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.
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