Highland Observation Unit: Right Patient, Right Bed, Right Length of Stay
The observation unit (OU) at Highland is a 26-bed unit. The unit is designed to decompress admissions to inpatient floors and aid in the minimization of ED boarding. Ideally the census in the unit would be 70% medical and 30% surgical patients who need a stay of 24-36 hours. Keely Dwyer-Matzky, M.D., serves as medical director of the unit, and last year developed a capstone project with several colleagues for her studies at the University of Rochester Simon Business School to improve utilization of the OU with appropriate patient population. The following is an interview with Dr. Dwyer-Matzky.
What was the impetus behind the Capstone Project?
We knew that there were opportunities to better utilize the Observation unit and decrease length of stay, improve patient flow, help alleviate ED boarding, and ensure that the right patient was utilizing the right bed at the hospital. We identified the opportunity costs and loss of revenue for Highland Hospital related to this. We also knew that costs associated with patient transfers out of the OU could be decreased or eliminated as well. So we strove to develop a plan to address these issues.
What were the goals of the project?
We had several long term goals including shortening patient length of stay in the OU, which would increase hospital bed capacity and improve patient flow. This would decrease ED boarders and ED overcrowding, in addition to decreasing costs of observation patients at Highland.
What was your action plan?
The first phase of the action plan involved a capacity analysis of Highland's eligible observation patients not currently in the OU. We created a patient characteristic predictive model for identifying inappropriate OU medical patients and generated a patient characteristic list to identify factors that will predict which observation patients will transition to inpatients. Then we abstracted one-year historical observation unit patient data from Epic with a collaborative of computer clinical build teams and applied the predictive model to the historical data to identify exact distinct patient characteristics. The second phase involved the formation of an OU interdisciplinary team of ED and Hospitalist providers, nursing, and an administrator to create an exclusion criteria list of inappropriate OU patients from the predictive model data and disseminated information to stakeholders including: Hospitalists, ED, OU Staff, Utilization Management, Admitting, Social Work and HH Administration.
What did you do in the Third phase of the Action plan?
We implemented the predictive model-generated new OU exclusion criteria, and we were able to improve bed capacity and patient flow. We have tracked metrics and found out what was causing inefficient OU utilization.
What are the results so far?
LOS has decreased significantly in the OU. Because of that we could increase volume of patients that are being admitted and discharged. We have increased our bed capacity as well. We have a place to grow and keep it filled to maximum capacity or census. We are continuing to re-evaluate and look to new patient populations who are OU appropriate. We are helping decompress inpatient floors and ED boarding that go to units currently as we fine tune the criteria. Given pressures of the current health care climate, Highland is strategically positioned to implement changes to appropriately utilize the OU. This will improve bed capacity and patient flow enabling additional inter-hospital transfers increasing our market share and marginal revenue. This will help Highland to continue to financially flourish as we grow services regionally as a premier community hospital.
Who worked on the project?
I was fortunate to work with an amazing team on the capstone project including: Daniel Lartey, Dr. Ayodele Sangosanya, Dr. David Tilson, and Dr. Robert McCann, who served as Institutional Liaison and Dr. Vera Tilson, our faculty advisor. I also worked with an interdisciplinary team at Highland representing each unit and department involved in the process. I can’t thank all those involved enough for their dedication to this project. The OU interdisciplinary team consisted of: Katie Holloway R.N., B.S.N., CMSRN, Assistant Nurse Manager of OU; Eric North, B.S.N., CCCRN, Nurse Manager of OU; Youngrin Kim, M.D., Chief Hospitalist; Joe Pereira, D.O., ED Physician; and Libby Jewsbury, Senior Program Administrator, Emergency & Observation Service. Additional Highland Staff who assisted include: Megan Tifft, LMSW, OU Social Worker; Jeff Huntress, Pharm.D, Director of Clinical Pharmacy Services, and the Utilization Management Nursing staff.
For more information or a copy of the presentation of the project contact Dr. Dwyer-Matzky at Keely_DwyerMatzky@urmc.rochester.edu.
Some members of the OU interdisciplinary team: Eric North, R.N., Nurse Manager of OU; Youngrin Kim, M.D., Chief Hospitalist, and Katie Holloway, R.N., Assistant Nurse Manager.