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Poster Day 2025: Abstracts: Quality Improvement

Leveraging Technology, Communication and Teamwork to improve Patient Flow

Authors:

Devesh Dahale MS, MBA, CPHQ, CPXP; Lara McCall RN, BSN, CCM

Background:

Patient flow is the movement of patients in the healthcare facility – involving medical care, physical resources and systems to identify and organize arrangements for relevant psychosocial needs of the patients upon discharge. (NEJM Catalyst, 2018). Our hospital’s specific patient flow related problems included excessive diversion hours which in turn resulted in excessive boarding hours in the ED – both problems adversely affecting patient care and experience as well as the hospital’s capacity to provide acute care services to the community.

Methods and Data Analysis:

We heavily leveraged our EMR (Epic) to set up data collection systems focused on capturing barriers related to patient flow at various points in the patient’s journey. Extracted data from Epic in the form of reports helped us assess baseline performance in various metrics of interest. Analysis of the data revealed the magnitude of problems affecting flow. Accordingly, we designed appropriate PDSA (Plan-Do-Study-Act) targeted interventions to relieve those barriers, streamline the workflows and improve the process outcomes. Out of the four phases of patient flow (admission, treatment, disposition and discharge), the last two phases offered the biggest initial opportunities (low hanging fruit) to make the largest observable impact on patient flow.

Key interventions:

  • Set up Patient flow bi weekly multi-disciplinary meetings: March 2024
  • Redesigned unit level patient flow morning huddles: April – August 2024
  • Set up barriers tracking data collection system in EMR: June 2024
  • Formalized the Discharge Lounge process: July 2024
  • Redesigned daily throughput huddle: August 2024
  • Created and deployed the weekly complex care huddle: September 2024
  • Created and deployed a training video describing the morning unit huddle: Jan 2025
  • Revised data collection system in Epic (barriers and milestones): May 2025
  • Adopted Epic CMLOS (Cosmos Length of Stay) tool in physician EDD determination: July 2025

Results:

  • The end outcome LOS (Length of Stay) reduced from an average of 5.26 days to 5.12 days (a statistically significant systemic change).
  • Discharge lounge utilization increased from 39% to 52% (the most recent two months had 76% utilization).
  • Internal transport processes accomplished 95% of transports occurring with 20 minutes of acknowledgement.
  • External transportation delays reduced in average times from request to discharge (wheelchair van: 4 hours to 1.7 hours; ambulance: 7 hours to 3.8 hours; personal vehicle: 4.4 hours to 3.1 hours)

Conclusions:

  • Patient flow is SYSTEM property.
  • Structure beats chaos.
  • Technology is only as good as how well you can leverage it
  • Communication is currency of flow in systems.
  • Barrier identification is the pre-requisite to effective solutions.
  • All team members play a role in improving patient flow.

QI902: Falls Reduction

Authors:

Donna L. Yost, DNP, MSN-CNL, RN, OCN, CNE; Devesh Dahale, Ms, MBA, CPHQ, CPXP

Background:

Fall event data ending FY 2019-2020 for a 420-bed regional community hospital, found 292 inpatient falls including 10 significant injuries with inpatient fall events peaking in FY 2022 at 359 events.  Inconsistencies found in risk screening revealed opportunities for standardization of assessment and application of interventions in fall prevention. 

Purpose:

To drive accountability by deploying best-evidenced based practices/risk assessment tools to reduce falls/falls with significant injury rates

Description:

October 2021 – September 2025:

EPIC® reports: data collection.

Hester Davis® Fall Risk Assessment Screening

Learning modules for staff.

Fall events reporting: ‘Post Fall Huddle Sheet’ and electronic methods.

High risk patients- yellow armbands, blue when multiple falls. 

Bed/chair alarms alerting patient movement.

ICONs for high risk patients/banners for age 75/older on dash/story boards.

Patient/family educational sheets, bedside table tents, electronic patient safety contracts.

Policy revision: escalation algorithm/high risk patient’s age 75/older automatic high risk.

Floor mats reduced fall w/injury, Shower Steps® socks decreased bathroom slippage.

Whiteboards include visual Fall Tips®.

Physical therapy: walkers and Sara Steady™

Interventions active for discharged patients. 

Nursing protocol for implementing Virtual Sitters.

Calls to action: April/October 2024 and January 2025, strategical escalations

Conclusion:

Falls have a narrow realm of care provider control with an unpredictable human factor which is difficult to guide and direct.  Review of the data shows the positive impact process standardization and adaptation to events have on improving patient safety and outcomes resulting in 94 fewer falls in FY 2024-2025 than at project start in FY 2021-2022.

 


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