The Rush University Medical Center census on the medical acute care units is typically high with most admissions coming from the emergency department (ED). Because the medical units were having an increase in average length of stay (ALOS) in early 2023, this impacted throughput for patients being admitted from the ED. A decrease in patient satisfaction was seen for the medical acute care units. In February 2023, the patients admitted through the ED to the medical acute care units had a Top Box Press Ganey score for “Rate the Hospital” of 77.78% and an ALOS of 5.14 days.
A nursing team, together with unit directors met with Performance Improvement to develop the “Improve Access to Medicine Units (AIM)” project. The goal of the project was to increase the Top Box Press Ganey patient satisfaction score for the “Rate the Hospital” question for patients admitted through the ED and discharged from acute care medicine units.
The unit clinical nurse lead(s) engaged in the following daily tasks to improve throughput:
- Review patients on the unit who were within two days of their ALOS to identify any care progression or discharge barriers that could be addressed to facilitate discharge
- Communicate concerns to a case manager or medical team member as appropriate
- Attend charge nurse report and multidisciplinary rounds to identify and solve potential barriers
- Escalate delays to appropriate departments (e.g., procedures, therapies, dialysis, etc.)
Daily huddles were used to discuss, problem solve and escalate overall trends, identify patients with barriers to care progression or discharge and metric progression. Processes were put into place to track barriers and successes. These tools helped identify larger system issues that needed to be addressed along with improved relationships with the pharmacy and physical therapy. The huddles also supported earlier discharge from the ED.
The AIM project provided an increased awareness of ALOS within the multidisciplinary team. Acute care medicine nurses now ask questions during multidisciplinary daily rounds to identify discharge needs or potential issues earlier in the patient stay and identify delays in care with appropriate escalation. Clinical nurses also identify those ALOS issues unmoved by the clinical nurse efforts which escalate the issue to the associate vice president to provide additional support for the moving of the patient care needs forward. Subsequently, this project allowed the ED to focus on appropriate admissions — some patients were discharged from the ED — and advancing care while still in the ED.