The purpose of this study was to describe the developmental process and effects of changes that occurred at our hospital following the implementation of the Patient Tracker software application to solve an important bed management efficiency challenge faced by academic children’s hospitals. Managing patient flow and controlling the discharge process with the software decreased surgical procedure cancellations and ED LOS while the number of inpatient admissions increased. The software system allowed physicians, nurses and care managers to communicate through a single web page using dialog boxes in Patient Tracker. Previously each clinician maintained a separate paper sheet that was not shared. No additional personnel were needed to execute the process.
To maintain a competitive edge, a major focus of hospitals today is to increase bed capacity without the need to build and staff additional beds. Hospitals need strategies to determine and communicate patient’s readiness for discharge, and to improve their ability to track bed availability. Coordination of patient activities is complicated at academic hospitals and requires that efficient communication of various disciplines be in place to minimize delays in admissions, discharges and cancellations of scheduled surgical procedures.
Previous studies have reported that hospital capacity can be increased without the need to build and staff additional beds. More than a decade ago, Clerkin et al.6
developed a decision support tool to improve hospital bed assignment of patients at the time of hospital admission or during the hospital stay. In 2000, Cohen and Martorella7
also implemented a bed availability report to provide relevant information about hospital-wide inpatient activity and facilitate patient placement. Recently, Twanmoh et al.8
reported that ED overcrowding is a critical problem nation-wide. To facilitate patient flow out of their ED, they identified the causes of delays in discharges and admissions, instituted the practice of flagging the charts of patients ready for discharge, and implemented admission orders to decrease patient waiting times.
Our study demonstrated the benefit of using health care information technology (HIT) for efficient hospital bed management. Several factors were critical in the success of Patient Tracker and included the following: 1) administrative support for project prioritization and resources allocation, 2) motivated system improvement/process improvement experts leading the team to design and test a discharge process flow before designing and implementing the software application, 3) local control for rapid cycle software application development, 4) the application required very little training because the user interface was simple and intuitive, 5) the application had labor-saving features that made it attractive to physician users such as a sign-out sheet for residents, hospitalists and subspecialists. Therefore, physicians were eager to use it.
One might reasonably suspect that the reduction in surgical cancellations achieved following the implementation of the software was a simple case of fallen demand. In fact, demand did not fall during this period. The improvement was achieved despite the fact that total hospital admissions rose significantly from 5725 to 6120 during the post implementation period. One might also argue that when hospitals experience inpatient bed shortages, the ED bears the major burden of the problem and patients awaiting admission are forced to remain in the ED for many more hours. However, reduction in the number of cancelled surgical procedures was achieved while the ED LOS during the post-implementation period decreased. This reduction, while small, is statistically significant, and tends to refute the notion that the reduction in cancelled surgical procedures was achieved by delaying admissions from the ED.
Our project plan for the future includes the following items: 1) Roll the software and discharge process out to all physician groups including surgical services to increase utilization to nearly 100% of inpatients. 2) Incorporate Patient Tracker into the existing EMR infrastructure to facilitate access to lab data and clinical notes and to eliminate duplicate documentation. 3) Incorporate alphanumeric paging within the application to further enhance nurse/physician communication and instantaneously notify the medical team whenever nurses identify patients as ready for discharge. 4) Incorporate a discharge check list for critical steps in the final stages of the discharge process. The team anticipates that these enhancements will continue to facilitate efficient use of our limited resources: beds and nursing staff.
Our study has some inherent limitations: 1) due to the nature of the evaluation conducted, we cannot necessarily presume a causal relationship between the software application and the outcomes. We did not implement Patient Tracker
under controlled laboratory conditions. Rather, the software was introduced into a dynamic real-life hospital situation, in which many other confounding factors may have affected the results. These factors could have been accounted for using a randomized controlled trial. 2) Secondary outcomes used in the evaluation have been used in previous studies9,10
of hospital bed management and are indirectly affected by inefficient discharge processes. We believe that, in addition to these outcomes, measuring hospital inpatient LOS would have provided our study with additional information directly related to the hospital discharge process. However, we did not have pre-intervention data identifying patients admitted to a specific medical team for comparison. 3) After achieving significant decrease in the number of cancelled surgical procedures in 2003 following the implementation of the software and with increasing hospital bed demands, the hospital did add six beds to its PICU in 2004. This expansion might have played a role in alleviating further the need to cancel surgical procedures during the latter part of the winter seasons and confounds our ability to gauge the impact that Patient Tracker
had on the number of cancellations during that period.