Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department.

BACKGROUND: Emergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time. METHODS: After initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric 'bed downtime'-the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre. INTERVENTIONS: Interventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures. RESULTS: This package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit. CONCLUSION: Use of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

Use of Systems Engineering to Design a Hospital Command Center.

BACKGROUND: In hospitals and health systems across the country, patient flow bottlenecks delay care delivery-emergency department boarding and operating room exit holds are familiar examples. In other industries, such as oil, gas, and air traffic control, command centers proactively manage flow through complex systems. METHODS: A systems engineering approach was used to analyze and maximize existing capacity in one health system, which led to the creation of the Judy Reitz Capacity Command Center. This article describes the key elements of this novel health system command center, which include strategic colocation of teams, automated visual displays of real-time data providing a global view, predictive analytics, standard work and rules-based protocols, and a clear chain of command and guiding tenets. Preliminary data are also shared. RESULTS: With proactive capacity management, subcycle times decreased and allowed the health system's flagship hospital to increase occupancy from 85% to 92% while decreasing patient delays. CONCLUSION: The command center was built with three primary goals-reducing emergency department boarding, eliminating operating room holds, and facilitating transfers in from outside facilities-but the command center infrastructure has the potential to improve hospital operations in many other areas.

PGJ2 inhibition of LPS-induced inflammatory mediator expression from rat alveolar macrophages.

Studies suggested that 15-deoxy-delta-(12,14)-prostaglandin J2 (PGJ2) may exert anti-inflammatory effects, including in the lung. Thus, in vitro studies were conducted to (1) investigate whether PGJ2 inhibited the production of inflammatory mediators from lipopolysaccharide (LPS)-exposed primary rat alveolar macrophages (AM), and (2) investigate possible mechanisms underlying PGJ2-mediated inhibition of inflammatory mediator production. These studies determined that PGJ2 inhibited LPS-induced nitric oxide (NO) production in a concentration- and time-dependent manner. PGJ2-mediated inhibition of NO, as well as of tumor necrosis factor-alpha (TNF-alpha) and macrophage inflammatory protein-2 (MIP-2), was also determined to be dependent on the time of addition of PGJ2 relative to LPS, and suggested the PGJ2 inhibitory mechanism is an early event. PGJ2 was shown not to interfere with binding or internalization of LPS by AM, indicating this was not responsible for PGJ2 inhibitory effects. Another possible mechanism underlying PGJ2-mediated inhibition was via peroxisome proliferator-activated receptor-gamma (PPAR-gamma). However, biochemical studies suggested that PGJ2-mediated inhibition was not occurring through PPAR-gamma dependent mechanism, and molecular studies further established that both LPS and PGJ2 decrease PPAR-gamma mRNA expression. A third possible mechanism underlying PGJ2-mediated inhibition was by alteration of nuclear factor (NF)-kappaB. Molecular studies confirmed that LPS stimulated NF-kappaB mRNA expression, and PGJ2 reduced this stimulation, which is consistent with PGJ2 effect on LPS-induced production of NO, TNF-alpha and MIP-2. Thus, data in this study established that PGJ2 inhibited LPS-induced inflammatory mediator production in rat AM, and this inhibition is mediated, at least in part, by reducing the expression of NF-kappaB mRNA.

Facilitating Early-In-Day Discharge for Multiple Sclerosis Patients Treated With Intravenous Methylprednisolone: A Quality Improvement Project.

BACKGROUND AND PURPOSE: Delays in patient hospital discharge affect care value through costs of prolonged length of stay and barriers to patient flow within the hospital. We sought to facilitate early-in-day discharges (EIDDs) without extending length of stay for inpatients with multiple sclerosis admitted for acute exacerbations and treated with intravenous (IV) methylprednisolone. METHODS: We developed a standardized admission order set, a provider checklist, and a patient checklist to better coordinate in-hospital care and discharge planning for patients with multiple sclerosis admitted for IV methylprednisolone treatment. The order set allowed providers to enter an accelerated dosing schedule of methylprednisolone, as appropriate, to ensure administration of the final dose of methylprednisolone in the morning on the anticipated day of discharge. We compared a prospective intervention cohort to a retrospective, preintervention baseline cohort. RESULTS: At baseline (N = 25), 12.0% of patients were EIDD compared to 40.7% of intervention patients (N = 27; P = .03). In all, 85.2% of intervention patients compared to 64.0% of baseline patients were discharged on the same day as last methylprednisolone treatment (P = .11). No difference was observed in median length of stay and 30-day readmission rate between groups. CONCLUSIONS: Use of a standard admission order set as well as provider and patient checklists can facilitate EIDD and hospital bed availability without compromising care quality for a select group of neurology inpatients.

Sleep rounds: a multidisciplinary approach to optimize sleep quality and satisfaction in hospitalized patients.

BACKGROUND: Poor sleep has adverse affects on heath, yet few studies have addressed the goal of improving sleep among hospitalized patients. We evaluated the effectiveness of a sleep-promoting intervention on the quality and quantity of sleep among inpatients. METHODS: This study was conducted on a neurological ward in a large, tertiary care hospital. Sleep quality, quantity, and disruptors were assessed using questionnaires completed by patients during their hospital stay and Press Ganey surveys completed retrospectively. Room noise was also measured using noise meters. Data from each of 4 chronological phases of the study (baseline, basic intervention, "washout," and deluxe intervention) were analyzed. In the intervention phases, nurses conducted "Sleep Rounds" at bedtime, during which sleep-promoting practices were implemented, including lights out, television off, temperature adjustment, and a final restroom usage. RESULTS: Patients reported 5 (interquartile range [IQR] 3) hours of sleep per night, awoke 3 (IQR 3) times nightly, and reported a median sleep latency of 11 to 15 minutes. Pain, staff interruptions, and roommates were the most significant barriers to good sleep. Noise levels were adequately low (35-40 dB) at night but were not positively impacted by our sleep-promoting interventions. Patients perceived noise on the unit to be worse during phases of the study in which there was no intervention. CONCLUSIONS: Patient perception of sleep experience improved during the phases in which Sleep Rounds were implemented, despite the fact that there was no measurable improvement in sleep or sleep-disrupting factors.