Patient Flow Checklist

The 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

• 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)

• Point of care testing: Troponin, VBG, urine preg, chem panel, …
• ED dedicated lab (full or mini-lab)
• Track and report turn-around times

• 24/7 radiologist reading
• Radiology speech to text transcription (real time results)
• No oral contrast for abdominal CTs
• Track and report turn-around times

• 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

• 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

• 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

• ED rooms down <10% for cleaning
• Terminal clean only when needed

• 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)

• 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.

• 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

• 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.