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Innovating Care at the Bedside

When patient progression slows on the inpatient units — that is, eligible patients are not being discharged in a timely fashion and much-needed beds are not turning over — it can wreak havoc on the Emergency Center. Just ask Sheri Silvestro, RN, BSN, a former charge nurse in the Emergency Center.

“There are times when we have 35 patients holding in the Emergency Center waiting for an inpatient bed, which means you can’t even get to the people in the waiting room,” says Sheri. This leads to unreasonably long wait times and a lot of frustration for patients and staff, not to mention potential safety issues.

These patient flow bottlenecks can occur for any number of reasons, from breakdowns in communication between members of the clinical team to delays in getting test results and finalizing discharge plans, to name just a few. Whatever the reason, however, the result is that patients at Lawrence General end up staying approximately one day longer than necessary when compared to the discharge data from similar hospitals across the country.

As part of an ongoing effort to address these systems issues, Lawrence General has been engaged in an initiative called Pathways to Patient Progression since May that is focused on better coordinating care, ensuring appropriate length of stay, decreasing wait times in the Emergency Center, and improving the patient and staff experience.

The most recent step in this initiative was the introduction of seven new clinical care coordinators — all hired from within the Lawrence General community — on all med/surg and telemetry units. Sheri Silvestro is one such care coordinator, and she is excited about being part of the patient flow solution.

“There’s a lot of room for improvement when it comes to patient flow and I think we can make a big difference,” she says. “Everyone is already working really hard, but they are focused on their own individual role. No one is looking at the big picture and making sure all the dots are being connected. It’s all about the patient and making sure we’re always focused on doing what’s in their best interest.”

“The clinical care coordinators are intended to be problem solvers who work collaboratively with clinical staff to remove barriers and expedite communication between members of the care team,” says Nicole Garabedian, RN, MSN, director of Integrated Care, who is overseeing the program. “They will proactively identify the reasons why patients are progressing slowly and find solutions before length of stay targets are missed.”

This innovative new approach to care delivery is being used in hospitals across the country to transform care at the bedside. The role of nurses, case managers, and hospitalists need support so that someone is accountable for managing the process of care, enabling them to focus on their specific roles. In the traditional model, this work may get done but is highly unreliable and many barriers to care persist, causing delays because no one has followed through. The clinical care coordinators have a broad understanding of patient care management and possess supervisory authority and accountability for outcomes.

“This is the most ambitious undertaking we have made around redesigning inpatient care and it will require support and close oversight of change management, including auditing of performance on agreed upon measures, communication, and celebrating success,” says Karen Moore, RN, senior vice president of Operations and Chief Nursing Officer.

The initial steps in the Pathways to Patient Progression initiative focused on improvements to the multidisciplinary rounding process, adding target lengths of stay for each patient to daily huddle discussions, and introducing a new standardized format called Status Now Action Planning. All of these enhancements are in alignment with the hospital’s broader strategic initiatives as reflected in the Annual Operating Plan to improve patient safety and quality, engage staff, and establish efficiencies while improving outcomes.

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