Patient Flow Checklist

patient-pickup-sign-1745442_1920The following is a work in progress. For all of us struggling with poor patient flow in the emergency department or throughout the hospital, this checklist has been developed to serve as a reference tool for what you have accomplished and what proven solutions remain. Everyone’s input is welcome.

Download PDF: Patient Flow Checklist

Emergency Department

Admissions
  • Bridge orders for admits
  • Case managers in ED
  • No wait nursing report for admits
  • Patient transporters
  • ED observation unit
  • Call for admissions early (don’t wait for all results if admission is obvious)
Lab
  • Point of care testing: Troponin, VBG, urine preg, chem panel, …
  • ED dedicated lab (full or mini-lab)
  • Track and report turn-around times
Radiology
  • 24/7 radiologist reading
  • Radiology speech to text transcription (real time results)
  • No oral contrast for abdominal CTs
  • Track and report turn-around times
Physicians & APPs
  • Physician scribes
  • Staffing providers to patient arrivals (predictive modeling)
  • Avoid ED physicians leaving the ED for codes
  • Track physician metrics and coach to improvement
    • CT utilization
    • ED LOS
  • Provider in triage
 Staff
  • Paramedics as staff in the ER
  • Building adequate surge plans (predictive modeling)
  • Use better communication devices (mobile, text capable)
  • Track nursing metrics and coach to improvement
    • Discharge order to completion
    • Lab order to blood draw
    • Med order to administered
 Flow
  • Avoid inpatients returning to the ED (for CT, for lines, etc)
  • Move patients to results waiting
  • Utilize stretchers for patients that need them (“keep vertical patients vertical”)
  • Patient flow coordinator
  • Order sets / protocols
  • Direct bedding
  • Fast Track
EVS/Housekeeping
  • ED rooms down <10% for cleaning
  • Terminal clean only when needed
EMR
  • Visual triggers for tests completed, results returned
  • Visual triggers for critical abnormal results
  • Visual triggers or alerts for new orders placed

Hospital Wide

Physicians

  • Track physician metrics (utilization, LOS) and coach to improvement
  • Utilize Hospitalists
  • Discharge order/plan written in advance
  • Discharge patients early (before noon)
  • Increase weekend discharges
  • Standardize specialty order sets (post op day orders)
  • Unit based rounding

Flow

  • Track admission process metrics
    • Admit order to bed assign (dirty or clean)
    • Bed assign to bed clean
    • Bed clean to transport
    • Transport to arrival
  • Move patients to floor to be seen by admitting team
  • Clinical Decision Unit – cohorting observation patients
  • Surgical schedule smoothing
    • Track busiest days
    • Incentivize elective surgeries on lighter days
    • Take advantage of outpatient surgical center availability
  • Standardize O.R. checklists / protocols
  • Inpatients in hallways when ED holding and Hospital at capacity (consider placing patients ready for discharge in the hallway)

Transfer center

  • Route all direct admissions through the transfer center, and track by physician.
  • Route out bound transfers through it, and track.
  • Track calls for transfers that result in consultation with specialist only (helpful to gauge telemedicine need)
  • Coordinate admissions across multiple facilities
    • Multi-hospital systems
    • Return patient transfers to home facility after care

Staff

  • Case Management 7 days a week
  • Improve communication utilizing devices – mobile, text capable, physician and nurse connected
  • Building adequate surge plans (predictive modeling)
EVS/Housekeeping
  • Response time to vacant dirty bed
  • Cleaning turnaround times
  • Surge plan (predictive modeling)

Discharges

  • Improve relations with SNF’s to accept patients on weekends
  • Consider creating a hospital owned follow up clinic for discharges.
    • Helps patients who can’t get in with primary care physician in a timely manner
    • Helps with follow up for uninsured patients.
    • Reduces hospital LOS
    • Allows for seamless care of patient within the same hospital system.
  • Create a discharge lounge
    • Patients discharged waiting on rides can sit here.
    • Appoint a staff member to make hourly rounds.
    • Place water, small snack items, a TV and a phone in the lounge.
Telemedicine
  • Engage surrounding hospitals in conversation regarding services available and frequent needs.
  • If in a state where telemedicine is billable, hospital can help administrate and build infrastructure.
    • Low cost third party video conferencing solutions (HIPAA compliant) are available. No need to invest in your own system ($$$).
  • Utilize telemedicine to offer specialty consultation remotely and prevent transfers
Transport
  • Track outbound patient transport time
    • How long do patients wait for transport
    • Is transport service available 7 days/week, what hours?
    • Consider a hospital employed or contracted service to improve availability.
Items in red text have yielded the highest success in patient flow and finance.

2 Comments on Patient Flow Checklist

  1. Updated 12/26/16 with more content, especially on the hospital side. Also added the patient flow survey. Please share your experience.

  2. Another update to the list. High yield items have been marked in red. Additionally, the patient flow survey results have been posted online, click on Patient Flow Survey Results in the menu bar. Once again, thank you to all of you who participated !

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