2013 CNL® Summit
January 17-19, 2013
Abstract Submission Form
Abstract title: Using Discharge Tickets to Facilitate Flow of Acute Care Patients to the
Community Living Center (CLC).
Authors & credentials: Susan Ottenfeld, MSN, RN, CNL
Institution: Jesse Brown VA Medical Center
City/State: Chicago, IL
Primary Contact Email: susan.ottenfeld@va.gov
Instructions: Please complete each of the following sections, when applicable. Each section
should contain between 50 and 250 words, using Times New Roman, 12 point font.
Background Information:
The process of transitioning patients from an acute care medical unit to the Community Living
Center (CLC) was taking an average of nine hours to complete, creating house-wide bed
shortages. Since the cost of a medical bed ranged about 50% more than that of a CLC bed, it
was in the best interest of this institution to study the patient flow problems between the two
units. The goals were to identify where the system delays were occurring and to reduce the total
cycle time for completion of patient transfers from high demand beds. As part of a Transitioning
Levels of Care (TLC) Collaborative, the Clinical Nurse Leader (CNL) worked with an
interdisciplinary team comprised of three MDs, a Clinical Social Worker, five RNs, and a
Utilization Manager to map out each step of the transfer progression. Over a six month period,
the group worked with a process improvement mentor to identify system roadblocks, gather data,
and ultimately redesign transfer procedures. The CNL identified that one delay was caused by
nursing staff on the sending unit often being the last to know about transfer orders. The CNL
worked with the CLC Transfer Coordinators to improve communication flow by initiating the
use of highly visible “CLC Discharge Tickets” designed to be placed on patient room doors
alerting caregivers of impending CLC transfers which would be expected to be completed within
a four hour window.
Aim:
The preliminary aims were to increase utilization of CLC beds by 25%, to have 100% of the
documentation in place prior to accepting patient for transition, and to reduce transition time
from the acute care unit to CLC to under four hours with the ultimate goal of reducing the
frequency of days of diversion due to lack of available medical-surgical beds.
Methods/Programs/Practices:
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The CNL and the CLC RNs tracked their unit bed supply, admissions, and discharges each day
for four months. Demand exceeded supply in the acute medical unit, however, supply exceeded
demand in the CLC, where the census was at 50% of capacity. The team analyzed three baseline
data points: the amount of time taken to complete all CLC preadmission criteria before orders
could be written, the amount of time taken for the sending unit to complete the transfer once
orders were placed, and the amount of time taken to complete entire transition cycle. The TLC
group determined that delays were occurring because of a general misconception of what criteria
needed to be in place. A “Complete Kit” protocol was developed which clearly outlined all of
the preliminary data required before any transfers could be ordered, which greatly reduced
processing time. An additional cause for delay was identified to be fragmented communication.
Medical teams, Unit Secretaries, CLC Coordinators, and patients were aware of transfer orders
long before nursing staff were advised. Timely discharges were a low priority, with overall
cycle time averaging nine hours. The CNL and the CLC Coordinators worked collaboratively to
initiate the use of “CLC Discharge Tickets”, which were printed on bright yellow paper and
posted outside of the patient’s room to signify acceptance to CLC. The ticket contained
information on the necessary nursing actions needed to transition the patient efficiently, as well
as a posted time expectation of four hours for completion.
Outcome Data
Clearly defined preadmission criteria using the “Complete Kit” protocol reduced pre-acceptance
time by one day. The TLC team's aim was to reduce transition time to four hours once CLC
transfer orders were written. With the use of the discharge ticket, this goal was met within 2
months after initiation of the process. The initiative was rolled out to two other medical units
with equally positive results and is still a sustained practice after one year. Nursing feedback
between all units has been overwhelmingly positive; Nurses commented on the easy visibility the
tickets, ease of use, and improved communication regarding discharge plans. CLC nurses noted
that discharges were being completed more readily on day shift, reducing the admission burden
during later shifts. CLC utilization increased by 25%. A comparison of 2012 transition cycle
times to those of 2011 showed an overall 39% reduction in transfer times for all three units
which met and exceeded the team's initial aim for completion within four hours. When potential
cost savings as a result of this project were analyzed, it was estimated that this TLC project
would potentially save this institution $535,867.00 in one year by freeing up higher cost medical
surgical beds, decreasing medical bed diversion days, and reduced costs incurred when patients
were "fee based" to other institutions for care due to diversions . Diversion rate dropped by 50%.
Conclusion:
This low cost and easily implemented initiative enabled this institution to improve patient
transition times by 39%, which reduced unit to unit backlogs, relieved bed occupation on over
utilized units to a less utilized unit, and reduced costs incurred with diversion and outsourcing
patients to other institutions. Potential savings were estimated at $535,867.00 per year. The
AACN Call for Abstracts, 2013 CNL Summit
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CNL played a leadership role in instituting a change in practice at the microsystem level.
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