Visual cues keep treatment team alert
Executive Summary
At Good Samaritan Medical Center in West Palm Beach, FL, a throughput initiative that uses colored magnets to indicate anticipated discharges has cut emergency department holding time and increased the number of discharges by 2 p.m.
• The charge nurse, case manager, and discharge planner meet daily, make their best clinical guess about the patient’s discharge and place a red, yellow, or green magnet on a white board at the nurses station.
• When team members pass the board, they are alerted to anticipated discharges and know to make patients with a green magnet a priority.
• The case managers and nurses write the expected discharge on a white board in the patient rooms and initiate a discussion with patients and family members to prepare them for discharge.
ED holding time cut by 26%
A program that uses colored magnets on a white board to alert staff to patients’ anticipated discharge dates has decreased the holding time in the emergency department at Good Samaritan Medical Center in West Palm Beach, FL, and increased the number of patients who leave the hospital by 2 p.m.
"We’ve decreased the emergency department holding time by 26% in the first month of the initiative and made progress toward our goal to get patients out by 2 p.m. We still struggle with this because even though we are priming them, family members aren’t always willing to take time off work to pick up patients early in the day," says Debra Brockmeyer, RN, BSN, ACM, director of case management for the 333-bed acute care hospital.
Before the initiative began, patients were staying in the emergency department for long periods of time after the order for admission was issued because the patients on the floor who were scheduled for discharge hadn’t left, Brockmeyer says. "We wanted to streamline throughput from the emergency department to the floor and from the floor and out the door," she adds.
Good Samaritan began the initiative with the help of a consultant who had been brought in to help the hospital improve patient throughput. The case management team took the consultant’s idea and modified it to meet the needs of the hospital.
Each nurses’ station has a magnetic white board with the patients’ last name and room number. Every morning, the charge nurse, case manager, and discharge planner for that unit meet at the nurses’ station, go over every patient one by one, and make their best clinical educated guess about each patient’s discharge status. "We don’t wait for the discharge order. We look at the clinical indicators and make a judgment as clinicians when the patient is likely to be discharged," she says.
Physicians often are at the nurses’ station documenting in the electronic medical record when the team is reviewing the potential discharges. "If the physicians are available, the team can ask questions. It’s an added benefit but we don’t count on it," Brockmeyer says.
If a patient is likely to be discharged within 24 hours, the team places a green magnet on the name. A yellow magnet means they believe the patient is two days away from a possible discharge. Red indicates that discharge is likely to be more than two days away.
A fourth magnet is white with "DC" written on it and is used when there is an order for discharge.
"People aren’t looking at the electronic medical records all the time, so they don’t see discharge orders the minute they are issued. This is a way for the nurses to rapidly identify patients who are likely to move out that day and have everything ready when the physician issues the order. It’s a way of communicating to everyone on the team what the expectation is," Brockmeyer says.
The nurses on the floor pass the board frequently and are aware of when patients are expected to be discharged. When the nursing staff know a patient is likely to be discharged the next day, they can alert family members when they visit in the evening after work. The night staff work on the paperwork the night before and everything is ready when the physician puts in the electronic order.
Case management and nursing are responsible for ensuring that whatever is on the board at the nurses’ station matches the information on the white board in the patient’s room.
"We don’t write the exact date. We write that discharge is expected within so many days. When we first talked about the initiative with physicians, they said they felt more comfortable if we were more tentative about the discharge time," she says.
When the nurses or case managers write the discharge information on the white board in the patient’s room, it usually prompts a discussion with the patient about discharge plans.
"The whole purpose of writing the anticipated discharge in the patient rooms is to get the patient and family thinking that they aren’t going to be here forever. Everybody on the staff knows that if the magnet is yellow, that patient’s discharge is two days away, barring unusual circumstances, and the case managers and nurses know to start alerting the family," she says.
The care team starts discussing discharge plans early in the stay, but the yellow magnet indicates that there is some urgency, Brockmeyer says. "If patients are not going home, we try to get the family to choose a facility and get the choice letters signed. It gives us a window to get the decisions made and the plans in place," she says.
The boards are also useful for ancillary staff such as physical therapists and occupational therapists. "When they come on the floor, they can see the board and prioritize their time with patients. If the magnet is green, they know the patient potentially could be discharged and they can see this patient first," she says.
Patients on the floor who are receiving observation services automatically get a green magnet. "The expectation is that observation patients will be discharged within 24 hours and a maximum of 48 hours. When patients are not being discharged, we talk to the physician to find out if it is appropriate to admit them," she says.
