Reservoirs Kill Patient Flow

Reservoirs often show up as extra capacity, and who wouldn’t welcome that?  Shiny new clinical space gets first place on hospital tours, center stage in photo shoots and prominent mention in ad covers.

We find reservoirs all over healthcare: special inpatient wards, waiting rooms, bigger clinics, bigger emergency departments…extra capacity.

But, mindlessly expanding capacity decreases patient flow – increases patient waiting – if we don’t guard against forming reservoirs.

 

5 features of reservoirs in healthcare:

 

 1. Reservoirs slow patient flow.  Like giant, hydro-electric dams, they convert high flow, hard-to-manage situations into low flow, contained events.

 

2. Reservoirs allow us to meter out patients – for example,
we trickle them in from the waiting room into the ED, or trickle them up to the inpatient wards – when we are ready to see them.

 

3. We find reservoirs familiar; a common solution to high flow demands. They’re socially acceptable.  In fact, most institutions pride themselves on the size of their reservoirs.

 

4. Reservoirs decrease chaos and make us feel safe, but patients feel just as scared and unsafe while parked in a reservoir.

 

5. Reservoirs fill easily.  They attract contents.  Reservoirs might empty now and then, but they tend to promote filling and storage (waiting).

 

Waiting rooms, gigantic emergency departments or even special inpatient wards are reservoirs, and patients do not benefit from them if they exist only to slow patient flow.

These fat areas in the stream of patient flow end up grinding flow to a halt without extreme vigilance to keep patients moving.

We have to match patient volumes with flow; not capacity.  Sure, we always need more beds, but we need increased flow more.   Flow doesn’t just mean flow out of the hospital; it means flow in, too.  We often blame long term care or families for not taking patients home, as though there’d be no waiting if there were no alternate level of care patients (ALC; patients who need long term care) in the hospital. Or, we blame the inpatient wards for not taking patients out of our EDs sooner.

Truth is: we didn’t have an ALC problem years ago, but we still had admitted patients in the ED.  ALC represents one (major) factor impeding flow, but it’s not the only issue.

In the same way, patients crowded ED waiting rooms long before holding admitted patients in the ED became such a problem.

 

Until we develop a culture of taking every patient in – in to the ED and up to the wards – when they present, and not just when we are ready for them, we will never get rid of reservoirs and crush patient waiting.

 

How can we balance maximal patient flow and institutional capacity?  Is bigger better?  How can we avoid building reservoirs?

 

 

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9 Replies to “Reservoirs Kill Patient Flow”

  1. Shawn, great visualization of a current problem in healthcare. It is distressing when you know your hospital is on ED Diversion (because you are boarding people in the ER, etc.), but then you walk down a hallway and see empty beds. Yikes. I feel we would avoid feeling compelled to construct larger EDs (reservoirs) to reduce divert times by simply enhancing our real-time visibility of bed statuses across our hospital. Hospital leadership should be able to see all the beds in their hospital, and the status of each patient in them. And most hospitals simply don’t currently have the tools to achieve that in real-time.

    I know that Patient Transfer Centers are also another great way to better manage capacity and stimulate care coordination. Transfer centers allow referring clinicians to directly admit patients, bypassing unnecessary ED visits, and reducing ED chaos and waits.

    Thanks for the great article!

    1. Great comment, Ruth!

      We started using an electronic bed management system, but it still requires providers to keep it up to date. Much better; still less than perfect efficiency. At least it makes things more transparent with live screens posted everywhere.

      Ambulance diversion finally stopped when everyone was on diversion all the time. After a few terrible outcomes, everyone agreed to take all crews from their area. There’s a great video about ambulance diversion from a hospital in California. I’ll try to find the link and post it under links.

      I like your idea of Patient Transfer Centers. We still have admits coming through the ED if we are ‘officially’ full.

      Let me know if you come across anything that you think would be useful to post, add or discuss. Thanks again for your comments!

      Shawn

      1. Shawn, I cannot imagine a situation where EVERYONE was on divert. Wow. And I will look for that video you reference. I would certainly be interested.

        You probably saw this article in Fierce Healthcare, but it presents research that crowded EDs are linked to more deaths (most likely a patient waiting issue, I would think): http://www.fiercehealthcare.com/story/crowded-emergency-departments-linked-more-deaths-costs/2012-12-06?utm_medium=nl&utm_source=internal

        And in full disclosure I do work for a healthcare IT group. We’ve recently been working with several clients (HCA, Atlantic Health, MSHA) to develop an industry white paper regarding the positive impact transfer centers have on ED congestion. I think you might find it interesting. The white paper should be available any day now, and I will pass it on for you to peruse.

        Thanks again for the great article!

        1. Wow, Ruth. Great link! I hadn’t seen that, yet. Thank you. Please feel free to share anything else you come across.

          I look forward to your white paper! Let me know when it’s out.

          Cheers

          Shawn

      2. Hi Shawn, just discovered your blog. Thanks for bringing these issues to light! Regarding bed management, have you looked into integrating with RTLS? The same network you’re using for patient flow and asset tracking should be able to drive bed management as well. Shoot me an email or connect with me on LinkedIn if you’d like more information.

        1. Great question, Jeanne.

          Real time locating systems definitely modernize emergency departments – especially if they’ve been operating without an information system (tracking board)! We have another tracking board already, as well as an inpatient tracking board. Adding a 3rd tracking board didn’t seem to work out for us. It would have been nice to explore Versus from the start. Again, great product; super features; definitely can see how it would improve flow and efficiency; best to consider from the start OR if you are looking to change your EDIS. Also, I thought the tech support was great, too!

          Thanks again for your post. I’ll look you up on LinkedIn.

          Best

          Shawn

          1. You probably know, we do integrate to other systems (tracking boards) – we can send location information to just about any system, but it all depends on the willingness of the other software vendor to integrate. True in the ED, same with bed management. We do have our own Bed Management system as well!

            Thanks for the kind words. If I can be of any help in your RTLS endeavors, let me know.

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