Reduction of hospital bed cost for inpatient overstay through optimisation of patient flow

Mapping patient flow along the admission-discharge process

Case management (CM) is an evolving department established at Al Hada Armed Forces Hospital, Taif, Saudi Arabia, to enable proper utilisation of hospital resources and to ensure the safe and efficient healthcare delivery to patients.

During 2018, 191 overstayed inpatients were identified with 11 672 overstay days. The CM department traced the process of patient flow from ED admission to discharge from the ward (the CM pathway) (online supplemental figure 1) to determine the bottlenecks of the hospital admission-discharge process. Tracing efforts uncovered multifactorial causes affecting the length of stay of inpatients (online supplemental figure 2). Some were patient related (eg, refusing discharge, undecided family member to whom the patient will be discharged, delay in home modifications); others were related to the healthcare provider (eg, lack of communication with patients, inefficient performance of the multidisciplinary (MD) team, deficient coordination between departments participating in patient care). Also detected were organisational factors (eg, absence of auditing for the admission-discharge process, inefficient discharge planning and/or implementation). Of over 30 reasons explaining inpatient overstay at Al Hada Armed Forces Hospital, 8 were responsible for prolonging the length of stay in 70% of cases (table 1).

Project team

A team was assembled to design and implement the necessary interventions. The team comprised the head of the CM department, a Healthcare Risk Management professional, a Continuous Quality Improvement and Patient Safety (CQI and PS) specialist, the head of a clinical department, and a case manager.

The interventions were designed to facilitate the discharge of patients and to reduce the bed costs of inpatient overstay. This was achieved through the implementation and monitoring of hospital policies for the length of stay, redesigning the discharge process, improving early engagement of patients and their families in the care plan, and remapping the patient flow process in the ED and inpatient wards. Overstay days and bed costs were calculated monthly. Twelve units were involved in this project: five medical units, six surgical units and one paediatric unit.

Measures

1. Process measures:

   • This was measured as a percentage of completion of the recommended improvement actions. Data for this measure were observed via the CM monitoring sheet for the action plan.

2. Outcome measures:

   1. ALOS: The average number of days of a single episode of hospitalisation. It is measured by dividing the total number of days stayed by all inpatients during a year by the number of discharges.9

   2. Inpatient overstay days: Total number of inpatient days exceeding 7 days following ED admission with no health-related need for the stay.

   3. Overstay bed costs: The cost of bed utilisation of overstayed days of inpatients in the hospital.

   4. ED boarding time: The duration of holding patients in the ED after the decision is made to admit the patient.

3. Balancing measures:

   • Readmission rate: The percentage of patients with unplanned readmission to the hospital within 30 days of being discharged divided by the total discharges in the same measurement period (excluding patients discharged against medical advice and transferred to other hospitals).

Balancing measures determine whether changes designed to improve patient length of stay were causing new problems in other parts of the system.

For calculating the outcome and balancing measures, data were collected on a weekly basis from the hospital information system (WIPRO) and submitted to the CQI and PS department for analysis.

Interventions

This project used the extension Deming Cycle method: Find-Organise-Clarify-Understand-Study-Plan-Do-Check-Act (PDCA).9 Solutions were implemented through three PDCA cycles (first, second and third phases), each consisting of 6 months, with 1 month intervals in between, conducted between January 2019 and July 2020 (online supplemental figure 3).

The improvement solutions comprised six axes (table 2):

1. Improving early patient and family involvement in healthcare delivery and the discharge process through:

   1. Providing an educational booklet published by the CM department (reviewed and approved by the Health Education department). The booklet covered the nature and prognosis of the disease, the medications administration and their side effects, daily care for bedridden patients, how to transfer patients to and from bed, regular hygiene, early recognition of deteriorating signs and how and when to seek medical advice. The booklet was easy to understand, visually attractive, clear and readable.

   2. Conducting periodic meetings for the families with the MD team.

2. Improving coordination between healthcare providers from different disciplines and focusing on how to address and respond to patient needs and changes in condition in a timely manner.

3. Enhancing the role of case managers in the healthcare process and enforcing their participation in morning rounds with the treating team for real-time recognition of patient status and progress of care and addressing any delays or problems in healthcare.

4. Implementing an MD team approach to monitoring and facilitating patient discharge. The MD team is an independent clinical team, not part of the treating team, which included a physician, a nurse, a social worker, a case manager, a rehabilitation physician and a home healthcare physician. The MD team conducted rounds on daily basis to supervise compliance with patient discharge policy and to help solve any problems facing the treating team and patients and/or their families to facilitate safe pulling of patients either to their homes or to any other suitable level of care facility (eg, rehabilitation, hospice, home healthcare service). The MD team also collected data about patients staying in the hospital for more than 7 days; reviewing individual patient data, fully investigating impediments to discharge, and studying resulting data in aggregate at least monthly for system improvement.

5. Developing an auditing plan to monitor the compliance of staff with the admission and discharge policies and to relay suggestions for improving practice to the concerned departments.

6. Increasing the awareness of clinical and non-clinical staff about admission and discharge policies (see later) through:

   1. Monthly in-service training for all departments about discharge policy.

   2. Hospital-wide educational and training activities for nurses, physicians and other allied healthcare practitioners to illustrate the importance of early discharge planning (including preparing equipment, need for transfer to another healthcare facility, need for nursing care and home healthcare). Staff were trained in how to streamline the process during patient admission (including investigations, consultation and procedures) and how to identify delays during patient admission and take immediate actions.

To improve the admission process through the ED and reduce the ED boarding time, the following interventions were implemented:

1. A gatekeeper was assigned to screen and assess all patients to ensure they meet the criteria of admission.

2. Improving coordination between healthcare providers from different disciplines and focusing on how to address and respond to patient needs and changes in condition in a timely manner thus speeding the treatment plan (ie, follow-up pending investigations, consultations, medications and referrals).

3. Enhancing the role of case managers in the healthcare process and enforcing their participation with the treating team for real-time recognition of patient status and progress of care and addressing any delays or problems in healthcare.

The discharge policy encompassed the following:

1. Early discharge planning should be initiated during the admission with the participation of the patient, the family and the caregiver.

2. All admitted patients must have a documented clinical criteria of discharge (CCD) form with corresponding milestones stating the expected date of discharge within 14 hours of admission.

3. The responsible physician must determine patient readiness for discharge based on the predetermined CCD and the need for continuing care services.

4. The MD team must document the assessment, findings and the plan of care for the patient in the patient medical record.

5. The discharge summary should be completed by one of the physicians in the treating team at discharge and be approved by the responsible physician within 24 hours of discharge.

Safe patient discharge comprised medication review, safe home transfer, home preparation, social support and family education. To ensure the management of proper transition, CM provided advocacy services to meet patient health needs. In collaboration with other treating team members, patients and their families were educated and prepared before discharge. Health educators and social workers were involved in the process of education and home preparation for safe patient discharge. When the patient had any clinical equipment to be used in the home (eg, nasogastric tube, percutaneous endoscopic astrostomy tube, portable mechanical ventilators), the patient and family were educated by the corresponding disciplines as an integral part of discharge planning. The milestones documented in the CCD form were monitored and managed during patient hospitalisation. Moreover, social workers, health educators and the MD team members were involved in the process leading to discharge. CM facilitated emergency medical service (EMS)/MEDIVAC transport, especially bedridden patients, for safe transfer through real-time coordination with the EMS. In case the patient needed assistance at home such as palliative/supportive care, the patient was referred to the home healthcare section affiliated with the hospital.

Analysis

The SPSS (V.26.0, IBM) was used. A p<0.05 was considered statistically significant. Since the data were abnormally distributed as shown by significant Shapiro-Wilk test, non-parametric test (Wilcoxon matched pairs signed-rank test) was applied to compare parameters before and after application of the interventional strategic plan.

Limitations

Several restrictions affected our target to decrease the overstay of all inpatients, including an inability to satisfy post-discharge needs of certain patient populations such as ventilated patients (due to lack of specialised long-term care units that can accept ventilated patients and unavailability of home services due to lack of trained and dedicated healthcare workers in their vicinity) and some haemodialysis patients (due to unavailability of haemodialysis centres for patients living in remote areas). Moreover, physicians raised the topic that population characteristics of Saudi Arabia are different than those of other countries which limited the usability of international definitions and data on length of stay for inpatients, necessitating a national effort to produce standardised definitions and guidelines, which will encourage the engagement of physicians from different clinical specialties towards a unified goal.

Despite encouraging results, our intervention plan still requires follow-up and further research, to examine the sustainability and the long-term impact of interventions. Further efforts are still required before these interventions could be generalised to other hospitals in Saudi Arabia. Generalisation to the outside of Saudi Arabia requires the consideration of logistics and population characteristics of the targeted country.

Patient and public involvement

Patient-related and/or family-related factors were found to remarkably affect the patient admission-discharge process which this project aimed to improve. Therefore, patients and their families were taken into account in designing and implementing the intervention plan and were addressed by several of the solutions introduced along the admission-discharge process.