Our industry has been struggling with decreased inpatient capacity for a number of years. With varying degrees of success, many hospitals have addressed fluctuations in census demands and Emergency Department (ED) access. According to the latest American Hospital Association (AHA) studies, opportunities for Patient Throughput improvement continue to exist and, although those studies were conducted in 2005, there is every reason to believe the same is true today.

This would suggest that just like the Revenue Cycle itself, managing Patient Throughput is worthy of dedicated resources charged with continually improving the management of patient volume demands. According to the AHA report, ED visits nationwide have increased by approximately ten percent since 2000, while the number of hospital EDs has declined by approximately eleven percent since then. During the same time period, the study shows that inpatient admissions have increased by approximately eight percent. Based on this data, it is not surprising that 48 percent of all hospitals reporting ranked their ED as either "at or over" capacity, while 40 percent of all hospitals reported being on Ambulance Diversion in the last twelve months.

The opportunity to improve Patient Throughput presents itself concurrently with the persistent reimbursement challenges from third party payers and the federal government, underscoring the imperative to streamline operations and control costs. As an example, the CMS final rule on Medicare discharge notice policy will necessitate some operational adjustments to ensure compliance.

While significantly less burdensome than what the agency had proposed last April, this new CMS regulation that becomes effective on July 1, 2007, will require hospitals to issue the Important Message from Medicare (IM) notice to beneficiaries within two days of admission, answer any questions, obtain the signatures of patients or their representatives on the notice, and provide the beneficiary with a copy of the notice. The operational challenge resulting from this regulation occurs if the hospital secures the signature more than two days prior to discharge, in which case another copy of the original IM must be presented to the beneficiary before discharge. Case Management/Discharge Planning time required to manage this new requirement could pull resources from other activities and impact the overall timeliness of patient discharges.

Ultimately, hospitals who best manage peak census periods, variations in patient volume, and the challenges of third party payers and the federal government will gain a competitive edge and position themselves to reap the potential benefits associated with increasing market share.

POTENTIAL SOLUTIONS
Investigate alternative treatment sites and methodologies for designated DRG's Identify high-volume DRGs reporting to your ED in conjunction with the average length of time it takes to treat the DRG from patient triage/assessment until final disposition. For example, if you find that the chief patient complaint "Chest Pain" presents to your ED an average of eight times per day and the average treatment time period for Chest Pain in the ED is six hours, then the equivalent of two ED treatment rooms are continuously occupied to manage Chest Pain patients (8 x 6 = 48 total hours of care per day divided by 24 hours per day = 2 treatment rooms). If you maintain an ED with twenty treatment rooms, Chest Pain patients would account for ten percent of your ED capacity. In this example, a significant opportunity exists to increase ED throughput by managing the Chest Pain patient population differently.

One of the most common alternative treatment sites and methodologies is the Rapid Cardiac Diagnostic Center concept to manage low-risk Chest Pain patients presenting to the ED. Patients are initially assessed in the ED and, based on meeting clinically established low-risk Chest Pain protocols, moved to an alternate outpatient setting within the hospital to be managed through the battery of diagnostic testing and clinical evaluations required to determine the patient's final disposition. The Society for Chest Pain Centers offers accreditation based on meeting stringent clinical requirements and hospitals have demonstrated that a dedicated Chest Pain treatment center can lead to better clinical patient outcomes.

Manage Length of Stay (LOS) reduction opportunities "from the beginning" Case Management review of all adult medical/surgical and telemetry patients 'prior to admission can significantly contribute to LOS reduction, while helping ensure patients are managed in the most appropriate setting (based on patient clinical needs, in conjunction with third party payer requirements, and in consideration of limited human and facility resources). This also ensures that a Treatment Plan, including Discharge Planning, is "in progress" at the time of admission. While there are numerous considerations involved in making this concept work, the key element to success is that Case Management provides 24 / 7 support to the ED and Admitting/Bed Management.

Reducing LOS equates to adding available beds, due to improved bed turnaround time. One of our Midwest client hospitals (400 + beds) recently embarked on an aggressive LOS reduction effort resulting in a .5 day average LOS reduction over a six-month time period. During the same six-month period, average ED bypass went down by 67 percent, ED LWOTs (left without treatment) decreased by 50 percent, ED visits increased by 10 percent and inpatient admissions increased by two percent.

Explore new technology and mobile communication devices
The effective use of technology continues to be a critical factor in efforts to better manage Patient Throughput. Technology that embraces the strategy of bringing patient orders, results, alerts, and related caregiver coordination via a single mobile device can minimize delays in decision-making and impact timely delivery of patient care. Cumulatively, more timely communications, decision-making, and care delivery can favorably impact clinical outcomes while minimizing administrative patient care delays. The combined effect can lead to reduced LOS and improved bed turnaround time.

Physician response time and decision-making can be enhanced through Portal Technology; a webbased service that affords physicians and their designated office staff members real-time access to patient diagnostic testing results, interpretive consultant reports, and on-line viewing of radiological images or EKG strip review. Portal technology may be of particular interest or relevance to those facilities not currently planning or working toward implementation of CPOE (computerized physician order entry).

Develop an ED Dashboard
Collecting data to measure the time lag existing in patient process steps can begin to clarify the opportunities for reducing variability and service delays negatively impacting Patient Throughput.

The ED often gets a "bad rap" for service delays when, in actuality, those delays are created by or exacerbated by ancillary or support departments within the hospital. Without objective time-lag data, finger-pointing rules the day and minimal progress towards improving process steps is realized.

For example, do you know your average ED wait times from "request for inpatient bed" to "bed assignment given?" In many large and busy hospitals, the average delay can easily be two hours or more. Drill down further and determine the lag time between "bed assignment given" and "patient transported to the bed". The myriad of potential delays is astounding and involves no less than ten other employees and/or departments. That's a lot of opportunity for things to go wrong! If your average delay is currently two hours and you admit 12 patients per day through your ED, one of your treatment rooms is unavailable 24 hours daily. If you are able to reduce this average delay to one hour, that would be a 50 percent reduction, effectively opening one ED treatment room for 12 hours daily. If your average LOS in the ED is two hours, that opens a room for as many as six additional patients daily which, in turn, could significantly reduce your LWOTs and minimize lost admissions.

SUCCESS IS ATTAINABLE AND THE PURSUIT IS NEVER-ENDING
Constantly assessing and reassessing Patient Throughput opportunities continues to open new doors to improvements and success stories. The process should be continuous and the organizational commitment unquestioned. Effectively managing Patient Throughput, like managing the Revenue Cycle, is becoming an agenda item healthcare leaders cannot afford to ignore.

IMA Consulting is pleased to have the opportunity to provide this information to you. If you have any questions, need assistance with the assessment of Patient Throughput opportunities, or help evaluating your current Patient Throughput efforts and use of Technology support, please do not hesitate to contact me at 610-517-1386.

Yours very truly,
Kim Hollingsworth, Principal
IMA Consulting