Patient Flow Discussion: From Community Hospitals to Busy EDs

Editor's Note: Maximizing patient flow is critical to a hospital’s survival in these days of increased demands and decreased revenue. Shaving off average length of stay by as little as one hour could translate to millions of dollars and make or break a hospital. It is better for the patient since they should be in the appropriate unit that can care for them as opposed to an ED gurney or worse yet, in a hallway. Getting patients home sooner, assuming they are ready to go, decreases their exposure to infection in the hospital, and makes them happier. Older patients in particular do better when they are back in their familiar surroundings.

A few months ago, I sat down with some of our clinical leaders to get an idea of the challenges of patient flow and all of the efforts that go into making it work. You can catch up on that blog post here.

They also gave their perspectives on the unique challenges facing small community or rural hospitals versus larger, busier facilities. It may seem like patient flow shouldn’t be an issue in those smaller EDs, but there are some surprising obstacles clinicians face in the single coverage atmosphere. Conversely, big corporate hospitals that have seemingly unlimited resources have their own hurdles to overcome.

Communication Gaps versus Communication Siloes

When shift change happens, there is often a mandatory delay in patient movement, sometimes due to incomplete communication. There is rarely a time when all the shift workers can sit down and brainstorm how to improve patient flow or impediments to patient flow.

In smaller hospitals, “communication is more difficult,” said Dr. Elizabeth James, Director of Emergency Medicine. “You have more Locums providers and independent contractors, and fewer meetings.” When shift change happens in a single coverage ED, there can be a big communication gap if the incoming and outgoing physicians don’t touch base. There is often no one else on each shift who can fill that gap. In these situations, you really have to rely on your site medical director to help fill that gap.

On the other hand, in a busier facility, “you have more people, more patients. Sometimes more is not always better. It’s hard to know the workflow of everyone else,” said Tye Murray, Nurse Liaison. Siloes can form between nurses, physicians, Hospitalists and ED physicians, making communication that much more difficult. This can make bottlenecks in the ED really difficult to remedy. Enter the charge nurse! “A good charge nurse can navigate the flow and know what is going on with everyone,” concluded Tye.

Shortage of Resources versus Competition for Resources

In rural hospitals, clinicians often deal with scarcity of resources. From drugs to labs and tests to equipment, certain resources can be harder to come by. Particularly in single coverage EDs, physicians have to be able to think on their feet and get creative with what they have at their disposal.

On the opposite end, bigger hospitals may have a lot of resources, but they also have a lot more providers competing for them. This can lead to longer wait times and bigger bottlenecks. It can be a challenge to find a balance.

CEO Participation in Patient Flow Meetings

Both Dr. James and Tye were adamant that you can’t have a successful workflow without the hospital CEO’s involvement, no matter the size of the facility. The CEO is such an important participant—he or she should have an idea of the “big picture” of how the hospital functions and can be a valuable resource for brainstorming ideas to optimize patient flow.

This is one of the advantages of the small hospital: the CEO usually has the time to be able to attend patient flow meetings and be more of a stakeholder in the process. When you start moving into larger hospitals, the CEO has so much on his or her plate that it can be difficult to get them engaged on a regular basis. In this case, if the CEO is unable to make patient flow meetings, other top decision makers can step in, but few have the influence of the CEO in changing culture, routine and turf protection.

No matter which hospital you work in, there will always be challenges to patient flow. “There is always an issue no matter where you are,” said Dr. Jeff Myers, System Medical Director at Upper Allegheny Health System. “But there is always a pattern. Find those patterns and staff the pattern.”