of them in the three afternoons when recovery holds occur. That is about 13 bed-hours per afternoon, or two to three beds available roughly five hours earlier than now. With an average of 1.8 patients a day waiting more than an hour, those beds would absorb most of the holds.

A two-hour improvement is realistic. One academic medical center that set a goal of discharge before noon saw its before-noon discharges climb from 11% to an average of 38% and moved the average discharge time about an hour and a half earlier in the day (Wertheimer et al., 2014). Our target is narrower: two hours earlier on three days a week, for a single unit.

Occupancy Is Not the Measure

It would be easy to read the unit's 83% average occupancy as a sign that it has room to spare. Simulation work has shown that hospitals begin to see bed shortages when average occupancy exceeds about 85% and regular crises above 90% (Bagust et al., 1999), but an average across the week says little about a unit whose demand peaks on three afternoons. At 1500 on a Wednesday, our effective occupancy is often 100% with patients waiting. The flow analysis replaces the average with the hour that matters.

Recommendations

Physical therapy first. Therapy will see patients scheduled for discharge before 1000, using a list printed by the night charge nurse at 0500.

Medications to the bedside by 1100. The outpatient pharmacy will prepare discharge prescriptions from the evening before, when the surgeon enters an anticipated discharge date.

Paperwork the evening before. Discharge instructions and education will be completed on the evening shift for any patient with an anticipated discharge the next day.

Rides confirmed at admission. Nurses will confirm the ride home and a pickup time at the preoperative visit and again the evening before discharge.

Measure. The same five timestamps will be tracked weekly, with midweek order-to-departure time and recovery holds reported to the staff and to the perioperative director. If holds persist after the median departure moves before 1400, the next step is the block schedule, not the unit. The measures will be shared at the unit's monthly staff meeting as well, because the changes ask nurses, therapists and pharmacists to work in a different order, and people keep a new routine more readily when they can see what it produced. The first report will compare the four weeks after the changes with the four weeks studied here, using the same timestamps and the same split between midweek and the rest of the week.

References

Bagust, A., Place, M., & Posnett, J. W. (1999). Dynamics of bed use in accommodating emergency admissions: Stochastic simulation model. BMJ, 319(7203), 155-158. https://doi.org/10.1136/bmj.319.7203.155

Litvak, E., & Fineberg, H. V. (2013). Smoothing the way to high quality, safety, and economy. New England Journal of Medicine, 369(17), 1581-1583. https://doi.org/10.1056/NEJMp1307699

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154