Alabama Hospital Benefits From Detailed Bed Capacity Management Plan

A patient throughput plan at USA Health University Hospital includes addressing patient safety, efficiency, transitions of care, and discharge processes.

An Alabama-based hospital is benefiting from developing a surge plan to manage inpatient bed capacity before the onset of the coronavirus pandemic.

The efficiency of patient throughput—the inpatient processes and transitions of care from admission to discharge—is a concern at all hospitals. For example, inefficient patient throughput can delay hospital admissions from emergency departments, which leads to emergency room crowding and decreased patient satisfaction.

USA Health University Hospital in Mobile, Alabama, started designing its surge plan in late 2018 and implemented the initiative in March 2019.

"The surge plan provides structure and guidance for how to manage bed capacity. We lacked that structure and guidance when we conducted an assessment prior to designing the surge plan. The surge plan tells us what to do when we are at a certain level of bed capacity," says Sheri Salas, MSN, RN, director of nursing at USA Health University Hospital.

The hospital's analysis of pre-surge plan data from March 2018 to February 2019 and post-surge plan data from March 2019 to March 2020 shows several benefits from the bed capacity management initiative:

• Partial diversion of patients to other hospitals was reduced from 331 hours in the pre-surge plan period to 202 hours in the post-surge plan period (39% decrease)
   
• Emergency department admissions increased from 553 per month in the pre-surge plan period to 713 per month in the post-surge plan period (29% increase)
   
• Hospital admissions increased from 798 per month in the pre-surge plan period to 916 per month in the post-surge plan period (15% increase)
   
• Hospital referral acceptance rate increased from 61% in the pre-surge plan period to 92% in the post-surge plan period (51% increase)
   
• Hospital discharge orders by 11 a.m. increased from 25% in the pre-surge plan period to 30% in the post-surge plan period (20% increase)

The surge plan initiative has been beneficial during the coronavirus pandemic, Salas says. "Just having a surge plan has helped during the pandemic. If we did not have a plan to begin with, we would have been all over the place. Having a plan with daily guidelines to follow has kept us from having to come up with a plan at the last minute."

Surge plan levels

The surge plan created color-coded levels of inpatient bed capacity, ranging from green, yellow, orange, red, and black.

"Green means we are wide open. Within the green level, we have daily practices that keep us in a mode of constantly monitoring and assessing our bed capacity levels. The policy for the green level includes a check list that we monitor several times a day to monitor bed capacity," Salas says.

The intensity of attention to patient throughput escalates along the color-coded scale, she says. "As we move up the levels of bed capacity, there are reminders and guidelines for what to do such as speeding up the cleaning of rooms so patients can be admitted from the emergency department. There are things that you do not want to assume are being done to keep everyone moving and make patient flow efficient."

Black is the direst bed capacity level in the surge plan.

"The black level is what most hospitals would have if they have a diversion plan. The black level is what we call full diversion. It means that we are at full capacity and are unable to take most new patients. If we are at full diversion, most of the area's hospitals are usually at full diversion as well. There has never been a time when we were absolutely unable to take new patients," Salas says.

Key surge plan elements

The implementation and operation of the hospital's surge plan includes six primary components.

1. Training: The first step in implementing the surge plan was training staff, Salas says. "We educated nursing, clinicians, environmental services, transporters, and patient care assistants. We did 'round robin' sessions, where we talked with staff members in person. We provided cards that were tailored to particular roles that told those staff members what to do to support the surge plan on the various color-coded levels."

2. Leadership: The Patient Throughput Committee has led the hospital's surge plan initiative. The panel, which is chaired by the hospital's CMO and is currently meeting monthly, is interdisciplinary. Members of the committee include hospital administrators, hospitalists, nurses, emergency department leadership, operating room staff, post-anesthesia care unit staff, the environmental services director, and the transport director.

"This team meets to discuss our bed capacity status, gaps, and what we need to do to address patient throughput. The committee looks at data and tackles challenges. One of the roles of the committee is to look at the surge plan and to revise it as needed. Especially since the pandemic began, there is always a new challenge to address," she says.

Focal points for the committee include patient safety, efficiency, transitions of care, and discharge processes.

3. Management team for patient throughput: "The Transfer Center is at the core of patient movement and throughput. It is a referral center. It is where patient bed movement happens. What some hospitals call 'house supervisors' work out of that department. We have staff in the Transfer Center who are nurses and paramedics who handle the referral portion of the Transfer Center," Salas says.

The Transfer Center was launched with a few staff members but has grown to about 19 staff members, she says.

4. Daily huddles: "We have a core group that we call our Surge Team that gets together every morning. They go over key points such as patients who need a bed, patients who are potential discharges, and operating room cases. It is a daily huddle regarding bed capacity status. The Surge Team includes our Transfer Center manager, our emergency department director, our operating room and post-anesthesia care unit teams, clinical nurse leaders, and our environmental services director," Salas says.

5. Transitional Care Unit: To reduce emergency department crowding and facilitate inpatient admissions, the hospital has a six-bed Transitional Care Unit. "It is a unit where patients can move from the emergency department until we have discharges throughout the day, then they can move to an inpatient bed. It helps with the patients being more satisfied from moving out of the emergency department," she says.

6. Clinician engagement: The surge plan initiative has boosted clinician engagement, Salas says. "They have been involved in assisting us, giving their input, and working with us on the surge plan and issues related to patient throughput. They are continuing to come to us with new ideas and areas we need to work on."

Related: Coronavirus: Northwell's 10-Step Recipe for Addressing Patient Surges