How can hospitals standardize admission and discharge processes to enhance patient flow? Discover the benefits of this approach and the key findings from a cross-sectional study..

Optimal Bed Management: A Strategic Aim for Hospitals

Hospitals today face increasing demands, including a rise in the need for hospitalization, the introduction of innovative diagnostic and therapeutic technologies, higher standards in clinical safety, and growing patient expectations for better quality services. Optimal bed management is a crucial strategic aim for hospitals, as the provision of inpatient beds, along with the associated staff and supplies, accounts for a significant portion of a hospital’s most complex and expensive activities.

The way beds are managed can affect the performance of other hospital departments, such as emergency services and operating theaters, which are dependent on bed availability. Conversely, these other departments can also impact bed usage. Therefore, it is essential to have an efficient and effective bed management system to improve overall service delivery.

The Patient Experience: Admission and Discharge Processes

For patients, admission to an inpatient bed in an acute hospital is a major event, regardless of whether it is an emergency or from a waiting list. The patient experience will largely depend on the availability of beds. When patients require emergency admission, it is crucial that they are admitted quickly and to an appropriate bed, avoiding delays.

Similarly, the discharge process is equally important, as it can impact the availability of beds for new admissions. Efficient and well-planned discharges can help improve patient flow and increase bed capacity.

The Study: Standardizing Admission and Discharge Processes

The aim of this study was to evaluate how hospital capacity was managed, focusing on standardizing the admission and discharge processes to improve patient flow. The study was conducted at a 900-bed university-affiliated hospital in the National Health Service near Barcelona, Spain.

Methodology: Cross-Sectional Study with Interventions

This was a cross-sectional study that examined a set of interventions gradually implemented between April and December 2008. The main focus was on standardizing the admission and discharge processes to enhance patient flow. The researchers obtained primary administrative data from the hospital’s database for the years 2007 and 2009 to assess the impact of these interventions.

Key Findings: Improved Patient Flow and Bed Management

The study found several significant improvements after the implementation of the interventions:

• The median length of stay for patients decreased from 8.56 days in 2007 to 7.93 days in 2009 (p < 0.051).
• The percentage of patients admitted on the same day as their surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05).
• The number of cancelled surgical interventions due to lack of beds decreased from 216 patients in 2007 to 42 patients in 2009.
• The median percentage of planned discharges increased from 43.05% in 2007 to 86.01% in 2009 (p < 0.01).
• The median number of emergency patients waiting for an in-hospital bed at 8:00 am decreased from 5 patients in 2007 to 3 patients in 2009 (p < 0.01).

Conclusion: Standardizing Processes for Improved Patient Flow

The study concludes that the standardization of admission and discharge processes can lead to significant benefits for increasing bed capacity and improving hospital throughput. By focusing on these key processes, hospitals can better manage their resources and enhance the overall patient experience.

Implications and Future Considerations

The findings of this study highlight the importance of optimizing hospital operations and logistics to improve patient flow. Hospital administrators and policymakers should consider implementing similar interventions to standardize admission and discharge processes, as this can provide tangible benefits in terms of reduced length of stay, increased bed availability, and more efficient use of hospital resources.

Further research could explore the application of these principles in different healthcare settings, as well as investigate the long-term sustainability and scalability of such interventions. Ongoing monitoring and continuous improvement of admission and discharge processes will be crucial to maintaining the gains achieved and adapting to evolving healthcare demands.

Standardizing admission and discharge processes to improve patient flow: A cross sectional study

BMC Health Serv Res. 2012; 12: 180.

,^#1,^#2,³,⁴,⁵ and ⁶

Berta Ortiga

¹Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Salazar

²Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Jovell

³Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

Joan Escarrabill

⁴Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

Guillem Marca

⁵Universidad de Vic, Vic, 08500, Spain

Xavier Corbella

⁶Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

¹Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

²Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

³Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

⁴Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

⁵Universidad de Vic, Vic, 08500, Spain

⁶Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Corresponding author.

^#Contributed equally.

Received 2011 Oct 11; Accepted 2012 Jun 28.

Copyright ©2012 Ortiga et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables.

Results

The median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64. 87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01).

Conclusions

In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

Keywords: Patient flow, hospitals, practice, management

Background

At the moment, hospitals face an increasing demand for hospitalization, for medical staff due to the introduction of innovative technology in diagnostic and therapeutic procedures, for higher standards in clinical safety and, finally, an increasing patient demand for better quality services [1,2]. Optimal bed management is a strategic aim in any hospital as the provision of an inpatient bed, together with the staff and supplies involved, accounts for much of its most complex and expensive activity. The way beds are managed affects the way other hospital departments perform since many are dependent on bed availability, such as emergency services, operating theatres, etc. At the same time, these other hospital departments have an impact on bed usage [3]. Therefore, it is essential to have an efficient and correct bed management in order to improve service delivery.

From patient experience, an admission to a bed as an inpatient in an acute hospital is a major event, independent of this admission being an emergency or from a waiting list. First of all, patient experience will depend on the availability of beds. That is to say, that when patients need an emergency admission, it is important to be admitted quickly and to an appropriate bed, avoiding unnecessary waiting times in the emergency room. On the other hand, if patients are being admitted from a waiting list for elective surgery, it is important to minimize the number of occasions that admissions are cancelled as a result of there being no bed available [4].

The hospitalization process has three main stages: an admission, an inpatient period and a final stage with the discharge process. An inefficient bed management in any of the three stages of the hospitalization can cause a mismatch between demand and capacity. It has been proved that when bed demand exceeds capacity, patient admissions and scheduled surgical procedures can be delayed or cancelled. Traditionally, it has been assumed that the variability in the demand comes from the emergency patient. Interventions focused primarily on emergency departments have had limited success [5]. However, repeated case studies have shown that elective admissions are often the major cause of variation as they are more unpredictable than the emergency admissions [6,7]. In addition, the greatest variation is typically in the number of discharges and, therefore, efforts to reduce variation should start with the discharge process and not in the admission process [8]. Then, to have information about planned discharges 24-h in advance would allow a higher planning and an optimal bed assignment. Moreover, the discharge process should start at the point of admission in the case of planned admissions, as in some cases the estimated length of stay without a medical complication is known. Discharge planning allows for a better and quicker bed assignment in hospitals and the development of nurses and other staff working in discharge coordinator roles [9]. In this sense, it has been proved that multidisciplinary teams can improve the delivery of health services and patient care [10-12]. All admissions and discharges of the hospital should be centrally managed [13] and planned, as single-department solutions may create or worsen bottlenecks in other areas.

During the hospitalization process, patient flow is a strategic aim for the healthcare enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Information is the foundation of any patient flow initiative. Patient flow is built upon the capture, integration and sharing of information, both within and across the different departments and staff [14]. This critical foundation can be immensely challenging to hospitals both with numerous information systems and departments that operate as silos [15]. Actionable information triggers patient care events and enables automated reminders. The aim of this study was to evaluate how hospital capacity was improved through focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital located in the metropolitan area of Barcelona (Spain) that belongs to the National Health System. It attends more than 120,000 emergency visits annually and the mean number of monthly elective admissions is 1,650 (95% CI 1,609 to 1,691), not taking into account day surgery. For our study, we created an interdisciplinary team of clinicians, hospital administrators and patients/families to examine bottlenecks and improvement areas in service delivery. We then selected high impact interventions focused on reducing the variation in the admission process for elective admissions, avoiding unnecessary cancellations of surgery interventions that have an impact on waiting lists, and on planning and standardizing the discharge process. All the interventions were implemented between April and December 2008. See Table for intervention lists.

Table 1

Discharge process management interventions:	Admission process management interventions:
▪ Enhance multidisciplinary teamwork: doctor, nurse, house officer and central admissions unit.	▪ Bed Management by a central admissions team planning and scheduling patient flows: right patient, right place and right time.
▪ Set a planned date for discharge on day of admission or at pre-admission, using protocols for common conditions with <72-h expected length of stay.	▪ Central admissions in a Surgery Admission Unit.
▪ Discharge planned 24-h in advance for >72-h expected length of stay.	▪ Patients admitted on the same day of surgery.
▪ Nurse-led discharge.	▪ Enhance day-surgery rates of selected processes.
▪ Plan discharge needs: discharge report, pharmacy prescriptions, sanitary transport, home care, etc.	▪ Avoid “on the day” cancellations of elective patients.

Standardization of the admission process included admission on the same day as surgery and promoting day-surgery rather than inpatient care, both aimed to free up bed days for emergency admissions and to admit major elective patients from a waiting list. To promote planning discharges 24-h in advance consisted in educating the clinicians on entering the discharge information in the electronic patient report. Then the house officers daily worked together with the physician in order to plan the discharge of the patient: discharge report, pharmacy prescriptions, the need of transportation to home, etc. At the same time, the nurse became the patient manager as he or she knew the discharges for the following day and that allowed an optimized task organization for the day, to identify possible home care arrangements for the patient, to collect patient documents from the house officer, and personally give them to the patient so that the patient could ask about any possible doubts. At the same time, the patient/family did not need to go personally to the house officer to collect the information and could get more feedback from their nurse manager. When the patient left the bed, the nurse entered the information in the system, which also prevented the patient/family to personally go and communicate their discharge to the admission unit when leaving the hospital. Bed management was done through a centralized team, with the help of the Information System, which placed emergency and elective patients in the most appropriate beds, allowed patient transfers between wards and checked patient discharge status, in order to have a correct patient allocation and a global vision of the hospital occupancy at all times.

For this study, we included all patients admitted to hospital wards before the multi-intervention, between the 1^st of January and the 31^st of December 2007, and after the implementation, between the 1^st of January and the 31^st of December 2009.

The following variables were recorded through the Hospital General Database: patient demographics, main diagnosis and procedure, admission and discharge dates, date of surgery, number of emergency patients waiting for a bed at 8:00 am, causes of patient cancellation, percentage of planned discharges 24-h in advance, number of patient outliers and number of day-surgery interventions. We did not look for ethical approval, as the organizational change described in this study did not cause any change in the clinical management of the patients and did not make any intervention to the individual patient.

The main outcome measures were: median length of stay, proportion of patients admitted on the same day of surgery, percentage of planned discharges, number of surgery cancellations, proportion of day-surgery, median number of delayed emergency admissions at 8:00 am due to lack of bed and median number of patient outliers, risk-adjusted mortality rate and risk-adjusted readmissions rate.

To describe categorical variables we used the total number of cases (N, days) and the percentage of each category and we used the Chi-squared for linear trend in bivariate analysis. All continuous variables were expressed as median ± interquartile range, and changes were assessed using the Wilcoxon signed ranks test and the Mann–Whitney test. A P value of less than 0.05 was considered statistically significant. All statistical analysis was conducted using the Statistical Software Program [16] for Windows (version 14).

Results

We included 53,361 admissions, of which 27,784 were done in 2007 and 28,577 were done during 2009. Table shows the general activity information during these two years, 2007 and 2009. The number of patient admissions for scheduled surgery was 13,824 patients in 2007 and 14,548 patients in 2009. The proportion of patients admitted on the same day of surgery significantly increased, from 64.87% in 2007 to 86.01% in 2009 (p < 0.05) (Table ). The patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009, without day surgery patients. The scheduled admitted patients length of stay was 4.85 days in 2007 and 4.54 days in 2009, especially caused by the “same day admission” policy implemented, as the pre-surgery length of stay was reduced from 0.58 days in 2007 to 0.26 days in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of day-surgery interventions per day increased, especially due to the increase in day-case rates for the procedures: knee arthroscopy, varicose veins and bunions (Table ).

Table 2

General hospital data during years 2007 and 2009

	2007	2009	P value
	Median (IQR: Q1-Q3)	Median (IQR: Q1-Q3)
Available hospital beds	776. 00 (724.00-819.00)	757.00 (699.50-790.00)	<0,01
Emergency daily visits	344.00 (319.00-367.00)	337.00 (307.00-361.00)	<0.01
All scheduled admissions (including day surgery)*	59.00 (20.00-85.00)	64.00 (10.00-91.00)	0.78
Scheduled hospital admissions*	45. 50 (13.00-69.00)	47.00 (8.50-75.00)	0.63
Emergency admissions	36.00 (31.50-41.00)	36.00 (31.00-40.00)	0.24
Day surgery admissions*	13.00 (0–23.00)	16.00 (0–24.50)	<0.05
Hospital occupancy	87.37 (87. 29-88.64)	91.8 (89.70-94.05)	<0.01

Table 3

Main Key Performance Indicators during years 2007 and 2009

	2007	IQR: Q1-Q3	2009	IQR: Q1-Q3	P value
Same day of surgery admission	64.87%	51.07% to 70. 02%	86.01%	83.50% to 88.93%	<0.05
Pre-surgery length of stay (days)*	0.58	0.53 to 0.70	0.26	0.24 to 0.32	<0.05
Global length of stay (without day surgery, days)*	8.56	6.88 to 10. 01	7.93	6.78 to 9.51	0.051
Scheduled patient length of stay (without day surgery, days)*	4.85	3.73 to 6.33	4.54	3.62 to 4.54	<0.05
A&E patient length of stay (days)*	11.64	9. 82 to 13.93	11.46	9.49-13.56	0.22
Cancelled interventions	216	_	42	_	_
A&E patients admitted to hospital	10.46%	9.26% to 11.90%	10. 49%	9.20% to 12.13%	0.33
Discharge planning	43.05%	40.09% to 45%	86.01%	84.92% to 87.10%	<0.01
Daily patients placed out of service	70	56 to 78	62	49 to 69	<0. 05
Emergency inpatients waiting for a bed	5	1 to 11	3	1 to 7.50	<0.01

The standardization of the discharge process was based on discharge planning and teamwork building (Figure ). In this sense, the median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009.

Comparison of percentage of planned discharges during 2007 and 2009, by months.

The median number of patients placed out of service in 2007 was 70 patients and 62 patients in 2009 (p < 0.05). That is to say, the percentage of inpatient outliers diminished from 9.71% in 2007 to 7.30% in 2009 (p < 0.05). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients per day in 2007 and 3 patients per day in 2009 (P < 0. 01). The percentage of emergency visits that were finally admitted to the hospital was 10.46% in 2007 and 10.49% in 2009. The percentage of emergency admissions over global admissions was 50.19% in 2007 and 49.10% in 2009. Risk-adjusted mortality rate diminished from 1.02 in 2007 to 0.89 in 2009 [17] (Table ).

Table 4

Quality indicators during years 2007 and 2009

Discussion

The optimization of hospital care resources by managing variation in the admission and discharge processes has proven to be effective. This multiple intervention project increased hospital productivity. Firstly, the main consequence due to the admission process has been the reduction of the length of stay, especially in scheduled admissions due to the reduction in the pre-surgery stay as a high percentage of patients were admitted on the same day as surgery. In addition, day surgery was considered as the first option for some surgery processes. Secondly, the significant increase in planned discharges helped sharing information among staff and enhanced teamwork. House officers were able to prepare all the information and patient arrangements for the day. In addition, patients and their families awaited comfortably in their rooms instead of being the messengers of information among the hospital silos. However, the implementation of these high impact changes required leadership, multidisciplinary teamwork and board level commitment as they affected the whole organization. All interventions were based on “lean” concepts, basically to reduce waste in terms of human resources, public health services and patient quality of care as well as to gain flexibility in hospital capacity.

Interventions included in this study are mostly dependent on the leadership and control of the management team [18] in order to assess the appropriateness of acute bed usage. There is an opportunity by process reengineering to increase bed capacity and productivity with the same fixed costs. In this sense, actions that lead to an increase of productivity without diminishing the service quality, or even increasing it, should be considered as successful key factors for best practices and a competitive advantage for any hospital. Bed management issues therefore warrant high consideration within the hospital’s management team. Some Boards have recognised the importance of hospital operations and that the person in charge of this area of management should be a senior member of the hospital’s executive committee.

In our study we have seen how redesigning operational aspects of the care delivery process that do not affect quality of care, can reduce scheduled admissions cancellations and the number of emergency admissions waiting for a bed. It is crucial not to block beds for elective admissions in advance, as supply of available beds will come through the discharges of the day. The way beds are managed has consequences on all organization levels: emergency and accident departments, surgery theatres, as in both cases their activity depends upon bed availability. However, there are many other aspects to consider when analysing bed capacity such as its efficient use. Departments that are inefficient can lengthen hospital stays and use beds unnecessarily [19].

Around 50 per cent of hospital admissions involve non-emergency patients who have been on a waiting list, mostly for a surgical operation. Waiting dominates many citizens’ perceptions of hospital care. While they are waiting, patients may be in considerable pain and discomfort and this interferes with their normal lifestyle and it adds to the workload of primary care [20]. On the other hand, in order to avoid last moment surgery cancellations due to lack of beds, a lot of professionals are likely to admit their patients the day before surgery and waste a one-day bed unnecessarily. It is then important to reach a consensus between the physicians and the management team in order to maximize profit for both parties, including patients and their families. The intervention for scheduled surgery consisted in a surgery admission unit [21] where the patient was admitted on the same day as surgery and was prepared without being given a bed. In this context, when patients were admitted each morning there were not any free beds in hospital wards, and they had to wait until other patients left the hospital. A possible drawback was that there could be a delay in bed assignments, which could have an impact on the rotation of patients in recovery theatres after the surgery and then in operating theatre flows.

In our hospital we reached 85% of planned discharges (Figure ). Delayed discharge triggered waits on trolleys in the emergency room and in operating theatres. Planning ensured an early and certain discharge as well as a better bed assignment because there was information about which beds would be available. Therefore, the number of patient outliers in the hospital significantly diminished. A limitation of planning discharge was that not all of them were effectively real the following day. The percentage of cancelled discharges was usually less than 10%. However, the importance of the planning was precisely to avoid improvisation of all the staff that participated in the discharge: physician, nurse, house officer, sanitary transport, families and patients and others. In fact, discharge process should start in the admission point, as it is the mismatch between demand and supply of beds that promotes delays and bottlenecks in the system [8,22].

Another limitation of our study was that this multi-intervention was only implemented in one hospital, so the study’s generalizability is limited. In our experience, it is crucial that management leaders focus on efforts to promote admission on the same day as surgery and to promote an early hospital discharge so that other patients can be placed in the most appropriate bed as soon as possible.

Conclusion

In conclusion, admission and discharge standardization and therefore length of stay are largely in our control. There is a significant opportunity to redesign patients’ pathways and improve patient flow to create important benefits for bed management and hospital throughput, which ultimately improve quality and the safeness of patient care.

Competing interests

There are not any financial and non-financial competing interests in relation to this manuscript.

Authors’ contributions

BO contributed to conception and design, acquisition of data, performed the statistical analysis and interpretation of data, as well as drafting the manuscript and adding all the comments from other authors; AS contributed to conception of the study as well as to the interpretation of data and to drafting the discussion of the manuscript; AJ and JE contributed to revising the manuscript critically for important intellectual content; GM participated in the conception, program design and in revising the draft manuscript; XC participated in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Acknowledgements

No funding was received by any of the authors for this study or preparation of the manuscript.

For the help and support in the implementation of the actions described in this study: Cristina Capdevila (Deputy Medical Director, Ambulatory Area), Carlos Bartolomé (Deputy Medical Director, Surgery Area), Antonia Casado (Nurse Director), Mari Fe Viso (Nurse Director Assistant), Lluís Murgui (Head of Information Systems), Rosa Redón (Information Systems), Sílvia Millat (Chief Administrative Area), Sílvia Salgado (Chief of Admissions), Jose Luís Parra (Security Officer) and Sergi López (Chief of Caretakers). For the support in statistical analysis: Nuria Ortega (statistician).

References

• Hendrich AL, Lee N. Intra-Unit Patient Transports: Time, Motion, and Cost Impact on Hospital Efficiency. Nurs Econ. 2005;23:157–64. [PubMed] [Google Scholar]
• Allder S, Silvester K, Walley P. Understanding the current state of patient flow in a hospital. Clin Med. 2010;10:441–4. [PMC free article] [PubMed] [Google Scholar]
• Management B. Review of national findings. Audit Commission, National Health Service of England and Wales; 2003. [Google Scholar]
• Management of admission in acute hospitals. Review of the national findings. Healthcare Commission, National Health Service of England and Wales; 2006. [Google Scholar]
• Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–11. [PubMed] [Google Scholar]
• Tamames S, Perez Rubio A, Castrodeza Sanz J, Canton Alvarez MB, Luquero FJ, Santos Sanz S, Lopez Encinar P, de la Torre Pardo MP, Gil Gonzalez JM. Factors associated with the appropriate use of preoperatory hospital stays: historical cohort study. BMC Health Serv Res. 2007;7:187. doi: 10.1186/1472-6963-7-187. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Ronen B, Pliskin J, Pass S. In: Focused Operations Management for Health Services Organizations.   Wiley, editor. Jossey-Bass a Wiley Inprint, San Francisco, CA; 2006. Effects of Fluctuations, Variability, and Uncertainty on the System; pp. 219–35. [Google Scholar]
• 10 High Impact Changes for service improvement and delivery: a guide for NHS Readers. NHS Modernisation Agency. 2011. http://www.ogc.gov.uk/documents/Health_High_Impact_Changes.pdf.
• Black D, Pearson M. Average length of stay, delayed discharge and hospital congestion. Br Med J. 2002;325:610–1. doi: 10.1136/bmj.325.7365.610. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;8:CD000072. [PubMed] [Google Scholar]
• Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AA, Wachter RA. Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project. Postgrad Med J. 2010;86:729–33. doi: 10.1136/qshc.2008.031252rep. [PubMed] [CrossRef] [Google Scholar]
• Proudlove N, Boaden R, Jorgensen J. Developing bed managers: the why and the how. J Nurs Manag. 2007;15:34–42. doi: 10.1111/j.1365-2934.2006.00632.x. [PubMed] [CrossRef] [Google Scholar]
• Salazar A. Gestión centralizada de los ingresos hospitalarios: modelo de priorización de camas. Emergencias. 2008;2(suppl 1):1–3. [Google Scholar]
• Improvement Leader’s Guide. Improving flow. NHS Modernisation Agency. 2011. http://www.internetgroup.ca/clientnet_new/docs/NHS%209%20-%20Improving%20Flow.pdf.
• Mahaffey S. Optimizing patient flow in the enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Health Manag Technol. 2004;25:34–6. [PubMed] [Google Scholar]
• SPSS version 12.0 for Windows. Computer program. SPSS Inc, Chicago; 2004. [Google Scholar]
• Hospitales Top 20 Metodología. Hospitales Top 20 Metodología. Iasist. 2011. http://www.iasist.com/files/Metodologia%20indicadores.pdf.
• McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds.A systematic review of methods and results. Health Policy. 2000;53:157–84. doi: 10.1016/S0168-8510(00)00092-0. [PubMed] [CrossRef] [Google Scholar]
• Hammond CL, Pinnington LL, Phillips MF. A qualitative examination of inappropriate hospital admissions and lengths of stay. BMC Health Serv Res. 2009;9:44. doi: 10.1186/1472-6963-9-44. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Waiting for elective admissions. Review of national findings. National Health Service, UK; 2003. [Google Scholar]
• Ortiga B, Capdevila C, Salazar A, Viso MF, Bartolomé C, Corbella X. Effectiveness of a Surgery Admission Unit for patients undergoing major elective surgery in a tertiary university hospital. BMC Health Serv Res. 2010;10:23. doi: 10.1186/1472-6963-10-23. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Green LV, Nguyen V. Strategies for cutting hospital beds: the impact on patient service. Health Serv Res. 2001;36:421–42. [PMC free article] [PubMed] [Google Scholar]

Standardizing admission and discharge processes to improve patient flow: A cross sectional study

BMC Health Serv Res. 2012; 12: 180.

,^#1,^#2,³,⁴,⁵ and ⁶

Berta Ortiga

¹Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Salazar

²Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Jovell

³Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

Joan Escarrabill

⁴Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

Guillem Marca

⁵Universidad de Vic, Vic, 08500, Spain

Xavier Corbella

⁶Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

¹Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

²Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

³Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

⁴Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

⁵Universidad de Vic, Vic, 08500, Spain

⁶Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Corresponding author.

^#Contributed equally.

Received 2011 Oct 11; Accepted 2012 Jun 28.

Copyright ©2012 Ortiga et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables.

Results

The median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01).

Conclusions

In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

Keywords: Patient flow, hospitals, practice, management

Background

At the moment, hospitals face an increasing demand for hospitalization, for medical staff due to the introduction of innovative technology in diagnostic and therapeutic procedures, for higher standards in clinical safety and, finally, an increasing patient demand for better quality services [1,2]. Optimal bed management is a strategic aim in any hospital as the provision of an inpatient bed, together with the staff and supplies involved, accounts for much of its most complex and expensive activity. The way beds are managed affects the way other hospital departments perform since many are dependent on bed availability, such as emergency services, operating theatres, etc. At the same time, these other hospital departments have an impact on bed usage [3]. Therefore, it is essential to have an efficient and correct bed management in order to improve service delivery.

From patient experience, an admission to a bed as an inpatient in an acute hospital is a major event, independent of this admission being an emergency or from a waiting list. First of all, patient experience will depend on the availability of beds. That is to say, that when patients need an emergency admission, it is important to be admitted quickly and to an appropriate bed, avoiding unnecessary waiting times in the emergency room. On the other hand, if patients are being admitted from a waiting list for elective surgery, it is important to minimize the number of occasions that admissions are cancelled as a result of there being no bed available [4].

The hospitalization process has three main stages: an admission, an inpatient period and a final stage with the discharge process. An inefficient bed management in any of the three stages of the hospitalization can cause a mismatch between demand and capacity. It has been proved that when bed demand exceeds capacity, patient admissions and scheduled surgical procedures can be delayed or cancelled. Traditionally, it has been assumed that the variability in the demand comes from the emergency patient. Interventions focused primarily on emergency departments have had limited success [5]. However, repeated case studies have shown that elective admissions are often the major cause of variation as they are more unpredictable than the emergency admissions [6,7]. In addition, the greatest variation is typically in the number of discharges and, therefore, efforts to reduce variation should start with the discharge process and not in the admission process [8]. Then, to have information about planned discharges 24-h in advance would allow a higher planning and an optimal bed assignment. Moreover, the discharge process should start at the point of admission in the case of planned admissions, as in some cases the estimated length of stay without a medical complication is known. Discharge planning allows for a better and quicker bed assignment in hospitals and the development of nurses and other staff working in discharge coordinator roles [9]. In this sense, it has been proved that multidisciplinary teams can improve the delivery of health services and patient care [10-12]. All admissions and discharges of the hospital should be centrally managed [13] and planned, as single-department solutions may create or worsen bottlenecks in other areas.

During the hospitalization process, patient flow is a strategic aim for the healthcare enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Information is the foundation of any patient flow initiative. Patient flow is built upon the capture, integration and sharing of information, both within and across the different departments and staff [14]. This critical foundation can be immensely challenging to hospitals both with numerous information systems and departments that operate as silos [15]. Actionable information triggers patient care events and enables automated reminders. The aim of this study was to evaluate how hospital capacity was improved through focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital located in the metropolitan area of Barcelona (Spain) that belongs to the National Health System. It attends more than 120,000 emergency visits annually and the mean number of monthly elective admissions is 1,650 (95% CI 1,609 to 1,691), not taking into account day surgery. For our study, we created an interdisciplinary team of clinicians, hospital administrators and patients/families to examine bottlenecks and improvement areas in service delivery. We then selected high impact interventions focused on reducing the variation in the admission process for elective admissions, avoiding unnecessary cancellations of surgery interventions that have an impact on waiting lists, and on planning and standardizing the discharge process. All the interventions were implemented between April and December 2008. See Table for intervention lists.

Table 1

Standardization of the admission process included admission on the same day as surgery and promoting day-surgery rather than inpatient care, both aimed to free up bed days for emergency admissions and to admit major elective patients from a waiting list. To promote planning discharges 24-h in advance consisted in educating the clinicians on entering the discharge information in the electronic patient report. Then the house officers daily worked together with the physician in order to plan the discharge of the patient: discharge report, pharmacy prescriptions, the need of transportation to home, etc. At the same time, the nurse became the patient manager as he or she knew the discharges for the following day and that allowed an optimized task organization for the day, to identify possible home care arrangements for the patient, to collect patient documents from the house officer, and personally give them to the patient so that the patient could ask about any possible doubts. At the same time, the patient/family did not need to go personally to the house officer to collect the information and could get more feedback from their nurse manager. When the patient left the bed, the nurse entered the information in the system, which also prevented the patient/family to personally go and communicate their discharge to the admission unit when leaving the hospital. Bed management was done through a centralized team, with the help of the Information System, which placed emergency and elective patients in the most appropriate beds, allowed patient transfers between wards and checked patient discharge status, in order to have a correct patient allocation and a global vision of the hospital occupancy at all times.

For this study, we included all patients admitted to hospital wards before the multi-intervention, between the 1^st of January and the 31^st of December 2007, and after the implementation, between the 1^st of January and the 31^st of December 2009.

The following variables were recorded through the Hospital General Database: patient demographics, main diagnosis and procedure, admission and discharge dates, date of surgery, number of emergency patients waiting for a bed at 8:00 am, causes of patient cancellation, percentage of planned discharges 24-h in advance, number of patient outliers and number of day-surgery interventions. We did not look for ethical approval, as the organizational change described in this study did not cause any change in the clinical management of the patients and did not make any intervention to the individual patient.

The main outcome measures were: median length of stay, proportion of patients admitted on the same day of surgery, percentage of planned discharges, number of surgery cancellations, proportion of day-surgery, median number of delayed emergency admissions at 8:00 am due to lack of bed and median number of patient outliers, risk-adjusted mortality rate and risk-adjusted readmissions rate.

To describe categorical variables we used the total number of cases (N, days) and the percentage of each category and we used the Chi-squared for linear trend in bivariate analysis. All continuous variables were expressed as median ± interquartile range, and changes were assessed using the Wilcoxon signed ranks test and the Mann–Whitney test. A P value of less than 0.05 was considered statistically significant. All statistical analysis was conducted using the Statistical Software Program [16] for Windows (version 14).

Results

We included 53,361 admissions, of which 27,784 were done in 2007 and 28,577 were done during 2009. Table shows the general activity information during these two years, 2007 and 2009. The number of patient admissions for scheduled surgery was 13,824 patients in 2007 and 14,548 patients in 2009. The proportion of patients admitted on the same day of surgery significantly increased, from 64.87% in 2007 to 86.01% in 2009 (p < 0.05) (Table ). The patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009, without day surgery patients. The scheduled admitted patients length of stay was 4.85 days in 2007 and 4.54 days in 2009, especially caused by the “same day admission” policy implemented, as the pre-surgery length of stay was reduced from 0.58 days in 2007 to 0.26 days in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of day-surgery interventions per day increased, especially due to the increase in day-case rates for the procedures: knee arthroscopy, varicose veins and bunions (Table ).

Table 2

General hospital data during years 2007 and 2009

Table 3

Main Key Performance Indicators during years 2007 and 2009

The standardization of the discharge process was based on discharge planning and teamwork building (Figure ). In this sense, the median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009.

Comparison of percentage of planned discharges during 2007 and 2009, by months.

The median number of patients placed out of service in 2007 was 70 patients and 62 patients in 2009 (p < 0.05). That is to say, the percentage of inpatient outliers diminished from 9.71% in 2007 to 7.30% in 2009 (p < 0.05). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients per day in 2007 and 3 patients per day in 2009 (P < 0.01). The percentage of emergency visits that were finally admitted to the hospital was 10.46% in 2007 and 10.49% in 2009. The percentage of emergency admissions over global admissions was 50.19% in 2007 and 49.10% in 2009. Risk-adjusted mortality rate diminished from 1.02 in 2007 to 0.89 in 2009 [17] (Table ).

Table 4

Quality indicators during years 2007 and 2009

Discussion

The optimization of hospital care resources by managing variation in the admission and discharge processes has proven to be effective. This multiple intervention project increased hospital productivity. Firstly, the main consequence due to the admission process has been the reduction of the length of stay, especially in scheduled admissions due to the reduction in the pre-surgery stay as a high percentage of patients were admitted on the same day as surgery. In addition, day surgery was considered as the first option for some surgery processes. Secondly, the significant increase in planned discharges helped sharing information among staff and enhanced teamwork. House officers were able to prepare all the information and patient arrangements for the day. In addition, patients and their families awaited comfortably in their rooms instead of being the messengers of information among the hospital silos. However, the implementation of these high impact changes required leadership, multidisciplinary teamwork and board level commitment as they affected the whole organization. All interventions were based on “lean” concepts, basically to reduce waste in terms of human resources, public health services and patient quality of care as well as to gain flexibility in hospital capacity.

Interventions included in this study are mostly dependent on the leadership and control of the management team [18] in order to assess the appropriateness of acute bed usage. There is an opportunity by process reengineering to increase bed capacity and productivity with the same fixed costs. In this sense, actions that lead to an increase of productivity without diminishing the service quality, or even increasing it, should be considered as successful key factors for best practices and a competitive advantage for any hospital. Bed management issues therefore warrant high consideration within the hospital’s management team. Some Boards have recognised the importance of hospital operations and that the person in charge of this area of management should be a senior member of the hospital’s executive committee.

In our study we have seen how redesigning operational aspects of the care delivery process that do not affect quality of care, can reduce scheduled admissions cancellations and the number of emergency admissions waiting for a bed. It is crucial not to block beds for elective admissions in advance, as supply of available beds will come through the discharges of the day. The way beds are managed has consequences on all organization levels: emergency and accident departments, surgery theatres, as in both cases their activity depends upon bed availability. However, there are many other aspects to consider when analysing bed capacity such as its efficient use. Departments that are inefficient can lengthen hospital stays and use beds unnecessarily [19].

Around 50 per cent of hospital admissions involve non-emergency patients who have been on a waiting list, mostly for a surgical operation. Waiting dominates many citizens’ perceptions of hospital care. While they are waiting, patients may be in considerable pain and discomfort and this interferes with their normal lifestyle and it adds to the workload of primary care [20]. On the other hand, in order to avoid last moment surgery cancellations due to lack of beds, a lot of professionals are likely to admit their patients the day before surgery and waste a one-day bed unnecessarily. It is then important to reach a consensus between the physicians and the management team in order to maximize profit for both parties, including patients and their families. The intervention for scheduled surgery consisted in a surgery admission unit [21] where the patient was admitted on the same day as surgery and was prepared without being given a bed. In this context, when patients were admitted each morning there were not any free beds in hospital wards, and they had to wait until other patients left the hospital. A possible drawback was that there could be a delay in bed assignments, which could have an impact on the rotation of patients in recovery theatres after the surgery and then in operating theatre flows.

In our hospital we reached 85% of planned discharges (Figure ). Delayed discharge triggered waits on trolleys in the emergency room and in operating theatres. Planning ensured an early and certain discharge as well as a better bed assignment because there was information about which beds would be available. Therefore, the number of patient outliers in the hospital significantly diminished. A limitation of planning discharge was that not all of them were effectively real the following day. The percentage of cancelled discharges was usually less than 10%. However, the importance of the planning was precisely to avoid improvisation of all the staff that participated in the discharge: physician, nurse, house officer, sanitary transport, families and patients and others. In fact, discharge process should start in the admission point, as it is the mismatch between demand and supply of beds that promotes delays and bottlenecks in the system [8,22].

Another limitation of our study was that this multi-intervention was only implemented in one hospital, so the study’s generalizability is limited. In our experience, it is crucial that management leaders focus on efforts to promote admission on the same day as surgery and to promote an early hospital discharge so that other patients can be placed in the most appropriate bed as soon as possible.

Conclusion

In conclusion, admission and discharge standardization and therefore length of stay are largely in our control. There is a significant opportunity to redesign patients’ pathways and improve patient flow to create important benefits for bed management and hospital throughput, which ultimately improve quality and the safeness of patient care.

Competing interests

There are not any financial and non-financial competing interests in relation to this manuscript.

Authors’ contributions

BO contributed to conception and design, acquisition of data, performed the statistical analysis and interpretation of data, as well as drafting the manuscript and adding all the comments from other authors; AS contributed to conception of the study as well as to the interpretation of data and to drafting the discussion of the manuscript; AJ and JE contributed to revising the manuscript critically for important intellectual content; GM participated in the conception, program design and in revising the draft manuscript; XC participated in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Acknowledgements

No funding was received by any of the authors for this study or preparation of the manuscript.

For the help and support in the implementation of the actions described in this study: Cristina Capdevila (Deputy Medical Director, Ambulatory Area), Carlos Bartolomé (Deputy Medical Director, Surgery Area), Antonia Casado (Nurse Director), Mari Fe Viso (Nurse Director Assistant), Lluís Murgui (Head of Information Systems), Rosa Redón (Information Systems), Sílvia Millat (Chief Administrative Area), Sílvia Salgado (Chief of Admissions), Jose Luís Parra (Security Officer) and Sergi López (Chief of Caretakers). For the support in statistical analysis: Nuria Ortega (statistician).

References

• Hendrich AL, Lee N. Intra-Unit Patient Transports: Time, Motion, and Cost Impact on Hospital Efficiency. Nurs Econ. 2005;23:157–64. [PubMed] [Google Scholar]
• Allder S, Silvester K, Walley P. Understanding the current state of patient flow in a hospital. Clin Med. 2010;10:441–4. [PMC free article] [PubMed] [Google Scholar]
• Management B. Review of national findings. Audit Commission, National Health Service of England and Wales; 2003. [Google Scholar]
• Management of admission in acute hospitals. Review of the national findings. Healthcare Commission, National Health Service of England and Wales; 2006. [Google Scholar]
• Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–11. [PubMed] [Google Scholar]
• Tamames S, Perez Rubio A, Castrodeza Sanz J, Canton Alvarez MB, Luquero FJ, Santos Sanz S, Lopez Encinar P, de la Torre Pardo MP, Gil Gonzalez JM. Factors associated with the appropriate use of preoperatory hospital stays: historical cohort study. BMC Health Serv Res. 2007;7:187. doi: 10.1186/1472-6963-7-187. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Ronen B, Pliskin J, Pass S. In: Focused Operations Management for Health Services Organizations.   Wiley, editor. Jossey-Bass a Wiley Inprint, San Francisco, CA; 2006. Effects of Fluctuations, Variability, and Uncertainty on the System; pp. 219–35. [Google Scholar]
• 10 High Impact Changes for service improvement and delivery: a guide for NHS Readers. NHS Modernisation Agency. 2011. http://www.ogc.gov.uk/documents/Health_High_Impact_Changes.pdf.
• Black D, Pearson M. Average length of stay, delayed discharge and hospital congestion. Br Med J. 2002;325:610–1. doi: 10.1136/bmj.325.7365.610. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;8:CD000072. [PubMed] [Google Scholar]
• Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AA, Wachter RA. Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project. Postgrad Med J. 2010;86:729–33. doi: 10.1136/qshc.2008.031252rep. [PubMed] [CrossRef] [Google Scholar]
• Proudlove N, Boaden R, Jorgensen J. Developing bed managers: the why and the how. J Nurs Manag. 2007;15:34–42. doi: 10.1111/j.1365-2934.2006.00632.x. [PubMed] [CrossRef] [Google Scholar]
• Salazar A. Gestión centralizada de los ingresos hospitalarios: modelo de priorización de camas. Emergencias. 2008;2(suppl 1):1–3. [Google Scholar]
• Improvement Leader’s Guide. Improving flow. NHS Modernisation Agency. 2011. http://www.internetgroup.ca/clientnet_new/docs/NHS%209%20-%20Improving%20Flow.pdf.
• Mahaffey S. Optimizing patient flow in the enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Health Manag Technol. 2004;25:34–6. [PubMed] [Google Scholar]
• SPSS version 12.0 for Windows. Computer program. SPSS Inc, Chicago; 2004. [Google Scholar]
• Hospitales Top 20 Metodología. Hospitales Top 20 Metodología. Iasist. 2011. http://www.iasist.com/files/Metodologia%20indicadores.pdf.
• McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds.A systematic review of methods and results. Health Policy. 2000;53:157–84. doi: 10.1016/S0168-8510(00)00092-0. [PubMed] [CrossRef] [Google Scholar]
• Hammond CL, Pinnington LL, Phillips MF. A qualitative examination of inappropriate hospital admissions and lengths of stay. BMC Health Serv Res. 2009;9:44. doi: 10.1186/1472-6963-9-44. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Waiting for elective admissions. Review of national findings. National Health Service, UK; 2003. [Google Scholar]
• Ortiga B, Capdevila C, Salazar A, Viso MF, Bartolomé C, Corbella X. Effectiveness of a Surgery Admission Unit for patients undergoing major elective surgery in a tertiary university hospital. BMC Health Serv Res. 2010;10:23. doi: 10.1186/1472-6963-10-23. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Green LV, Nguyen V. Strategies for cutting hospital beds: the impact on patient service. Health Serv Res. 2001;36:421–42. [PMC free article] [PubMed] [Google Scholar]

Standardizing admission and discharge processes to improve patient flow: A cross sectional study

BMC Health Serv Res. 2012; 12: 180.

,^#1,^#2,³,⁴,⁵ and ⁶

Berta Ortiga

¹Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Salazar

²Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Jovell

³Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

Joan Escarrabill

⁴Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

Guillem Marca

⁵Universidad de Vic, Vic, 08500, Spain

Xavier Corbella

⁶Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

¹Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

²Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

³Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

⁴Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

⁵Universidad de Vic, Vic, 08500, Spain

⁶Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Corresponding author.

^#Contributed equally.

Received 2011 Oct 11; Accepted 2012 Jun 28.

Copyright ©2012 Ortiga et al.; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.This article has been cited by other articles in PMC.

Abstract

Background

The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables.

Results

The median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01).

Conclusions

In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

Keywords: Patient flow, hospitals, practice, management

Background

At the moment, hospitals face an increasing demand for hospitalization, for medical staff due to the introduction of innovative technology in diagnostic and therapeutic procedures, for higher standards in clinical safety and, finally, an increasing patient demand for better quality services [1,2]. Optimal bed management is a strategic aim in any hospital as the provision of an inpatient bed, together with the staff and supplies involved, accounts for much of its most complex and expensive activity. The way beds are managed affects the way other hospital departments perform since many are dependent on bed availability, such as emergency services, operating theatres, etc. At the same time, these other hospital departments have an impact on bed usage [3]. Therefore, it is essential to have an efficient and correct bed management in order to improve service delivery.

From patient experience, an admission to a bed as an inpatient in an acute hospital is a major event, independent of this admission being an emergency or from a waiting list. First of all, patient experience will depend on the availability of beds. That is to say, that when patients need an emergency admission, it is important to be admitted quickly and to an appropriate bed, avoiding unnecessary waiting times in the emergency room. On the other hand, if patients are being admitted from a waiting list for elective surgery, it is important to minimize the number of occasions that admissions are cancelled as a result of there being no bed available [4].

The hospitalization process has three main stages: an admission, an inpatient period and a final stage with the discharge process. An inefficient bed management in any of the three stages of the hospitalization can cause a mismatch between demand and capacity. It has been proved that when bed demand exceeds capacity, patient admissions and scheduled surgical procedures can be delayed or cancelled. Traditionally, it has been assumed that the variability in the demand comes from the emergency patient. Interventions focused primarily on emergency departments have had limited success [5]. However, repeated case studies have shown that elective admissions are often the major cause of variation as they are more unpredictable than the emergency admissions [6,7]. In addition, the greatest variation is typically in the number of discharges and, therefore, efforts to reduce variation should start with the discharge process and not in the admission process [8]. Then, to have information about planned discharges 24-h in advance would allow a higher planning and an optimal bed assignment. Moreover, the discharge process should start at the point of admission in the case of planned admissions, as in some cases the estimated length of stay without a medical complication is known. Discharge planning allows for a better and quicker bed assignment in hospitals and the development of nurses and other staff working in discharge coordinator roles [9]. In this sense, it has been proved that multidisciplinary teams can improve the delivery of health services and patient care [10-12]. All admissions and discharges of the hospital should be centrally managed [13] and planned, as single-department solutions may create or worsen bottlenecks in other areas.

During the hospitalization process, patient flow is a strategic aim for the healthcare enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Information is the foundation of any patient flow initiative. Patient flow is built upon the capture, integration and sharing of information, both within and across the different departments and staff [14]. This critical foundation can be immensely challenging to hospitals both with numerous information systems and departments that operate as silos [15]. Actionable information triggers patient care events and enables automated reminders. The aim of this study was to evaluate how hospital capacity was improved through focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital located in the metropolitan area of Barcelona (Spain) that belongs to the National Health System. It attends more than 120,000 emergency visits annually and the mean number of monthly elective admissions is 1,650 (95% CI 1,609 to 1,691), not taking into account day surgery. For our study, we created an interdisciplinary team of clinicians, hospital administrators and patients/families to examine bottlenecks and improvement areas in service delivery. We then selected high impact interventions focused on reducing the variation in the admission process for elective admissions, avoiding unnecessary cancellations of surgery interventions that have an impact on waiting lists, and on planning and standardizing the discharge process. All the interventions were implemented between April and December 2008. See Table for intervention lists.

Table 1

Standardization of the admission process included admission on the same day as surgery and promoting day-surgery rather than inpatient care, both aimed to free up bed days for emergency admissions and to admit major elective patients from a waiting list. To promote planning discharges 24-h in advance consisted in educating the clinicians on entering the discharge information in the electronic patient report. Then the house officers daily worked together with the physician in order to plan the discharge of the patient: discharge report, pharmacy prescriptions, the need of transportation to home, etc. At the same time, the nurse became the patient manager as he or she knew the discharges for the following day and that allowed an optimized task organization for the day, to identify possible home care arrangements for the patient, to collect patient documents from the house officer, and personally give them to the patient so that the patient could ask about any possible doubts. At the same time, the patient/family did not need to go personally to the house officer to collect the information and could get more feedback from their nurse manager. When the patient left the bed, the nurse entered the information in the system, which also prevented the patient/family to personally go and communicate their discharge to the admission unit when leaving the hospital. Bed management was done through a centralized team, with the help of the Information System, which placed emergency and elective patients in the most appropriate beds, allowed patient transfers between wards and checked patient discharge status, in order to have a correct patient allocation and a global vision of the hospital occupancy at all times.

For this study, we included all patients admitted to hospital wards before the multi-intervention, between the 1^st of January and the 31^st of December 2007, and after the implementation, between the 1^st of January and the 31^st of December 2009.

The following variables were recorded through the Hospital General Database: patient demographics, main diagnosis and procedure, admission and discharge dates, date of surgery, number of emergency patients waiting for a bed at 8:00 am, causes of patient cancellation, percentage of planned discharges 24-h in advance, number of patient outliers and number of day-surgery interventions. We did not look for ethical approval, as the organizational change described in this study did not cause any change in the clinical management of the patients and did not make any intervention to the individual patient.

The main outcome measures were: median length of stay, proportion of patients admitted on the same day of surgery, percentage of planned discharges, number of surgery cancellations, proportion of day-surgery, median number of delayed emergency admissions at 8:00 am due to lack of bed and median number of patient outliers, risk-adjusted mortality rate and risk-adjusted readmissions rate.

To describe categorical variables we used the total number of cases (N, days) and the percentage of each category and we used the Chi-squared for linear trend in bivariate analysis. All continuous variables were expressed as median ± interquartile range, and changes were assessed using the Wilcoxon signed ranks test and the Mann–Whitney test. A P value of less than 0.05 was considered statistically significant. All statistical analysis was conducted using the Statistical Software Program [16] for Windows (version 14).

Results

We included 53,361 admissions, of which 27,784 were done in 2007 and 28,577 were done during 2009. Table shows the general activity information during these two years, 2007 and 2009. The number of patient admissions for scheduled surgery was 13,824 patients in 2007 and 14,548 patients in 2009. The proportion of patients admitted on the same day of surgery significantly increased, from 64.87% in 2007 to 86.01% in 2009 (p < 0.05) (Table ). The patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009, without day surgery patients. The scheduled admitted patients length of stay was 4.85 days in 2007 and 4.54 days in 2009, especially caused by the “same day admission” policy implemented, as the pre-surgery length of stay was reduced from 0.58 days in 2007 to 0.26 days in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of day-surgery interventions per day increased, especially due to the increase in day-case rates for the procedures: knee arthroscopy, varicose veins and bunions (Table ).

Table 2

General hospital data during years 2007 and 2009

Table 3

Main Key Performance Indicators during years 2007 and 2009

The standardization of the discharge process was based on discharge planning and teamwork building (Figure ). In this sense, the median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009.

Comparison of percentage of planned discharges during 2007 and 2009, by months.

The median number of patients placed out of service in 2007 was 70 patients and 62 patients in 2009 (p < 0.05). That is to say, the percentage of inpatient outliers diminished from 9.71% in 2007 to 7.30% in 2009 (p < 0.05). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients per day in 2007 and 3 patients per day in 2009 (P < 0.01). The percentage of emergency visits that were finally admitted to the hospital was 10.46% in 2007 and 10.49% in 2009. The percentage of emergency admissions over global admissions was 50.19% in 2007 and 49.10% in 2009. Risk-adjusted mortality rate diminished from 1.02 in 2007 to 0.89 in 2009 [17] (Table ).

Table 4

Quality indicators during years 2007 and 2009

Discussion

The optimization of hospital care resources by managing variation in the admission and discharge processes has proven to be effective. This multiple intervention project increased hospital productivity. Firstly, the main consequence due to the admission process has been the reduction of the length of stay, especially in scheduled admissions due to the reduction in the pre-surgery stay as a high percentage of patients were admitted on the same day as surgery. In addition, day surgery was considered as the first option for some surgery processes. Secondly, the significant increase in planned discharges helped sharing information among staff and enhanced teamwork. House officers were able to prepare all the information and patient arrangements for the day. In addition, patients and their families awaited comfortably in their rooms instead of being the messengers of information among the hospital silos. However, the implementation of these high impact changes required leadership, multidisciplinary teamwork and board level commitment as they affected the whole organization. All interventions were based on “lean” concepts, basically to reduce waste in terms of human resources, public health services and patient quality of care as well as to gain flexibility in hospital capacity.

Interventions included in this study are mostly dependent on the leadership and control of the management team [18] in order to assess the appropriateness of acute bed usage. There is an opportunity by process reengineering to increase bed capacity and productivity with the same fixed costs. In this sense, actions that lead to an increase of productivity without diminishing the service quality, or even increasing it, should be considered as successful key factors for best practices and a competitive advantage for any hospital. Bed management issues therefore warrant high consideration within the hospital’s management team. Some Boards have recognised the importance of hospital operations and that the person in charge of this area of management should be a senior member of the hospital’s executive committee.

In our study we have seen how redesigning operational aspects of the care delivery process that do not affect quality of care, can reduce scheduled admissions cancellations and the number of emergency admissions waiting for a bed. It is crucial not to block beds for elective admissions in advance, as supply of available beds will come through the discharges of the day. The way beds are managed has consequences on all organization levels: emergency and accident departments, surgery theatres, as in both cases their activity depends upon bed availability. However, there are many other aspects to consider when analysing bed capacity such as its efficient use. Departments that are inefficient can lengthen hospital stays and use beds unnecessarily [19].

Around 50 per cent of hospital admissions involve non-emergency patients who have been on a waiting list, mostly for a surgical operation. Waiting dominates many citizens’ perceptions of hospital care. While they are waiting, patients may be in considerable pain and discomfort and this interferes with their normal lifestyle and it adds to the workload of primary care [20]. On the other hand, in order to avoid last moment surgery cancellations due to lack of beds, a lot of professionals are likely to admit their patients the day before surgery and waste a one-day bed unnecessarily. It is then important to reach a consensus between the physicians and the management team in order to maximize profit for both parties, including patients and their families. The intervention for scheduled surgery consisted in a surgery admission unit [21] where the patient was admitted on the same day as surgery and was prepared without being given a bed. In this context, when patients were admitted each morning there were not any free beds in hospital wards, and they had to wait until other patients left the hospital. A possible drawback was that there could be a delay in bed assignments, which could have an impact on the rotation of patients in recovery theatres after the surgery and then in operating theatre flows.

In our hospital we reached 85% of planned discharges (Figure ). Delayed discharge triggered waits on trolleys in the emergency room and in operating theatres. Planning ensured an early and certain discharge as well as a better bed assignment because there was information about which beds would be available. Therefore, the number of patient outliers in the hospital significantly diminished. A limitation of planning discharge was that not all of them were effectively real the following day. The percentage of cancelled discharges was usually less than 10%. However, the importance of the planning was precisely to avoid improvisation of all the staff that participated in the discharge: physician, nurse, house officer, sanitary transport, families and patients and others. In fact, discharge process should start in the admission point, as it is the mismatch between demand and supply of beds that promotes delays and bottlenecks in the system [8,22].

Another limitation of our study was that this multi-intervention was only implemented in one hospital, so the study’s generalizability is limited. In our experience, it is crucial that management leaders focus on efforts to promote admission on the same day as surgery and to promote an early hospital discharge so that other patients can be placed in the most appropriate bed as soon as possible.

Conclusion

In conclusion, admission and discharge standardization and therefore length of stay are largely in our control. There is a significant opportunity to redesign patients’ pathways and improve patient flow to create important benefits for bed management and hospital throughput, which ultimately improve quality and the safeness of patient care.

Competing interests

There are not any financial and non-financial competing interests in relation to this manuscript.

Authors’ contributions

BO contributed to conception and design, acquisition of data, performed the statistical analysis and interpretation of data, as well as drafting the manuscript and adding all the comments from other authors; AS contributed to conception of the study as well as to the interpretation of data and to drafting the discussion of the manuscript; AJ and JE contributed to revising the manuscript critically for important intellectual content; GM participated in the conception, program design and in revising the draft manuscript; XC participated in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Acknowledgements

No funding was received by any of the authors for this study or preparation of the manuscript.

For the help and support in the implementation of the actions described in this study: Cristina Capdevila (Deputy Medical Director, Ambulatory Area), Carlos Bartolomé (Deputy Medical Director, Surgery Area), Antonia Casado (Nurse Director), Mari Fe Viso (Nurse Director Assistant), Lluís Murgui (Head of Information Systems), Rosa Redón (Information Systems), Sílvia Millat (Chief Administrative Area), Sílvia Salgado (Chief of Admissions), Jose Luís Parra (Security Officer) and Sergi López (Chief of Caretakers). For the support in statistical analysis: Nuria Ortega (statistician).

References

• Hendrich AL, Lee N. Intra-Unit Patient Transports: Time, Motion, and Cost Impact on Hospital Efficiency. Nurs Econ. 2005;23:157–64. [PubMed] [Google Scholar]
• Allder S, Silvester K, Walley P. Understanding the current state of patient flow in a hospital. Clin Med. 2010;10:441–4. [PMC free article] [PubMed] [Google Scholar]
• Management B. Review of national findings. Audit Commission, National Health Service of England and Wales; 2003. [Google Scholar]
• Management of admission in acute hospitals. Review of the national findings. Healthcare Commission, National Health Service of England and Wales; 2006. [Google Scholar]
• Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–11. [PubMed] [Google Scholar]
• Tamames S, Perez Rubio A, Castrodeza Sanz J, Canton Alvarez MB, Luquero FJ, Santos Sanz S, Lopez Encinar P, de la Torre Pardo MP, Gil Gonzalez JM. Factors associated with the appropriate use of preoperatory hospital stays: historical cohort study. BMC Health Serv Res. 2007;7:187. doi: 10.1186/1472-6963-7-187. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Ronen B, Pliskin J, Pass S. In: Focused Operations Management for Health Services Organizations.   Wiley, editor. Jossey-Bass a Wiley Inprint, San Francisco, CA; 2006. Effects of Fluctuations, Variability, and Uncertainty on the System; pp. 219–35. [Google Scholar]
• 10 High Impact Changes for service improvement and delivery: a guide for NHS Readers. NHS Modernisation Agency. 2011. http://www.ogc.gov.uk/documents/Health_High_Impact_Changes.pdf.
• Black D, Pearson M. Average length of stay, delayed discharge and hospital congestion. Br Med J. 2002;325:610–1. doi: 10.1136/bmj.325.7365.610. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;8:CD000072. [PubMed] [Google Scholar]
• Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AA, Wachter RA. Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project. Postgrad Med J. 2010;86:729–33. doi: 10.1136/qshc.2008.031252rep. [PubMed] [CrossRef] [Google Scholar]
• Proudlove N, Boaden R, Jorgensen J. Developing bed managers: the why and the how. J Nurs Manag. 2007;15:34–42. doi: 10.1111/j.1365-2934.2006.00632.x. [PubMed] [CrossRef] [Google Scholar]
• Salazar A. Gestión centralizada de los ingresos hospitalarios: modelo de priorización de camas. Emergencias. 2008;2(suppl 1):1–3. [Google Scholar]
• Improvement Leader’s Guide. Improving flow. NHS Modernisation Agency. 2011. http://www.internetgroup.ca/clientnet_new/docs/NHS%209%20-%20Improving%20Flow.pdf.
• Mahaffey S. Optimizing patient flow in the enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Health Manag Technol. 2004;25:34–6. [PubMed] [Google Scholar]
• SPSS version 12.0 for Windows. Computer program. SPSS Inc, Chicago; 2004. [Google Scholar]
• Hospitales Top 20 Metodología. Hospitales Top 20 Metodología. Iasist. 2011. http://www.iasist.com/files/Metodologia%20indicadores.pdf.
• McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds.A systematic review of methods and results. Health Policy. 2000;53:157–84. doi: 10.1016/S0168-8510(00)00092-0. [PubMed] [CrossRef] [Google Scholar]
• Hammond CL, Pinnington LL, Phillips MF. A qualitative examination of inappropriate hospital admissions and lengths of stay. BMC Health Serv Res. 2009;9:44. doi: 10.1186/1472-6963-9-44. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Waiting for elective admissions. Review of national findings. National Health Service, UK; 2003. [Google Scholar]
• Ortiga B, Capdevila C, Salazar A, Viso MF, Bartolomé C, Corbella X. Effectiveness of a Surgery Admission Unit for patients undergoing major elective surgery in a tertiary university hospital. BMC Health Serv Res. 2010;10:23. doi: 10.1186/1472-6963-10-23. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
• Green LV, Nguyen V. Strategies for cutting hospital beds: the impact on patient service. Health Serv Res. 2001;36:421–42. [PMC free article] [PubMed] [Google Scholar]

Patient Admission, Hospital Stay & Discharge

Patient Admission, Hospital Stay & Discharge | Yashoda Super Speciality Hospitals

Admission Process:

• Patient Reports To The Reception Of The Hospital.
• Front Office Executive Enquires About The Patient’s Problem.
• Front Office Executive Refers The Patient To The Concerned Department/Doctor.
• Patient Reports There, And Concerned Doctor Investigates The Patient’s Case History.
• If Required, Patient Is Advised For Admission In The Hospital. In Case Of Admission, The Patient Is Being Sent To Emergency Department For Initial Assessment By The CMO From Where He/ She Gets The Admission Request Form.
• Along With The Admission Request Form Patient’s Attendant Is Being Referred To Admission & Registration Counter.V
• Except For Emergency Cases, Admission To The Hospital Is Done Once It Is Being Recommended By The Specialist During The Patient’s Outpatient Consultation.

Before admission, the patient is counseled by the Front Office Executive regarding the treatment package which includes:

• Estimated Bill Size
• Average Length Of Stay
• Various Modes Of Payment Accepted- Cash/ Credit Or Debit Card/ DD, Personal Cheques Are Not Accepted
• Documents Required For Admission Under Cashless Facility
• When The Patient Arrives At The Ward With The Coordinator, Our Ward Staff Will Educate The Patient To The Ward And The Facilities Available. Patient Will Then Be Reassessed By The Ward RMO – This Involves Taking A Detailed Medical History And Ordering Of Tests If Necessary.
• During The Patient’s Stay In The Hospital, He/She Will Be Attended By A Team Doctors Comprising Of Medical Specialists, Assisted By Medical Officers. Every Care Is Taken In Respect Of Patient Care, Treatment (Conservative/ Surgical), Meals, Dress And Health Recovery.
• The Daily Routine In The Ward Includes Activities Such As Ward Rounds By Doctors, Medication, Meals, Visiting Hours And Bedtime. However, This Routine May Vary As Laboratory Tests, X-Ray, Treatment And Other Procedures Will Take Place When Required.
• For All Kind Of Diagnostic & Therapeutic Procedure, Informed Consent Is Being Taken As Per Hospital Policy.
• The Patient’s Medical Records And Information On Their Medical Condition Are Confidential. We Will Only Share This Information With The Patient And The Next-Of-Kin. If The Immediate Family Members Wish To Know More About The Patient’s Condition, They Can Approach The Appropriate Coordinator To Arrange For Convenient Time To Meet The Concerned Doctor.
• The Safety And Wellbeing Of Our Patient Is Our Utmost Concern To Us. We Advise Our Patients To Remain Within The Hospital Premises Until They Are Discharged By The Concerned Doctor.
• A Discharge Summary Certificate Will Be Given To The Patient Before Leaving The Ward. In Case The Patient Needs A Medical Certificate, He/She Has To Inform The Doctor Or Nurse In Advance So That It Can Be Prepared Before The Patient’s Leaves
• The Nurse Will Hand Over The Signed Discharge Summary Which Includes Doctor’s Advice On Their Further Follow-Up Treatment, Daily Routine Diet, And Medication Prescription And Other Relevant Documents At The Time Of Discharge. The Doctor Signs The Discharge Sheet Of The Patient. The Final Bill Is Prepared At The Billing Office.
• The Patient/Attendants Are Informed About The Interim Bills On A Daily Basis. The Patient Has To Settle All His Bills At The Time Of Discharge.

Admission Process – TallaghtHospital

Contact Information: 
Admissions & Scheduled Care Office – We are open Monday to Friday from 9am – 5pm
General Surgery/ENT/Gynaecology/Vascular/ Urology Enquiries 01 414 2800 / 01 414 2801
Orthopaedic enquires 01 414 2805 (9am-2pm)
Admissions Assessment Office – 01 414 3028/ 3030

How to find us:
To find the Admissions Assessment Office enter main reception, turn right at the lifts, take first left and the office is the first door on the left.

Referral Procedure for Elective Surgery: 
Patients who need to be placed on a waiting list for in-patient treatment are referred from the Out Patients Department and entered onto the hospital waiting list.

Admission Arrangements:
We have approximately 2,000 patients on our inpatient waiting lists for whom we expect to deliver the highest standards of care including appropriate and timely medical care.
Patients are admitted to Tallaght University Hospital either by elective admission (pre-arranged) or emergency admission through our Emergency or Outpatients Departments.

Waiting Lists:
Please advise the Admissions Office immediately if you are unable to attend your scheduled admission or need to request to have it rescheduled. This enables the hospital to offer the bed assigned to you to another patient on our waiting list.
If you change any of your contact details i.e. address or phone number please contact the office as soon as possible to update your records and allow us to contact you in a timely manner.

Pre Assessment Clinic:
You may receive an appointment to attend a pre-assessment clinic within three months of your intended admission to the Hospital. This appointment takes approximately 30-45 minutes. For further information please read the attached leaflet.

Appointment Instructions: 
A letter will be sent to patients informing them of their provisional admission date and instructions to contact the admissions office.

It is important that you follow the instructions on this letter. If instructed, please contact the office, prior to travel, to ensure that there is a bed available and prevent a possible wasted journey, as your admission is contingent on availability of beds.  Once your bed is confirmed please report to the admissions assessment office. To find the Admissions Assessment Office enter main reception, turn right at the lifts, take first left and the office is the first door on the left.

If you are booked to come in as a Day of Surgery Admission (DOSA) you will have attended our pre-assessment clinic (see above).
On the morning of your admission you will report directly to the Admissions Assessment Office at your allocated time where you will be checked in to hospital and taken to the DOSA lounge. Here you will be admitted by the nurse, the doctor and reviewed by the anaesthetist prior to your surgery. You will have your surgery that day so it is important you have followed all instructions given to you at pre-assessment and by your doctor. For further information please read the attached leaflet.

On Day of Admission:
Being admitted to a Hospital may seem daunting and make you feel anxious, however, the staff at Tallaght University Hospital are dedicated to your care and wellbeing please tell them if you are feeling anxious or having any questions.

When Can My Family and Friends Visit Me?
You can read about our visiting hours here

Where should I go?
On your day of Admission please proceed to the Admissions Assessment Office where staff will confirm your patient details and register you to the Hospital system. To find the Admissions Assessment Office enter main reception, turn right at the lifts, take first left and the office is the first door on the left.

What happens when I need to go home?
You will be advised by your medical team when you are ready to go home. But to be prepared it is important to ensure you have arranged a lift home, you have all your belongings and that you have any prescriptions or letters of referral that you may require after discharge.

Where possible the Hospital try to have patients home by 11am in the morning, if you cannot get a lift home at this time you will be directed to the Hospital’s Transition Lounge, this is to enable other inpatients access to beds as soon as possible.
Please note the Hospital cannot provide a laundry service so please make suitable arrangements with family / friends

Useful Information: Please note the selection of leaflets below for further information prior to your admission. 

The flow of patients through the hospital admission process for…

… It is a quantitative measure, that is usually associated with the amount of patients that is served. Table 4 The performance criteria are: waiting time, leveling, utilization-related measures, idle time, throughput, preferences (e.g., priority scoring), financial (e.g., maximization of financial contribution per pathology), makespan (completion time), patient deferral/postponement and other (e.g., number of required porter teams) Waiting time Patient [3,8,17,26,42,52,57,60,[62][63][64]87,88,95,96,98,[108][109][110][111]113,124,128,131,132,135,136,142,146,[155][156][157]164,[187][188][189]191,194,202,[204][205][206]213,215,224,225,227,228,235,236,239,[242][243][244][245][246]250,255,265,273,279] Surgeon [20,54,62,64,156,170,212,260,265,[280][281][282] Leveling OR [24,41,84,174,175,194] Ward [22,23,25,41,49,85,86,99,115,166,167,196,223,241,257,258] PACU [24,45,46,85,127,172,173,226,239,253] Patient volume [171,194,241,245] Overutilization OR [2,3,20,26,35,39,41,42,51,52,54,55,60,[62][63][64][65][66]68,73,79,82,85,87,88,[90][91][92][93][94][95][96][108][109][110][111]116,126,128,[132][133][134][135][136][137]141,146,[150][151][152][154][155][156]158,163,[170][171][172]174,176,183,184,[186][187][188]194,195,199,[205][206][207]210,212,213,[215][216][217][218]227,228,234,[241][242][243]245,247,250,252,254,264,269,272,273,277,280] Ward [41,51,87,264] ICU [2,3,60,137,199,264] PACU [2,3,45,46,60,82,183] Underutilization OR [2,3,30,31,51,54,55,60,68,[90][91][92][93][94]115,126,[135][136][137]141,146,152,156,158,163,176,184,194,195,199,216,229,241,245,250,253,264,269,277,279,[281][282][283] Ward [264] ICU [2,3,60,137,264] PACU [2,3,60,243] OR idle time [26,54,62,64,88,102,111,121,125,134,157,170,176,210,212,225,[280][281][282] OR utilization [8,14,16,17,21,[34][35][36]42,52,56,68,70,87,95,96,98,104,116,118,138,146,155,156,167,[177][178][179]194,206,227,236,239,245,247,250,252,260,273] Throughput [8,[14][15][16][17]21,34,41,104,118,119,138,146,158,176,178,179,184,192,193,214,223,227,236,245,247,255] Preferences [4,5,15,25,29,39,45,46,56,59,78,85,105,137,147,154,166,186,187,189,198,199,202,203,215,224,237,238,241,244,[246][247][248][260][261][262]270,278] Financial [20,29,40,55,58,65,[69][70][71][72]75,79,101,111,128,148,161,164,167,168,176,190,237,259,272] Makespan [10][11][12]59,90,93,94,102,125,127,153,157,158,163,172,183,207,219,224,234,249,271,274,275] Deferral/postponement [3,13,35,42,55,58,60,82,85,87,103,118,121,142,145,146,162,[204][205][206]213,227,239,240,247,283] Other [2,3,15,17,19,21,52,59,60,82,85,98,99,110,115,121,131,133,147,[150][151][152]161,164,167,172,175,176,183,184,188,196,201,205,207,217,218,225,235,242,243,245,261] In contrast, preference-related measures most often cover some qualitative aspect. They experienced a peak of interest around 2010. …

Admission Procedure – Central Clinic

The admission procedure is comprised of the following:

1. Personal details of the patient are recorded.
2. The tests ordered by the patient’s doctor are charged.
3. The room is assigned after the patient has been updated by either the Patient Accounting Department or the Customer Service Department.
4. The patient is provided with the admission form which has been filled in by his doctor. Later the same day or on the next day the patient may visit the Patient Accounting Department for further information.
5. Once admission has been completed, the patient is taken by nursing staff to his ward and his file is handed to the Matron.

What documents should I bring with me?

• ID Card
• Medical Record Book
• Admission Form from Social Security Organisation
• Private Health Insurance Policy Number, if applicable (in these situations, the patient must be aware of the type of room he is covered for)
• Orders and instructions from the doctor

What may I bring with me?

• Personal toiletries
• Pyjamas, night gowns, slippers
• Personal care items

What should I avoid bringing with me?

• During the admission procedure, do not bring electrical items (hair dryers, electric shavers), valuable jewellery, laptop computers or large quantities of cash with you. The Clinic is not liable for the loss of these items. Personal items must be placed in the safe each time you leave your room.

What procedure should I follow while being admitted to the Central Clinic of Athens?

If you will be undergoing a surgical procedure, be sure to ask for the special information pamphlet available from the Clinic and read it through carefully.

What should I do with medication I am currently taking?

Once you arrive in your ward, be sure to inform your doctor or nurse about medication you are currently taking when providing them with your medical history. The medication must be handed to the nursing staff for safe keeping. You should not store any medication in your bedside table nor should you take any medication except that which is given to you by the doctors as your condition may be distorted and improvement delayed.

Rules and terms of hospitalization | GAUZ SO SOB No. 2

Rules and terms of hospitalization

1. Hospitalization of patients is carried out in a planned manner:

1.1. in the directions of state medical healthcare organizations;

1.2. on the direction of specialists of the polyclinic GAUZ SO “SOB No. 2” in a planned and urgent manner;

2. Determination of medical indications for hospitalization of persons is carried out by the doctor of the polyclinic at the reception or the doctor of the admission department during the examination and examination of the patient.In difficult or disputable cases, the question of the need for hospitalization is decided by a commission, with the participation of the head of the specialized department of the hospital, the responsible doctor on duty or the hospital administrator on duty.

3. In case of refusal of the patient from hospitalization, if there is evidence, he must confirm his refusal in writing by signing in the form for giving voluntary consent or refusal to medical intervention and in a special journal in the presence of a doctor, a doctor in the emergency department or a responsible doctor on duty, after receiving clarifications about the need for hospitalization and the consequences of refusal.

4. The waiting times for the provision of primary health care in an emergency form should not exceed 2 hours from the moment the patient contacts a medical organization, the waiting times for the provision of specialized medical care – 30 calendar days from the date the attending physician issued a referral for hospitalization.

5. The patient or his legal representative, upon admission to the hospital, routinely submits the following documents to the medical staff of the admission department:

– referral for hospitalization;

– identity document;

– compulsory health insurance policy.

6. Persons accompanying adult patients await the examination results in a specially designated lobby of the admission department.

7. The presence of an accompanying person is permitted during examination in the admission department of an adult patient, contact with whom is difficult due to his severe condition or existing visual, hearing, mental or movement disorders.

8. The presence of persons accompanying the patient is not allowed in intensive care, X-ray, procedural, manipulation and other security rooms.

9. Accompanying persons are allowed to participate and assist the emergency department medical staff in transporting the patient to hospitalization in departments, with the exception of intensive care, radiological and diagnostic departments.

10. When registering a patient for hospitalization in the emergency department, things, money, valuables, documents of the patient are returned to accompanying relatives or accepted for storage in accordance with the established procedure until discharge. It is allowed to take personal hygiene items and utensils into the ward (toothbrush, paste, soap, toilet paper, handkerchiefs, towel, razor, cup, spoon, etc.)).

11. In the admission department, the patient must be examined for the presence of infectious diseases, if necessary, sanitary or disinsection treatment is performed (in case of detection of widespread head lice, the hair can be removed).

12. In the process of providing medical care, the doctor and the patient have equal rights to respect for their human dignity and can protect it in accordance with applicable law. The relationship between the doctor and the patient should be built on the basis of mutual trust and mutual responsibility.The patient is an active participant in the treatment process.

13. The doctor, in exceptional cases, has the right to refuse to work with the patient, in agreement with the head of the department, entrusting him to another specialist:

a) in the absence of the necessary technical capability to provide the required type of assistance;

b) if it is impossible to establish contact with the patient.

14. All medical interventions and manipulations are carried out only with the informed consent of the patient and with the execution of the relevant documents in the medical record of the inpatient, except in special cases when the severity of the physical or mental condition does not allow the patient to make an informed decision, or in other cases provided for by law.

15. The patient is discharged from the hospital by the attending physician in agreement with the head of the department. An extract is issued at the end of the working day of the attending physician, on weekends and holidays, by the doctor on duty of the department.

16. At the request of the patient or his legal representative, the discharge of the patient may be carried out ahead of schedule only with the knowledge of the chief physician or his deputy, provided that the discharge of the patient does not pose a danger to his life. The application of the patient (or his legal representative) for his early discharge is filed in the medical record of the inpatient.

17. Temporary home leave for patients undergoing inpatient treatment at SOB No. 2 is prohibited.

UHF Next Step in Care

You may feel some pressure from the team to take your relative home as soon as possible. Your relative may also insist that you take him home as soon as possible. Returning home may be the best option for everyone. but both you and your relative should see the point in this.This means that the house where your relative will return must be safe, equipped with a telephone and not require major repairs. It also means thinking about how to pay for the care and combine caring for a relative with your other responsibilities.

There is a lot to think about here. It may take a while for you to think things over. Tell the team if you are not ready or able to provide care for your relative after they are discharged.They will try to help you solve the problem (s).

Up (pages)

Appeal the discharge decision (if necessary)

Sometimes the hospital accepts a discharge plan that you do not want, that you disagree with, or that you think is unreliable. You have the right to challenge this decision (ask for a review). By law, the hospital must tell you how to apply for a review of the decision and explain what happens next. Make sure the hospital provides you with contact information for the Beneficiary and Family Assistance Unit of the Office for Quality Improvement.BFCC-QIO), which deals with such appeals. You can find a list of them by state at http://www.nextstepincare.org/Links_and_Resources/Federal/Medicare_Appeals/.

Up (pages)

Next Step: Prepare to Return Home

There are many issues you will need to resolve as you prepare your relative to return home. Here are some points to keep in mind:

Equipment and consumables

Purchase all necessary equipment and supplies.Find out what the home care facility or service provides and what you need to get yourself. Here are some questions to be answered:

• Does my relative need a hospital bed, shower chair, pot toilet, oxygen tank, or other equipment? If so, where can I get these things?
• What consumables do I need? These include diapers, disposable gloves, and skin care products.
• Will my home care facility or service provide them, or do I need to buy them myself?
• If I need to buy these materials, where can I find them?
• Will my relative’s insurance pay for them?

Up (pages)

Home space

Your relative’s home must be comfortable, safe, and suitable for medical care.Ask the team if you need any special preparation. For example:

• Make room for a hospital bed or other large equipment.
• Remove items that could cause a fall, such as carpets and electrical cables.
• Prepare a suitable storage area for medical supplies.
• Prepare a seat to sit comfortably next to your relative.
• Find a place to store important information such as a bulletin board, notebook or desk drawer

Up (pages)

Care Tasks

You will most likely need to perform a number of tasks while caring for your relative.It is important to know how to do them correctly. Try to find out as much as possible about this while your relative is still in the hospital. You will learn this by observing the actions of the rehab staff as they perform these tasks. You can ask them to watch you while you try to do them yourself.

Occasionally, rehabilitation staff will only begin teaching these tasks when the day of discharge approaches.However, this may not be the right time if you feel overwhelmed. Find out everything you can and ask for the phone number of someone to call in case you need help at home.

You may be given the phone number of someone in the hospital, home care nurse, or other caregiver.

Inform if you are afraid to perform tasks (such as caring for a wound) or cannot help with personal hygiene (such as helping your family member shower or go to the toilet).Some caregivers may feel comfortable changing their relative’s diapers, while others feel very uncomfortable with the task. Think about how you and your relative will feel. The team needs to know which tasks you can and cannot do so that the necessary assistance can be prepared.

Up (pages)

Specialty food

Ask the team if there are any foods your family member should or may not eat. These can be individual foods, such as milk or meat, and in general, specific foods, such as very soft foods or liquids. If your family member needs special foods, try to buy them before check-out, when you can find time to shop.

Up (pages)

Medicines

One of your responsibilities as a Caregiver may be to manage your medication intake when you need to make sure your family member is taking the right medication, at the right time, and in the right amount. Here are some questions to help you do this job:

• What new medications will your relative need to take?
• How long will he need to take new drugs?
• Should this medication be taken with food? At a certain time every day?
• Does this medicine have any side effects?
• Can it be taken with other medicines?
• Is this drug listed on the Medication Cue List among other prescribed medications, over-the-counter medications, vitamins, and herbal supplements my relative is taking?
• Will I get this medicine at my pharmacy or hospital?
• Will my relative’s insurance pay for these drugs? If not, is it possible to find other drugs that have the same effect, but are cheaper?

A Medication Guide and Checklist to help you understand your family member’s medication information are available at www.nextstepincare.org

Up (pages)

Home: Providing care

Hospital Discharge Planning | Memorial Sloan Kettering Cancer Center

This information explains the discharge process after an inpatient treatment at Memorial Sloan Kettering (MSK).

to come back to the beginning

What is hospital discharge planning?

Discharge scheduling is the process of preparing for your leaving the hospital.Your healthcare team will review what care you need after you are discharged. Being discharged from the hospital does not mean that you have completely recovered. This means that, according to your doctor, you no longer need to be in the hospital.

Your discharge plan may stipulate that you are leaving:

• to yourself or someone else’s home;
• to the rehabilitation center;
• to a nursing home.

Your healthcare team may recommend a variety of services, such as visits by a visiting nurse, use of equipment, or short stays in rehabilitation facilities.If you need these services, your claims specialist (a member of your healthcare team who helps plan and coordinate services) will work with your insurance company and various agencies to make sure the services are provided.

to come back to the beginning

Who is responsible for my discharge?

Only a doctor can discharge you from the hospital.
At the same time, a whole team of specialists is working on drawing up a plan for your discharge.Your doctors, nurses, and social workers will work with your claims specialist to consider what help you might need after you leave the hospital.

to come back to the beginning

When is discharge planning carried out?

Planning for hospital discharge may begin even before you arrive for inpatient care. If your hospital treatment has been planned in advance, your doctors and nurses can tell you how long your hospital stay will be.They will discuss this with you during your hospital stay and make changes to the plan if necessary.

If you are admitted to the hospital from an Urgent Care Center (UCC), your healthcare team will begin planning your discharge the moment you arrive. They will keep you informed of what might happen when you are discharged.

to come back to the beginning

How do I know which services will be covered by my insurance after I am discharged?

The insurance indemnity is different for everyone.What services you can get after you are discharged will depend on your coverage and your health condition. People are often surprised to learn that their insurance does not cover many of the services or medical items they need after they are discharged.

If you know you will be hospitalized, contact your insurance company. Find out if you are being reimbursed for home and long-term care services.
However, even if your insurance covers the cost of home care or long-term care services, your insurance company may decide that you do not need these services at this time.In this case, you may not be paid. You can talk with the claims specialist about calling the insurance company to discuss your coverage. If you need or would like services that are not covered by your insurance, you can pay for them yourself. Contact your social worker for information about financial resources that may be available to you and find out if you are eligible to receive them.

Your insurance company makes the final decision about what costs it will pay.Their solution depends on:

• Information provided by your healthcare team;
• compensation provided by your insurance;
• services that you need according to the company.

The Claims Specialist will work with you to check what is covered by your coverage. He will review the options available to you with you and the caregivers.

to come back to the beginning

What kind of care can I expect after I leave the hospital?

Some people, after returning from the hospital, only need the help of family and friends.If you need extra care, you can use the options below. The claims specialist will discuss this with your insurance company, but the insurance company makes the final decision on which services to cover and which not.

• The Visitor Service provides home care services such as wound care or medication through an intravenous (IV) catheter. The claims specialist will arrange these services with a home care agency on your insurance company’s preferred provider list.This home care agency will then work with your insurance company to determine the number of visits you need. The schedule of visits will change as your care needs change. You may have to pay for some services yourself.
• Emergency Rehabilitation Institutions provide intensive physiotherapy (FT) services. You should be able to attend therapy sessions for 3-5 hours a day. This usually involves a short stay of 1-2 weeks.
• Skilled Nursing Homes provide specific services such as wound care, IV medication, or PT. To be admitted to one of these institutions, your doctor must have a strong belief that your condition can improve. Services are often provided in a skilled nursing home.
• Hospice care is the care of people who are nearing the end of their lives. Hospice care is provided by a team of specialists that includes a physician, nurse, home health care professional, social worker, and spiritual mentor.This team focuses on your physical, emotional and spiritual condition.
  • Inpatient hospice care is palliative care (also called supportive care) and care for terminally ill people in an inpatient setting. It may also involve short-term care (such as wound care or IV antibiotics) when you need to stay in a hospital setting.
  • Home Hospice Care is home care for someone who is nearing the end of their life.Care and support services are provided by associations of visiting nurses / nurses and hospice facilities in the community. Your insurance may cover the cost of these services.

to come back to the beginning

Will my insurance cover my transportation from the hospital after I leave the hospital?

If you need transportation from the hospital, you will have to pay for it yourself, as it is usually not covered by insurance.It is best to be picked up by family or friends by car.

If you are transferred to another facility after you are discharged, the claims specialist will check to see if the insurance covers the cost of transportation in this case. If it does not cover it and your family or friends cannot pick you up, the claims specialist may suggest that you use a car or ambulance service. You will have to pay for such services.

to come back to the beginning

What happens the day I leave the hospital?

On the day of your discharge, you should schedule to leave the hospital around 11:00.Before you leave, your doctor will issue a discharge order and prescriptions for you. You can buy prescription drugs from our outpatient pharmacy or from your local pharmacy. Memorial Hospital’s outpatient pharmacy is located at:

425 East 67 ^th Street

Haupt Pavilion, Room A105

New York, NY 10065

646-888-0730

You will receive written prescription instructions including information about all of your medications.Before you leave, your nurse will explain these instructions to you and teach you how to take care of yourself. Make sure you understand how much of the medicine you should take, how and when you should take it, and what the possible side effects are. Also make sure you know when to call your doctor. If you have any questions or concerns, talk to your nurse and write down the answers.

If a home care service has been arranged for you, the name and telephone number of the facility will be listed on the discharge instructions provided to you.They will also indicate when exactly the provision of such services will begin. If you have questions about these services, please contact your claims specialist.

If you are ready to be discharged and the pick-up person has not yet arrived at the hospital, you can wait in the Patient Transition Lounge. A member of your healthcare team will give you more information.

to come back to the beginning

Who can I contact if I and my caregivers have questions?

If you have any questions or concerns about being discharged from the hospital, talk to your doctor, nurse, or claims specialist.In addition, social workers can also help you and your caregivers cope with illness, treatment, and any concerns you may have about leaving the hospital.

If you have any questions after discharge, please contact your doctor’s office. You can also contact the Claims Department directly by calling 212-639-6860.

to come back to the beginning

GBUZ JSC “AOKB” – Perinatal Center

PERINATAL CENTER

Welcome to the Perinatal Center
of the Arkhangelsk Regional Clinical Hospital!

The Perinatal Center of the State Budgetary Healthcare Institution of the Arkhangelsk Region “Arkhangelsk Regional Clinical Hospital” was opened on May 29, 2018.This is a unique obstetric care facility of the highest level in the Arkhangelsk region, equipped with all the necessary medical and technological equipment.

The perinatal center is in the region the coordinator of a three-tier system of medical care for mothers and children and provides a full cycle of medical care for married couples with reproductive disorders, pregnant women with a high degree of obstetric risk and newborns, including diagnostics, specialized treatment, counseling at the stage of pregnancy, obstetrics, surgical interventions, monitoring a baby with perinatal pathology.

Currently the following are working in the structure of the Perinatal Center:

• Consultative and Diagnostic Polyclinic;

• outpatient department for young children in need of follow-up and rehabilitation;

• admission department;

• Department of pregnancy pathology for 50 beds;

• maternity ward for 10 individual maternity wards with operating rooms;

• Department of Anesthesiology and Intensive Care for Women with a wake-up ward for the delivery ward and the operating unit of the delivery ward;

• obstetric physiological department with a joint stay of mother and child for 55 beds;

• gynecological department with operating rooms for 20 beds;

• Department of newborns, obstetric physiological department for 55 beds;

• neonatal resuscitation and intensive care unit, neonatal operating room;

• two departments of pathology of newborns, 30 beds each, with a centralized dairy unit;

• remote obstetric advisory office;

• Neonatal Remote Advisory Office;

• visiting obstetric, neonatal, anesthetic and resuscitation teams.

The work of auxiliary units was also organized: functional diagnostics, ultrasound diagnostics, X-ray diagnostics, laboratories, rehabilitation, and a centralized sterilization department.

The work of the Perinatal Center as part of a multidisciplinary hospital makes it possible to use all the diagnostic and treatment capabilities of the institution around the clock, which is especially important given the deteriorating health of pregnant women and the increase in the average age of women giving birth.

In addition to the medical component, the comfort of stay is also important, and in the Perinatal Center it is provided by the presence of individual delivery rooms, small wards in all departments with a joint stay of mother and child in the postpartum department and in the department of the second stage of newborn care. Each delivery room and all wards are equipped with bathrooms and showers.

For free antenatal hospitalization of pregnant women from remote areas of the region, special beds for obstetric care are provided in the Perinatal Center, and you can go to childbirth on a doctor’s referral in advance.

For three years of work in the Perinatal Center, over 9.5 thousand births were taken, almost 11 thousand children were born, of which twins – 314, triplets – 9.

In difficult situations, the staff of the Perinatal Center is always ready to help medical specialists and patients in the districts of the Arkhangelsk region, providing consultations using telemedicine or making an emergency flight / departure, if necessary. From 2018 to 2020, the anesthesia and resuscitation obstetric teams performed 738 flights / trips, as a result of which 828 patients were evacuated.

Our main goal is to help every family to have healthy children. The perinatal center has everything you need to make the process of giving birth to a little man as safe as possible for both the newborn and his mother!

RELATED TO TOPIC:

90,000 College Admission Rules – 2021 – Ucheba.ru

IThub college is an international college of information technology.The key advantage of the college is an intensive training program designed to meet the requirements of the leading IT companies in Russia and the world. Students receive a practice-oriented education: they learn through business roles (a set of relevant competencies), building a development trajectory on an interactive online platform.

The only college in Russia where international certification is built into the educational process. During their studies, students receive international certificates from Microsoft, Adobe, Autodesk, Cisco, Oracle, etc.and start a career in IT with a portfolio of projects and a strong resume.

College admissions are now open. To enter, you need to write an application and submit documents. Before enrollment, testing in Russian, mathematics and English is carried out to determine the level of training.

“In 2021, we are waiting for students who are ready for a new generation of education. The main feature of the college is practice-oriented learning. Students solve real-life business problems. We cooperate with QIWI, CROC, Rosreestr, Rostelecom, Mildsoft, Astra Linux, etc.Everything works when teachers are practitioners, multi- and mono-specialists with experience in mentoring in a business environment.

Current knowledge and methods . In college, blended learning: we build a development trajectory on an interactive skills map. The program provides enhanced English: 6 lessons per week. We accept applicants with any initial level of knowledge of a foreign language, freshmen are divided into 5 groups.

Developing comfortable environment .Classes start at 10:00. The college consists of two campuses: an agile office on Kurskaya and a technological space in the VDNKh park.

Student benefits . Everything that is required by law: a state diploma, deferral from the army, payment by maternity capital, reduced fare.

International certification . Certificates are an advantage when hiring.

Partnership programs with universities . Continuing studies after college on an accelerated program at universities such as PRUE.G.V. Plekhanova, RANEPA, Moscow Polytech, etc.

Global connections . Opportunity to undergo an internship abroad and participate in international projects (Germany, China).

We are enrolling 600 students in 2021. Acceptance of documents will end on August 25, but now there are 400 places left. Until May 1 – a simplified interview set. After – according to the results of the average score of the certificate and entrance testing. I advise you to submit your documents as soon as possible. See you at IThub! ”

90,000 Testing of the system of online admission to Russian universities is planned to begin in 2020 – Society

MOSCOW, October 22./ TASS /. Testing of a complex of digital public services, or the so-called super service “Online university enrollment” will begin in 2020. The project will allow applicants to apply online for admission to the university, and a special built-in assistant will assess their chances of admission, the press service of the Ministry of Science and Higher Education told TASS.

Russian Prime Minister Dmitry Medvedev earlier, at the plenary session of the Open Innovations Forum in Skolkovo, said that Russia plans to create a system with which it would be possible to enter Russian universities online.More than fifty Russian universities have already been selected to participate in the project. The press service of the Ministry of Education and Science said that the department is working on the creation of a super service “Enrollment in a university online” within the framework of the national project “Digital Economy”.

“In the process of admission through the super service, built-in assistants will be provided to assess the chances of admission and get a complete list of suitable educational institutions of higher education,” the press service said.

The introduction of such a service, according to the ministry, will lead to a reduction in the time and transport costs of applicants, provide an opportunity to track the competitive situation in a single rating, and also receive complete information on the passing scores of the last academic year.

Testing of service mechanisms will take place as part of the admissions campaign for the 2020-2021 academic year, 52 universities have been selected for this. “The subsequent stages of the implementation of the super service, following the pilot testing, provide indicators for the annual scaling of educational organizations participating in”, – added in the press service.

Superservice will allow applicants to submit documents using the Unified Portal of Public Services. For this, a special additional channel for submitting documents to universities will be created.At the same time, traditional methods will continue to work, including the full-time submission of a package of documents, delivery by mail or courier service, the press service specified.

Ambulance process | Ilsan Medical Center CHA

.