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7 Management of Patient Flow

7.1 A Four Part Perspective
7.1.1 In examining the management of patient flow throughout the 10 organisations and
scope for improvement we have taken a four-part perspective of the high level flow and
management of the patient journey shown in Figure 4 below.

Figure 4 – A High Level Overview of Patient Flow

Flow 3
Flow 1
Flow 2

Flow 4

7.1.2 Flow 1 looks at presentation to the emergency department from a variety of sources
and the role of demand management initiatives, to reduce and/or influence the
numbers of people presenting to the department in the first instance.

7.1.3 Flow 2 looks at the organisation and flow of the emergency department itself and how
the patient is progressed.

7.1.4 Flow 3 looks at what happens to the emergency patient who requires in-patient
admission and the management of patient flow through the hospital.

7.1.5 Flow 4 then finally looks at the discharge process and transfer from the acute setting
to home or other care facilities.

7.1.6 The tables presented under each of the four part perspective headings next are a
synthesis of the common issues across the hospitals as a group and the areas where
emergency patient management could be improved. They are not intended as exact
representations of every organisation’s process. This description is provided in the
individual reports provided to the 10 hospitals.

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7.2 Flow 1: Emergency Presentation & Demand Management

Issue Consequence Improvement

Insufficient numbers of GPs o ED used as a resource for Solutions need to be linked to

and primary care teams all health care needs. the National Primary Care
available, particularly in areas o Increased waiting times Strategy and the development
of deprivation. of PCT coverage and
extension.

Inability for GPs and PCCC to o Increased waits in ED Better access within PCCC to
access acute services in the o Increased workload diagnostic facilities and
community (e.g. tests, reporting
observation facilities) – o Patient perception of ED as
therefore referring patients to a standard treatment service
the ED as a first line care
service, rather than an
emergency service.

Perception/reality that ED o Increased waits in ED Support to PCT model to

presentation will be cheaper o Increased workload provide one-stop services in
than attending the GP the community (tests,
o Diffusion of ED focus diagnosis and treatment)

Lack of consistent cover o Increased waits in ED Reviewing out of hours

arrangements in the o Lack of consistency for arrangements locally and with
community out of hours, patient, particularly if the hospital networks.
increasing ED attendances presenting condition is more
which could be avoided with acute than emergency and
more care continuity between there is little or no admission
day and evening in the information.
community. o Diffusion of ED focus

Limited access for GPs for Patient need to present to ED Improved PCCC access to
direct admission department, causing an observation beds and direct
unnecessary wait for an admission beds, via the
available bed and repeat proposed AMU model

Lack of systematic availability Repeat attendances at the ED Formalisation of those

of disease management clinics of people with long term schemes which have good
within ED, such as COPD, conditions, who may need evidence of preventing
Chest Pain etc. Some admission, which could have admission, e.g. diabetes, chest
organisations throughout the been prevented. pain, heart failure. Also the
review had a comprehensive development of shared care
range of disease management schemes with patients
clinics, whilst others were managing long term conditions
developing them.

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Issue Consequence Improvement

Lack of senior cover at busy Increased waiting within the This is linked to the
times and/or out of hours. In ED. Increased pressure upon recommendations for moving
the evenings and at the in-patient bed availability, to a more consultant-led
weekends, ED’s can mainly be cancellations of elective service, outlined in the Hanly
staffed by junior doctors, who procedures, where newly report. In addition, review of
may make more lateral admitted emergency patients on-call arrangements and good
referrals (inc tests) and admit are overflowing into day wards. admission and treatment
more patients protocols in place to support
junior doctors and prevent
defensive admissions.

7.3 Flow 2: Emergency Department & Flow

7.3.1 It has already been stated that the size and physical state of the ten emergency
departments within the project differed greatly, from new to extremely old facilities. In
many ways, the level of physical space available to an emergency department was a
major factor in the organisation’s ability to manage patient flow and demand within the
department. For example, larger and more purposes built departments were more
able to separate patient cohorts presenting to the department, for example, paediatrics
and adults (where the department served both groups) major trauma from minor
emergencies, providing both with separate entrances and flows around the
department. The ability for the emergency department to provide some observation
beds, for patients requiring a period of observation or input from emergency staff, to
prevent a full inpatient admission also was more highly correlated with larger and more
bespoke departments.

7.3.2 Given the difference in genesis and set up across the ten departments, it is perhaps
not surprising that there were also a number of department models in place. The
overview of the models picked up throughout the review is shown in Figure 5, showing
the relationship of the ED to the community and also to the rest of the hospital. This is
not intended as a description of all emergency models in operation across the country,
but simply those at play within this review. A fuller exploration of models across the
Country was contained in the national acute medical unit report.

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Figure 5 - Emergency Models in Operation

Major referral
routes
Current models of emergency care
•Wexford General Hospital

SELF In patient

AMBULANCE A&E MAU Beds

GP REFERRAL
•St James Hospital

SELF In patient
AMBULANCE
A&E AMAU Beds
GP REFERRAL

•Cork University Hospital

SELF •UCHG
Other •The Mater Hospital
In patient
AMBULANCE A&E “admission type”
ward
beds
GP REFERRAL

SELF •The Beaumont Hospital

Inpatient
AMBULANCE
A&E beds
•St Vincent's Hospital
•Our Lady of Lourdes
GP REFERRAL •The Adelaide and Meath
Hospital
•Leterkenny Hospital

7.3.3 The access of emergency departments within the review to observational/short stay
wards was very variable. Observation/short stay wards have been proposed as a way
of reducing the time spent in the main emergency department and providing the patient
with more comfortable and appropriate surroundings during their early investigation
and treatment phase. There is also evidence to suggest that the appropriate use of
such facilities can reduce medical admissions to hospital and even cut down the length
of stay of patients in hospital overall.15

7.3.4 However, to work efficiently, such units which have been variously described
throughout the project and indeed, the literature as a whole as: clinical decision units
(CDUs); medical assessment/admission units (MAUs), acute medical units (AMU);
medical emergency department (MED); emergency admission units (EAU) need to
provide a clear framework of operation.

7.3.5 Given the significant amount of work already undertaken by Comhairle na nOspidéal in
their report on acute medical units (AMUs) (October 2004), it is suggested that this
term is taken up universally. And that the key components described in the report for
the functioning of an AMU is also adopted, namely that there is:

15
Cooke M. et al Reducing Attendances and Waits in Emergency Departments A systematic
review of present innovations. NCCSDO January 2004

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■ strong management and clinical support to the AMU;

■ clear and agreed protocols and guidelines for access to and discharge from the
AMU;
■ designated consultant leadership of the unit;
■ consultant physicians with the appropriate training having a dedicated commitment
to the AMU;
■ all consultant physicians in the hospital being involved in providing designated
services to the unit;
■ evidence based protocols for the management, diagnosis and treatment of patients
in the AMU which would be reviewed and updated on a regular basis;
■ fast-track access to the full range of diagnostic services for AMU patients;
■ provision of high level multidisciplinary services in AMUs,
■ effective communication systems in place between the AMU, the emergency
department, general practitioners, bed management and the hospital’s outpatient
department.

7.3.6 A great advantage of such observation/short stay facilities is that they can provide the
GP with direct access for acute medical patients, who they feel need a period of
observation and treatment, reducing the likelihood of a referral to the emergency
department.

7.3.7 However, throughout the review, we found a lack of clarity in the role and use of what,
for convenience here, we shall call acute medical units, in line with recent work across
the State. Also, throughout the review, we only found one organisation who would take
direct referrals from GPs in the community. Although at a time of extreme bed
pressures for most organisations, it is understandable that organisations want to
control as much as possible the number and flow of admissions to the organisation.
However, it is our contention that the lack of direct access provision for GPs to deal
with emergency medical patients is directly contributing to the waiting situation in many
emergency departments across the country and importantly fragmenting the GP-
Consultant relationship still further.

7.3.8 AMUs should not however be substitutes for admission to a specialty ward if assessed.
A patient who arrives in the emergency department who is assessed as having an
acute medical need (requiring longer intervention than approximately 72 hours) should
be transferred to the appropriate medical ward. Likewise a surgical patient should be
directly transferred to the appropriate surgical ward. Patients should not be left in the
emergency department, who have no requirement of emergency services.

7.3.9 Other factors in the management of flow around the emergency department are shown
in the table shown next.

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Flow 2 Emergency Department

Issue Consequence Improvement

Lack of consistent see & treat o Long waiting times in ED More consistent application of
schemes for minors to cover o Overcrowding see and treat principles for
peak hours across EDs. The minors
idea of such fast track systems o Patient dissatisfaction and
for minor emergencies is to unrest
speed up treatment and
discharge for patients, whose
acuity is low and therefore
treatment can be rapid. At
busy periods, it is often this
group who end up waiting
excessive amounts of time in
the department, as more acute
patients are expedited in a
single queue system,
extending the waiting time for
minors.

Waiting for treatment post o Additional waiting time Encouragement of consultant

triage. Although we found o Overcrowding in the input to triage system, to
minor injury facilities in department at busy rapidly discharge patients from
operation across the study, periods the ED. Extension of Advanced
frequently triage was a nurse Nurse Practitioner role to
o Poor utilisation of
led service and patients often contribute to a see and treat
professional time
were required to wait for a model alongside triage, to
doctor’s assessment before reduce waiting and expedite
starting treatment. treatment. It is recognised in
this last point that this has to
be linked to wider issues of
workforce flexibility and
willingness to embrace
extended roles.

Lack of consistent near patient o Waiting in the ED Introduction of more near

testing. Few departments o Overcrowding patient testing within EDs.
within the review had
dedicated facilities in the o Conflicting demands
department contributing to placed on central
diagnostic support
delays in treatment times

Variable access within the ED o Waiting in the ED Clear categorisation of

to tests, which may be deemed diagnostic and discharge
o Inability to safely
to be in the domain of other facilities required by ED to
discharge patients from
specialties, such as exercise manage patient flow and clear
the ED, resulting in either
stress tests being the protocols with other
a prolonged stay or
provenance only of cardiology departments to ensure access.
admission.
for example.

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Issue Consequence Improvement

Competing for priority in o Delays in ED Priority slots given to ED for

diagnostics with other diagnostic support
o Delays in length of stay for
departments. Some
other ward patients
departments had negotiated
clear protocols and emergency
access out of hours, but this
was not the case across all.

Proliferation of outpatient o Blocked referral routes for Close review of all OPDs, to
clinics at hospitals, without ED for patients who do not assess numbers,
clear attendance and review need ED services, but appropriateness of attendance
procedures. Often outpatient who cannot be offered and duration of attendance.
clinics and in particular, alternative services.
fracture and dressing clinics o Overcrowding at busy
were situated close to EDs. periods, particularly,
Monday mornings
Inconsistencies in the o Waiting in ED Review the configuration and
members of the ED team. operation of multi-disciplinary
o Significant delays between
Some organisations within the team in ED, ensuring cover
interventions within the
review had good arrangements, as far as
dept
representation from a possible, serve the peak times
multidisciplinary team, o Inability to safely discharge of the department. Where
including physiotherapists, from ED there are a number of
occupational therapists, social departments in an area shared
o Can result in extended
workers, ANPs cover should be explored. Also
lengths of stay where
formal holiday cover procedure
patient is admitted.
Delays in accessing the o Waiting in the ED The use of an AMU would
relevant medical or surgical on obviously support this situation,
o ED being used as an
call team to assess or admit particularly where it is very rare
inappropriate holding
patient to a specialist bed. for ED consultants to have
facility for patients
direct admitting rights to other
o Increased risks to patients in-patient beds.
being cared for on a
trolley or other temporary Introducing a dedicated
facility. medical registrar for such
purposes within the ED. If not
o Lack of appropriate privacy
possible, a member of on call
and dignity for patients
teams should be freed from
other competing duties, or
attending the ED at regular and
predictable time intervals
throughout the day.

Duplication of work-up o Waiting in the ED Clear protocols between ED

between emergency and and medical and surgical
o Inefficient use of clinical
admitting teams teams to reduce duplication
time
o Inefficient use of resources

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Issue Consequence Improvement

Duplication of work-up o Waiting in the ED Clear protocols between ED

between emergency and and medical and surgical
o Inefficient use of clinical
admitting teams teams to reduce duplication
time
o Inefficient use of resources

Toleration of trolleys within the o Waiting within the ED Clear policy about maximum
ED. This is not to suggest that length of stay on trolleys for all
o Increased risks for
there was any deliberate policy organisations. There should
patients, particularly
in place, or that any also be protocols for overflow
where there are
organisation/clinician was arrangements at times of bed
inadequate hygiene and
happy with the situation. pressure. The entire length of
treatment facilities
However, in the 10 stay, including trolley waits
organisations reviewed, we did o Lack of privacy and dignity should be introduced.
find vastly different for patients
organisational responses to Review bed allocation pools
o Increased infection risk
trolley waits – irrespective of throughout the hospital, to
size of the institution or in- o Increased dissatisfaction ensure allocation for correct
patient bed challenges. Some and complaints demand.
had adopted a ‘zero tolerance’ o Low staff morale
policy for trolleys, whilst others
had lengths of stay of 3-4 days

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7.4 Flow 3: Patient ThroughputFlow 3: Patient Throughput

7.4.1 The issues associated with the management of patient flow from in-patient admission,
from the emergency department, to discharge are presented next. In many ways, the
challenges facing the organisations are reflective of those which the high impact
changes presented earlier in this report are designed to solve. This does not mean to
imply that organisations within the A&E Mapping and Efficiency Review were not
implementing areas of good practice. On the contrary, we saw a good deal of
excellent practice and innovation across the participating hospitals. Rather the issue is
one of continuity and consistency both within organisations and particularly across
them, to more efficiently predict and manage demand.

Issue Consequence Improvement

Inconsistent patterns of on- o Extended length of stay Review take arrangements to

take. Patients can therefore ensure that they are not
o Significant wait from
experience considerable delay contributing to significant
admission to treatment
before being seen by the delays in handover and
consultant/team of required thereby length of stay.
specialty from first admission.
Traditional use of most junior
o Decision delays Ensure senior decision-making
member of the admitting team
as first point of contact with is available at every step in the
o Increase in possible
patients. This can, particularly patient pathway (changing the
avoidable admissions
at weekends result in an order of the accepted pattern).
increase in admissions to in- This requires staffing to match
patient beds. workload including known
peaks and troughs. The use of
admission/discharge protocols.

Inconsistent balancing of daily o Trolley waits in ED Measure and analyse

demand for beds (admissions) predicted demand for elective
o Admissions to hospital to
and the daily capacity for beds and emergency workloads.
‘secure’ beds/ procedures
(discharges). Consistently Review elective schedules and
throughout the review it was o Patients inappropriately procedures. Consider
reported that the rise of scattered throughout extending scheduling of
emergency medical patients hospital elective workload, keeping
had negatively impacted upon open 5 day wards into the
o Cancellation of elective
the planned elective weekend for patients receiving
work
procedures within the surgery later in the week.
organisation, causing frequent o Patient and staff Consider separating, where
cancellations. However, dissatisfaction possible hot and cold activity
analysis of admissions and within organisations. Promote
discharges by day of the week use of emergency clinics,
illustrated a high degree of emergency and trauma theatre
variability across demand and lists (usually from 9 am to 9
capacity. pm) and same day
investigations to ensure urgent
patients are dealt with
appropriately.

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Issue Consequence Improvement

Inconsistent clinical o Disassociation from clinical Consistency in clinical

involvement in bed action and accountability in involvement in bed
management. All bed management at the management
organisations had a bed organisation
manager(s) responsible for Consistent roles and grades in
o Inefficiencies in bed
looking at the balance between bed management across all
overview
demand and capacity. organisations.
However, some roles were run
as an administrative function,
often in isolation from
consistent input from clinical
staff. Although central
organisation of bed function
can support effective
management, this is only as
long as it is systematically
linked to operational routine.

Lack of real-time bed o Delays in flagging bed Development of real-time bed

management information. availability status procedures and
mechanisms
o Admission delays
Inconsistent utilisation of care o Variation in length of stay Utilisation and review of care
pathways for common areas of pathways and procedures for
o Variability in available
admission and treatment. The common areas of care to
capacity
case note tracking exercise improve inpatient flow.
highlighted uncertainty as to o Inefficiency in the use of
whether care pathways were diagnostic capacity. Ensure a care bundle
routinely being to ‘plan’ approach is used for
diagnostic interventions. diagnostics

Wards competing for o Extended length of stay Review efficiencies in order

diagnostic and results o Inefficiencies in waiting for communications to the wards.
availability. In addition, real tests and/or results of tests
time order communications Scheduling tests around a care
and reporting was not often o Inefficiencies in use of pathway approach
clinical time ‘chasing
available to wards
paper’ for ward patients.
Audit bottlenecks and address

Variable and inconsistent o Longer waiting lists and Increase the routine use of day
performance on the use of day cancellations surgery as an alternative to
case surgery elective inpatient surgery
o Greater pressure on
theatre time
o More people requiring
scare beds
o Inefficiency in use of
clinical time and resources

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Issue Consequence Improvement

Variable utilisation of pre- o Competing pressure for Improve pre-admission and

admission clinics and same beds same day admission
day admission for surgery
o Cancellation of elective
Exploit B&B options
procedures
Separating hot and cold activity

Lack of formalisation of o Contributory factor to Institution and review of

discharge planning (including extended lengths of stay predicted discharge date in the
predicted discharge date) early patient’s notes.16
o Poor communication and
in the admission process and
handover for ward and
notes
consultant staff
Lack of consistent audit within o Contributory factor to If not in place, programme of
organisations on known, or extended lengths of stay clinical audit which includes
perceived process bottlenecks process bottlenecks to support
o Lack of quantifiable data
clinical and support staff
o Failure to learn and improve patient flow locally.
improve
Inconsistent use of Diagnosis o Poor understanding and Not withstanding data
Related Groups and Length of comparison within and improvement across the
Stay data within organisations between clinical groups on hospital system as a whole,
general (or benchmarked) individual organisations should
length of stay make better utilisation of
clinical and activity data and
o Potential inefficient use of
provide regular updates to
overall bed capacity
clinical teams and groups.

Lack of formal clinical o Weak mechanisms to Instigation of clinical

governance and/or and peer review and address clinical governance and accountability
review structures within interface issues, such as model
organisations. Only one admission, care pathways,
organisation within the review discharge.
seemed to have in place a
o Delays
model for clear clinical decision
making and accountability o Poor length of stay
across the hospital. management.

16
It was reported during the review that one possible disincentive for clinicians to formally record
predicted discharge date (PDD) in the notes was to do with third party insurers requiring notification
of the PDD.

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7.5 Flow 4: Discharge

7.5.1 Although discharge is the final area of examination, it is by no means less important
than other areas. On the contrary, the effective management of patient discharge is
one of the single most important aspects of controlling the variability between capacity
and demand in the hospital environment.

7.5.2 The national challenge of ‘delayed discharge’, both for the elderly and the younger
patient with chronic conditions has already been discussed at length in the preceding
section of this report. It is again acknowledged that without significant improvement in
alternatives to acute hospital care for both these groups at a national and regional
level, the management of acute capacity will continue to be a significant operational
problem for many institutions within existing bed capacity levels.

7.5.3 However that said there were also a number of areas of good practice within the
effective management of discharge, which could be implemented across the country.
These are shown next in the final table.

Issue Consequence Improvement

Inconsistent formalisation of o Extended lengths of stay Formalisation of discharge

discharge planning from planning from, or close to, day
o Confusion for ward staff,
admission. Planning for of admission. This should be
patient and relatives about
discharge should begin at the responsibility of every
the planned process and
admission, to ensure that the clinician and member of the
importantly, discharge date
patient only remains in hospital treating team. It should not be
for the time necessary for the responsibility of discharge
treatment and recovery. planners
Without planning, even if this
has to be changed, the various
parts of the pathway can be
delayed.

Inconsistent pattern of ward o Delay in confirmation of Consistency in frequency and

rounds within and across discharge decision. If this coherence in decision-making
specialities. occurs late in the ward rounds across the
afternoon, this can mean organisation. Ward rounds
an unnecessary and should occur earlier in the day,
extended stay. by midday, to ensure the
optimum numbers of
completed discharges by mid
afternoon.

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Issue Consequence Improvement

Patients spread in all available o Inefficient use of clinical Grouping specialty patients as
wards across the organisation, time much as possible throughout
requiring time consuming and the hospital. This may require
o Patients may get missed, if
inefficient ‘safari wards’ review of traditional bed pools
other priorities delay
and allocations, to ensure that
teams, or the patient gets
they are fit for current purpose,
‘lost’ – i.e. is not
rather than historical usage.
appropriately tracked
throughout the hospital
Given that many of these
o Inefficient review process, patients are the elderly, there
impacting upon length of is a case for a more developed
stay care of the elderly service in
hospitals. It is clearly
preferable that such patients
are managed together in ward
settings with the ethos of
multidisciplinary care – the
hallmark of geriatric medicine.
Such initiatives may also
require the creation of
discharge and intermediate
care wards.

Unevenness of discharge o Chaotic discharge process Spacing out discharge process

profile. In most of the to earlier in the week and
organisations reviewed, there making more use of seven-day
was a peak in Friday discharges.
discharges, often
disproportionate to the rest of
the week and certainly to the
weekend. Such peaks, place
unnecessary strain on the
organisation.

Only the consultant can make o When unavailable, or tied This issue is obviously tied to
the decision to discharge in other duties, discharge national agreements.
can be blocked However, all organisations
should ensure that there is a
clear practice of ‘criterion
discharge’ – i.e. all members of
the ward team know what has
to happen for a patient to be
able to be fit for discharge (e.g.
results, prescriptions etc, so
that the decision is the final
step.

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Issue Consequence Improvement

Delays in processes supporting o Discharge delay Criterion discharge process

discharge – discharge should be in place, whereby all
o Extended lengths of stay
documentation, prescriptions, facilitating elements of
transport, family discharge can be clearly
communication organised.

Inconsistent use of discharge o Patient occupying bed for Where discharge lounges are
lounge. extended lengths of time available, they should be
staffed appropriately and used
o Bed is blocked for new
to support early discharge from
patients
wards.

Management of long term care/ o Duplication of effort Single assessment and

application process. This is application process.
o Discharge Delay
not adequately co-ordinated
across the acute and o Development of secondary
community sector morbidity or condition
whilst in hospital

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