Imagine arriving at the Emergency Department in need of immediate medical care. Waiting on a stretcher, you are told that you will need to be admitted for additional care, but unfortunately, there are no beds available – and not just on the unit you need, but anywhere in the hospital. So you wait.
Why isn’t there always a bed available?
As one of Canada’s largest acute-care teaching hospitals and a regional referral centre, LHSC provides patient care for approximately 150,000 emergency visits, 50,000 admissions and more than 15,000 operating room inpatients each year. With these volumes, LHSC and other large reginal acute-care hospitals are consistently over capacity and unfortunately patients who need to be admitted can spend hours—sometimes days—waiting for a bed to become available.
In order to keep a hospital running smoothly, an equal focus must be placed both on getting patients admitted and on discharging those who no longer need acute-care.
Discharge planning, which helps move patients back home or to alternative levels of care, involves many considerations and is an important piece of the healthcare puzzle. Ideally, it helps guide patients down the road to recovery and predicts the next available opening for the next patient in need, but discharge planning is a multifaceted process subject to frequent change by forces both in and out of the hospital’s control.
Why is it so hard to figure out when a patient will leave the hospital?
Health-care teams are skilled at assessing patients to determine when they will likely be ready to leave the hospital. This helps the hospital to know the number of beds available for admission at any given time, and whether or not the anticipated available beds will be sufficient to support current patient volumes.
While the process of predicting discharge is robust, each patient is unique and each discharge plan is adapted daily according to the patient’s condition and readiness to go home.
LHSC is an acute-care facility, meaning that resources are optimized to provide urgent care for patients with severe injuries or illnesses. Acute-care facilities are not intended to provide long-term care, and patients are discharged as soon as they are considered healthy enough to return home or to be transferred to another facility.
In any health-care journey, there are many factors that can change the anticipated discharge time and date.
An anticipated discharge date may be adjusted based on a patient’s condition – but it may also be affected by other factors. A simple miss in communication, or a seemingly innocent delay in picking a family member up from the hospital can quickly domino into delays in discharging patients who are well enough to leave.
I’ve heard of patients being placed in beds stationned in hallways – why does this happen?
When patient volumes surge above the hospital’s capacity, LHSC makes the most of all available space in order to care for patients in a timely manner. This may mean that some patients are placed in ‘non-traditional space,’ which encompasses placing a fifth bed in a four bed room, cohorting male and female patients, retaining patients in the Post-Anesthesia Care Unit (PACU), keeping temporary spaces like the Decant Unit open 24 hours or placing patients under supervision in hallways and conference rooms.
To free up a valuable inpatient bed, those who have been cleared for discharge the following day may be given the option to leave earlier, for instance, on the evening before their designated discharge date. This often works better for family members who work during the day as they can pick up their loved ones from hospital in the evening.
As a patient at LHSC, how do I know what my progress is and when I’ll be going home?
From the moment a patient is admitted, the health-care team is focused on the road to recovery.
All new patients receive a discharge letter that outlines their anticipated check-out time and requests their assistance with their discharge. While many are surprised to receive the letter, it is an important tool the healthcare team uses to help prepare the patient and provide information on their length of stay.
Many strategies are used to track a patient’s daily progress. For example, each day, the health-care team meets for “bullet rounds” where they discuss:
This information is communicated to patients in a number of ways, including whiteboards that are placed in the patient’s room, which outline their status and their next health-care goal. The board is updated daily and is discussed during nursing bedside reporting, which occurs at shift change. Incoming and outgoing nurses will talk to the patient and their family about their goals, progress and discharge plan.
In addition, patients can monitor their progress towards discharge through “stoplight” signage placed on their whiteboard, where:
Red = discharger greater than 72 hours
Yellow = discharge within 72 hours
Green = discharge within 24 hours
LHSC has designated “check-out” times at 11 a.m. and 2 p.m. Sometimes, in order to better serve those with the highest need, those who have been cleared for discharge may be asked to wait in a common area for their ride.
The patient always has the right to refuse, but in moving out of the bed when they are strong enough to do so, it frees that bed for the next patient needing acute-care.
I’ve heard that some patients are discharged only to return to acute-care at a later date. What are you doing to ensure this doesn’t happen?
The health-care team’s aim is to ensure that all patients have the tools and resources they need to continue their recovery outside of the hospital’s walls.
While some patients may be readmitted due to changes in their condition, other returns to acute care are driven by patient questions and concerns regarding their recovery. Encouraging patient education, increasing access to resources are strategies aimed at increasing understanding of what is a normal part of recovery, and when a return to acute-care is medically necessary.
To help address additional concerns after discharge, LHSC has initiatives aimed at providing helpful information and resources outside of the hospital walls. Online hospital resources for the public are available to help answer patient’s frequently asked questions, with the hope of preventing the need for patients to return to the hospital.
In addition, initiatives are being developed to address the concerns of specialized patient populations.
For instance, the Department of Orthopaedics has embarked on a pilot project to determine if performing follow-up phone calls to track patient progress and answer any questions, results in fewer return visits to the hospital.
It has also been identified that patients with heart failure, often called congestive heart failure (CHF), frequently return to the hospital as their condition is complex. To better serve our patients, LHSC began a quality improvement project in mid-2012. Over the course of the past year, a team developed a new toolkit for the care of these patients. The kit includes a range of tools and educational materials that will guide care of the patient from admission through to discharge and self-care at home.
What happens when a patient no longer needs acute-care at LHSC, but they’re not well enough to go home?
Although most patients will go home when they are medically ready for discharge, some require ongoing care. This can include patients who may need home-care, palliative-care facilities, long-term-care homes, rehabilitation or complex continuing care facilities. For most patients, leaving an acute-care environment will provide them with the benefit of regaining a sense of normal life.
In the instances where these patients are not from London, every effort is made to move patients closer to their home hospitals.
“When a patient no longer requires acute-care and they don’t need to complete their recovery period at LHSC, we work with community partners to ensure patients receive care closer to home,” says Judy Kojlak, Director of Access and Flow. “The number of patients that we have been able to repatriate to their community is increasing.”
When repatriation to the home hospital is not an appropriate solution, patients may also be moved to other facilities in the community. For example, many patients requiring rehabilitation may be moved to St. Joseph’s Health Care London’s Parkwood Hospital.
In addition, the South West Community Care Access Centre (CCAC) – a community partner – provides in-home nursing and personal support.
A CCAC case manager is considered an essential part of the health-care team at LHSC. He or she works closely with hospital staff and physicians to identify and assist patients who would benefit from at-home care, or who require assistance connecting with an alternate or long-term-care facility.
Even with the processes in place, beds can still be hard to come by. How is LHSC working towards improving?
Discharge planning is constantly being reviewed to ensure patients are getting the care they need. There is constant focus on improving communication between staff and patients as well as optimizing space and resources.
LHSC’s Predictive Discharge Planning Committee recently examined hospital practices as part of ongoing efforts to provide better patient flow – and improve the patient experience.
Ensuring patients flow through the hospital in a timely manner is a complex problem that must be solved on the ground level – with health-care providers and patients working together as a team.
In addition to the previously mentioned strategies for communicating progress with patients, the health-care team is being held accountable for the role they play.
Discharge outcomes are analyzed and used to inform training on predictive care expectations so the hospital can continually reinforce the practices that are working.