June 18, 2004

VUH decreases patient diversion

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Allen B. Kaiser, M.D.

VUH decreases patient diversion

At Vanderbilt University Hospital, when no beds are available, patients are reluctantly diverted to other hospitals. Vanderbilt pediatric units rarely go on diversion, but for areas of the hospital that serve adult patients, increased demand for services has in recent years made patient diversion a routine occurrence.

In recent months, thanks to the efforts of staff and faculty, patient diversion has decreased significantly at Vanderbilt.

From December to April, diversion from adult units eased by 1.6 hours per day, which amounted by April to a 40 percent reduction from previous-year levels, said Allen B. Kaiser, M.D., VUH chief of staff and associate chief medical officer.

Much of the improvement is likely due to steadily increasing physician adherence to new bed management policies, Kaiser said. He also said there is still considerable room to improve adherence to these policies and to reduce diversion further.

Unless there is a good reason to keep a patient around until later in the day — a pending test result, for example — VUH wants patients ready for discharge by 10 a.m. Late last year, having studied what it takes to prepare VUH patients for discharge, the VUMC Clinical Enterprise Group said that whenever it is apparent that a patient is likely to be in shape for discharge within 24 hours, the doctor needs to write an “anticipate discharge” order. The CEG also said that, unless there is a clinical reason to wait until later in the day, doctors need to write discharge orders by 9 a.m.

In December, departments began receiving monthly reports of compliance with these policies. From December to April, use of anticipate discharge orders increased from 4 percent of admissions to 15 percent, and writing of discharge orders before 9 a.m. increased from 20 percent to 28 percent.

“Patient diversion is our worst administrative nightmare,” Kaiser said. “This recent progress toward more timely orders is all because doctors started getting feedback on what they’re doing.”

When it comes to improving bed management, some patient groups are more tractable than others. In Vanderbilt’s top-performing clinical service, Kaiser said, doctors are able to write discharge orders before 9 a.m. 80 percent of the time. In the absence of national benchmarks, optimum bed management for a given clinical service can be gauged with reference to the service’s best individual performers.

Within most Vanderbilt services, there is still a considerable spread between the best and worst individual performers, Kaiser said, indicating significant additional opportunity to improve bed management.