Hours Matter
Fall 2009
Patient Flow at Sunnybrook: Hours Matter!
When you hear or see the term ‘patient flow’ at Sunnybrook,
what we are talking about is the safe and timely movement of
patients throughout the hospital from the time they enter the
Hospital until they are discharged. When we look at the entire
patient experience of our patients we examine our processes
to find opportunities to streamline our work and ensure that
anything that is not considered value added or safe to the
patient is removed from the care process. In many areas of
the hospital, this work has resulted in saving minutes, hours
and in some cases days from the amount of time patients
have had to stay with us. With our patients, Hours Matter.
If you have ever heard of the old saying that a butterfly flapping
its wings in one part of the world can result in a hurricane in
another, you will probably have a good idea about how patient
flow works in the Hospital. Time spent waiting for test results,
orders to be written or for beds to be prepared may not seem
like an immediate issue in one part of the hospital but it can
cause chaos in another. We have to treat the entire Hospital as
a system and each of us in the organization has a role to play in
ensuring Sunnybrook is able to care for those who need us most.
HOURS MATTER
For more than a year, many people across the organization
have been looking at patient flow issues in their areas. They
have come up with innovative solutions to improve the
movement of patients in and out of the hospital and through
this publication our intention is to share many of these ideas
with you. In the coming weeks, there will be several changes
taking place throughout the Hospital that will require the
effort of everyone to ensure their success. As a member of
the Sunnybrook team, you are encouraged to get involved
in this issue and do your part to improve patient flow. If you
have ideas about improving patient flow in your areas, please
speak to your manager.
Patient Discharge Planning Begins at Admission
Each patient admitted to Sunnybrook will have an expected
date of safe discharge from hospital included on their charts.
The admitting team will determine this timeframe based on
several factors specific to each patient but the fact is that
even though we may not know when exactly patients will be
admitted, we will have a fairly good idea of how long they
should be with us to receive their optimal levels of care.
they will be transferred to the most appropriate nursing
unit immediately. This initiative allows the Emergency
Department to make room for patients who require
urgent treatment. Currently, the average admitted patient
in the ED spends about 18 hours in the department and
about half of this is time spent waiting for a bed on the
nursing units. This rule should see some reductions in
wait times for ward beds.
It is important to remember that focusing on discharging
patients does not mean in any way that we are rushing people
out of the hospital or are more focused on their departure as
opposed to why they arrived at our facility. Quite the opposite
is true. Sunnybrook is component of a larger health care
system and to play our role effectively we have to ensure
we have resources available to care for all of our patients.
For example, if we have a patient who has had a heart attack
and we have provided care for the most acute phase of their
illness, it is not in their best interest to wait in one of our
beds when the patient needs to go to a rehabilitation facility
at another location. It is also not in the best interest of the
acutely ill patient who presents with chest pain in the ED to
have someone who can be cared for in another organization,
occupying an acute care bed and blocking a vital assessment
and possibly admission.
To facilitate effective discharge from the Hospital there are a
number of innovative projects that are either already underway
or are about to be rolled out across the hospital.
•
•
Bullet Rounds – These rounds take place daily on the
units and involve a multi-disciplinary team including
physicians, nurses, allied health (physiotherapists,
social workers, etc.) and others involved in the care
of the patient, The rounds are designed to discuss the
patient’s case with the entire care team and trouble
shoot any challenges the patient may be having and
make plans for discharge. These rounds will involve
members of the Community Care Access Centres
( CCAC ) for example to help arrange suppor tive
care such as home care which allows the patient to
return home with nursing care or other professional
follow-up.
Seven Hour Rule – When an admitted patient has been
waiting in the Emergency Department for seven hours,
•
Weekend Discharges – There has been difficulty
in the past discharging patients on the weekend but
there is increased pressure from the government to
ensure rehabilitation hospitals and complex continuing
care and long term care facilities admit patients on the
weekends. As this becomes more common, Sunnybrook
will be working with its clinical teams to ensure that
appropriate planning in advance makes weekend
discharges possible.
•
Electronic Bed Management System – Planned for
installation in November, staff across the Hospital will
be able to get a ‘real time’ view of the bed availability
throughout Sunnybrook. This will help move patients
from the ED to the units and from other parts of the
Hospital.
•
White Boards – There are two types of ‘white boards’
that are either already on the patient care units or are
being installed soon. These can be written on with
erasable markers and will include one at the nursing
station and one in each patient room. The Boards will
have on them information for the patient and family
and care team that includes questions that need to
be resolved, daily appointments, expected date of
discharge, name of people on the care team (MD, Nurse,
and Allied Health Professionals) as well as CCAC status
if applicable.
Emergency Department Innovations
Since Sunnybrook’s new Emergency Department (ED)
opened in the spring of this year, there has been a significant
increase in the number of patients arriving each day and the
main challenge has been how to improve processes and
patient flow to manage those who need to be admitted to
the Hospital while at the same time ensure patients who are
less acutely-ill are seen in a timely manner.
Each day about 130 patients are seen in the ED and of those
about 30 are admitted to the Hospital and the remaining 100
go home. Sunnybrook has one of the highest admission
rates of any ED in the GTA, which means we tend to care for
the most acutely-ill patients in the city. The large majority of
patients admitted through the ED go to the general medicine
floors while others are seen in cardiology, surgery and
medical oncology.
To try to improve patient flow in and out of the ED, the
Department has developed a number of highly innovative
strategies to ensure wait times are reduced and patients are
seen in a timely and safe manner.
•
ACT Zone – In the Accelerated Care and Treatment (ACT)
Zone, patients who may not need to occupy a stretcher
for the extent of their stay are seen here. Patients who
are assessed may be asked to wait in a comfortable
chair in an area separate from the general waiting room.
As patients require tests or other care, they are brought
back on to one of the stretchers. This initiative has had
great results in reducing wait times in the ED.
•
MD/RN Triage – Sunnybrook has launched a new
research project which involves nurses and doctors
assessing and beginning treatment for patients literally at
the front door of the Emergency Department. This early and
rapid assessment helps direct and organize patient flow
as soon as people arrive in the Department. By having a
senior nurse and a physician seeing patients upon arrival,
requests for diagnostic tests and other interventions
can be streamlined. A similar process has been used in
Australia, the United Kingdom and Hong Kong and has
generated encouraging reductions in wait times.
•
Floor Coordinators – Think of this part of the team
as patient flow trouble shooters. Although everyone in
the Department is responsible for ensuring the efficient
and safe movement of patients in and out of the ED, this
focused part of the team includes senior nursing staff
who are dedicated solely to solving patient flow issues
during each shift.
•
Flex Zone – This area of the ED allows the Department
to provide rapid unloading of ambulance patients. The
Flex Zone includes four functional beds, which can also
act as a ‘safety valve’ to ensure flow in the other areas
of the Department continues to run smoothly.
•
Staffing – Sunnybrook is fortunate to have a leading
team of professionals in its ED who are leaders in their
fields and have consulted around the world in developing
efficient departments and systems of emergency care.
The ED has recently made adjustments to its nursing
staffing patters and has recruited six more physicians
to the team who provide additional coverage in the
department. The ED has also hired a new Physician
Assistant to help manage the busy patient load.
•
ACCESS and the Four Hour Rule – Teams from
General Surgery and the Emergency Department have
come together to develop an understanding to improve
the time it takes to receive a patient consult and have
had some early success in achieving reductions in wait
times. Practices and learning from the ACCESS initiative
will be applied to a strict four hour rule for specialist
consults in the ED. Implementation of this will obviously
take some significant partnership between ED staff and
teams throughout the organization but this is vital to
trying to reduce wait times in the Emergency Department
and ensuring patients receive the most appropriate care
as soon as possible.
•
IT – To ensure the Department is able to measure and
track its success in achieving wait time reductions, the
ED staff have developed real-time applications such
as dashboards and flow and consultation reports that
produce metrics that are used constantly to guide the
actions of the ED team.
Communicating with Staff and Patients to Improve Flow
In addition to letting staff know about the important work
to reduce wait times and improve flow across the Hospital,
Sunnybrook is also going to be sharing success stories
with the public to educate people about these initiatives
and to help set expectations about a potential hospital stay.
Patients and families will be gently reminded through a poster
campaign that will appear in patient rooms to talk to their care
teams about discharge planning.
Posters such as the one seen here will be displayed in patient
lounges and rooms in general medicine and surgery floors
throughout Sunnybrook to ensure people are thinking ahead
to make certain the proper family or care giver support is in
place when it is time to leave the hospital.
Ongoing communication on these and other initiatives
will appear in future editions of this newsletter and in
several other areas. So stay tuned to SunnyNet and our
Returning Home
Partnering with our
Community to Reduce
ALC
Designation of Alternative Level of Care (ALC) is made
after a patient has completed the acute phase of their
care and is waiting to be transitioned to a rehabilitation
hospital, complex continuing care setting, long term care
home or home with supportive care. Sunnybrook Health
Sciences Centre in conjunction with the Toronto Central
Community Care Access Centre (CCAC) and the Toronto
Central Local Health Integration Network have developed
a strong partnership to facilitate patients designated for
ALC to long term care to receive enhanced services to
support the person to return home to make their long
term care planning decisions.
Toronto Central Community Care Access Centre has
dedicated on site coordination staff and a community
team with expertise in the frail senior population to
facilitate this process. The Home First strategy supports
Sunnybrook Health Science Centre to discharge clients
as early as possible and free up acute care space.
One of the early successes of this partnership has been
the rapid embracement of the Home First strategy which
works with patients and their families to build a network
of support which facilitates the patient to transition safely
into the place of their choice. The Community Care
Access Centre home first lead works with the acute care
team to develop a service plan to safely transition the
patient to the community.
At Sunnybrook, the Home First strategy has had some
excellent results and in a two week period reduced the
number of new ALC designations to zero on one in patient
unit which is a phenomenal success. It is anticipated
that this strategy will continue to reduce the number of
ALC patients at Sunnybrook in the coming months and
become a model for other institutions.
www.sunnybrook.ca for more news about improving patient
flow at Sunnybrook. If you have ideas about how to improve
patient flow at Sunnybrook, please speak to your manager
about this or if you are a member of the community, please
contact our Patient Relations office at 416.480.4010.
Have you talked with your care team
about planning for home?