When patients are admitted to the hospital through the Emergency Department, they often have to wait there until a room is available. This “boarding” of patients in the ED is the result of many factors, including high occupancy rates. Capacity concerns and ED overcrowding peaked during the COVID-19 pandemic, so UAB Medicine nursing leadership designed and implemented a solution to reduce boarding times and improve patient care.
A temporary patient discharge lounge was created within just two months, opening in January 2022, and a permanent location with improved procedures opened in August 2022. Patients who’ve been discharged from the hospital but are waiting for transportation home are moved to the patient discharge lounge, which frees up hospital rooms to be cleaned and occupied by other patients.
UAB Medicine policy calls for patients to be discharged within two hours after the discharge order is written, but meeting that goal is a challenge. In 2021, the average boarding time for patients waiting to be admitted to a room was 7-8 hours. These delays increase boarding times in the ED and create a burden on Environmental Services (EVS), as discharges tend to happen after most EVS staff have left for the day.
Room for improvement
UAB Hospital operates at 95-99% capacity and often uses a hallway bed protocol called “z bed” to reduce the number of patients boarding in the ED while waiting to be admitted. This protocol calls for moving such patients to a hallway on the assigned inpatient unit. The patients receive inpatient care in the hallway until the occupant of the assigned room leaves (pending discharge) and the room is cleaned.
Recognizing the importance of improving patient throughput, UAB Medicine Chief Nursing Officer Terri Poe, DNP, RN, NE-BC, incorporated the following goal into UAB Hospital’s FY 2022-2026 Nursing Strategic Plan: “Maximize patient throughput by creating a culture of right place, right time, right care – implement strategies to maximize throughput during times of high capacity.”
In November 2021, Poe met with Sasha Harris, MSHQS, RN, RN-BC, director of Nursing for Medical Services and Doctor of Nursing Practice (DNP) student, to discuss Harris’ DNP project. Poe informed Harris of several ideas she had for improving patient throughput, including creating a discharge lounge for patients waiting to be picked up from the hospital.
Poe believed that moving discharged patients to a special location while waiting for their ride home could reduce wait times for patients in hallway beds or boarding in UAB’s ED. Harris was enthusiastic about the idea and thought it could address some of the challenges her units were facing. Poe approved Harris’ DNP project, Implementation of a Discharge Care Bundle: Throughput and Discharge Efficiency Strategy, and she served among the executive leadership for the initiative.
The long-range plan became an immediate priority in January 2022, as many patients were waiting over eight hours for a hospital room. The chair of the Department of Emergency Medicine called an impromptu hallway meeting with Poe and others, including leaders from Emergency Services, Nursing, Acute Care Therapy, Hospital Medicine, the Center for Patient Flow, and numerous physicians and professors. An ED physician highlighted the immediate need for something beyond the z bed protocol.
Poe discussed her plans for the discharge lounge, and there was swift consensus that the idea needed to be fast-tracked. She collaborated with Clinical Operations and the Center for Patient Flow to plan a “pop-up” discharge lounge in an atrium adjacent to the ED in the North Pavilion, and the team worked to equip it with supplies, privacy partitions, and staff. This temporary lounge opened on Jan. 12, 2022. It only hosted four patients that first day, but that would change quickly.
Poe tapped Harris to develop the structure and processes for the discharge lounge. Ronny Taylor, MSHQS, BSN, RN, nurse manager for the Center for Patient Flow, provided operational oversight. Together, they took the following actions over the following two weeks to make the pop-up lounge work better:
- Developed patient criteria and operational processes
- Designed educational information for patient and family members, clinical nurses, and patient care technicians (PCTs)
- Added a column in the patient tracking system to indicate when a patient is appropriate for the lounge and added the discharge lounge as a disposition option for Patient and Guest Escort personnel
- Collaborated with the Guest Services and Patient & Guest Escort departments to educate transporters on the location and purpose of the discharge lounge and create scripting for escorts to use in promoting it
- Engaged Communication Services to install phones in the lounge
- Communicated with Transportation Services to ensure that parking attendants were aware of the new discharge location and process and that signs were posted in key areas outside of the hospital
- Collaborated with the director of Food & Nutrition Services to create a process for obtaining patient snacks, drinks, and meals in the discharge lounge
- Drafted a memo to educate physicians on the new process and request their support in initiating timely discharge orders
Further refinements to policies, procedures, and promotion of the lounge were made between February and May 2022, including a permanent staffing plan. Although the discharge lounge saw greater use and was reducing average boarding hours, UAB Hospital experienced a record number of patients boarding in the main ED in June 2022.
In July, Poe approved two PCT positions to be moved from the nursing resource staffing pool to the discharge lounge. The PCTs helped change discharge lounge utilization from a push process to a pull process. Instead of nursing units and physicians pushing patients to the discharge lounge, the PCTs used available software to look for opportunities in the patient tracking system and patient charts to pull discharged or ready-to-discharge patients to the lounge.
Pulling patients to the discharge lounge accomplished the following:
- It created a primary location for patient pickup.
- Case managers could coordinate the distribution of medical equipment to multiple patients in the discharge lounge at one time.
- Pharmacy could coordinate the filling and delivery of discharge prescriptions for multiple patients.
- Patients no longer needed to wait in their rooms for meals and snacks, which were now available in the discharge lounge.
- EVS had faster access to vacated rooms for cleaning during peak EVS staffing hours.
- Nurses could move more patients from hallway beds faster, thereby decreasing wait times for clean rooms.
- Patient transporters can move patients boarding in the ED to a clean room, thereby reducing boarding times.
By August 2022, the patient discharge lounge was fully implemented. The accompanying chart helps illustrate the positive impact on the organization. As the number of patients being moved to the discharge lounge increased, ED boarding hours decreased.
In short, nursing leaders successfully coordinated a complex initiative that produced systemwide improvements. Amid unprecedented resource and admission challenges, UAB nursing leadership found a way to make a positive difference for patients and staff alike.
This story is part of the Nursing Annual Report 2022. Click here to view the report.