Editor’s Note: the following is an excerpt from Dr. Robbin Dick’s forthcoming book on Hospital Capacity Management. Dr. Dick is MEP’s Director of Observation Services. He will be speaking on hospital capacity management and other subjects at MEP’s third annual observation medicine conference, Observation Care ’15.
Bed assignment often sets the pulse for the entire hospital, affecting every patient and every department from minute to minute, yet is often poorly managed.
I have been amazed over the years at how many people desire the position of bed assigner. Nurses, Surgeons, Private internists, Hospitalists, ED providers and even Hospital Administrators at some point in time want to assign beds to patients. They often have no idea, however, how their decisions will affect ED wait times, operating room and cath lab needs, and the flow of non-ED patients throughout the hospital, to name just a few factors that need to be considered. Yet bed assignment has far reaching effects.
Many think that bed assignment is a simple task. In theory it should be. A bed is available and the patient gets assigned. There are certain constraints—sex, semi-private versus private, isolation issues, acuity, telemetry and specialty needs. All need to be taken into account to ensure that each patient goes to the right place and receives the proper care. But good capacity management demands that bed assignment be carefully considered and executed.
Centralize bed assignment authority. All beds need to be assigned by a centralized authority – and no one else. Patients cannot be moved without a reason. Patients cannot be assigned by others. All discharges must quickly and accurately be handed over to environmental services for bed cleaning then immediately handed back to bed assignment.
I can recall an analysis of environmental services staffing on the evening shift. Beds vacated by discharged patients at 5 p.m. weren’t being cleaned until 1 or 2 a.m. All the data said that there was sufficient staffing. Drilling down we discovered that nursing staff had decided to transfer patients from bed to bed, for multiple reasons, without contacting bed assignment. This was being done so frequently that it consumed 1/3 of the environmental staff that was allocated to clean beds for discharged patients. Thus the need for rule 1.
Use Non-clinical staff to do bed assignment. Set the rules and parameters on when and where patients can go and let them do their job. Nurses tend to look through clinical content to assign just the right bed. This wastes time and energy while producing no better results than non-clinical staff. The main reason clinical staff are involved at all is that there is an idea that bed assignment provides a report to the accepting unit. This is not only inappropriate but dangerous since the true clinical status of a patient can rarely be gleaned from reviewing the chart not to mention that care handoffs need to be done by the current care provider (where they are) and the receiving care provider. Bed assignment simply provides the proper location based on specific patient attributes like sex, isolation, telemetry, acuity and specialty needs.
Provide a mechanism of escalation. When problems arise the bed assignment staff need help. Assistance with inadequate telemetry availability, limits on private room use, prevention of patient movement within the hospital all can have a significant impact on bed assignment and timely patient placement.
Provide priorities and establish mechanisms to maintain them. Priorities for bed assignment need to be linked to the needs of the sickest patients in the organization wherever they may be. Those patients requiring ICU level of care whether in the ED, PACU, Floor or another facility needing to transfer the patient would have the highest priority. It has been demonstrated that patients requiring this level of care have a lower mortality rate and suffer the fewest complications the quicker they are placed in the intensive care unit.