University of Michigan



University of Michigan Health SystemAdult Medical Observation UnitPre-Expansion Analysis of Adult Medical Observation Unit Final ReportTo: Jason Ham, MD, Medical Director, Adult Medical Observation UnitBrendon Weil, Lean Coach, Michigan Quality System Matthew Shirer, POA Fellow, Program & Operations AnalysisMark Van Oyen, IOE 481 Professor, Industrial and Operations Engineering From: IOE 481 Student Project Team 10, University of MichiganAlexander AbrahamCurtis GreerSeokJoo KwakWhitney NudoDate: April 22, 2014Table of ContentsExecutive Summary1Background1Methods2Findings and Conclusions2Recommendations3Introduction4Background4Key Issues6Goals and Objectives6Project Scope6Methods7Surveys7Interviews7Billing and Discharge Records7Findings and Conclusions 8Key Findings8Large Patient Pool9Medium Patient Pool12Small Patient Pool14Small Patient Pool w/ 2-Midnight Rule16Recommendations 18Census Recommendations 18Reduce Services Treated by Expanded AMOU18Adopt 2-Midnight Rule19Workload and Staffing Recommendations19Future Work20Simulations202-Midnight Rule20Financial Impact21Expected Impact21Appendix A: Large Patient Pool Discharge Workload22Appendix B: Large Patient Pool Arrival Workload22Appendix C: Medium Patient Pool Arrival Workload 23Appendix D: Medium Patient Pool Discharge Workload 23Appendix E: Small Patient Pool Arrival Workload24Appendix F: Small Patient Pool Discharge Workload 24Appendix G: Workload with Two Midnight Rule 25Appendix H: Small Patient Pool w/ 2-Midnight Rule, Patient Admits Per Hour 25Appendix I: Small w/ 2-Midnight Rule Patient Pool, Patient Discharges Per Hour 25Appendix J: Survey Results26EXECUTIVE SUMMARYThe Adult Medical Observation Unit (AMOU) at the University of Michigan Health System (UMHS) cares for patients who require additional observation before being discharged, or observation status patients. The AMOU is an 18-bed unit that has not been able to treat the full observation status patient demand. ?The University Hospital (UH) would like all observation status patients to be treated by the AMOU, which led to a plan to expand the AMOU. ?This planned expansion will result in a two-location service. ?The current AMOU, AMOU I, will remain in its current location and will continue to be staffed by the Emergency Department (ED). The new location, AMOU II, will be located in the 4th floor of the previous C.S. Mott Children’s Hospital and will be staffed by MFH employees. AMOU II will include an additional 23 beds, such that the AMOU service will have a total of 41 beds. The Medical Director of the AMOU asked an IOE 481 student team from the University of Michigan, Team 10, to collect and analyze data of observation status patients to accurately determine the potential demand for the expanded AMOU service. The team analyzed historical data, distributed employee surveys, and conducted interviews to better understand observation status patient flow within the AMOU and the UMHS as a whole. From the team’s analysis, the team determined demands, arrival rates, discharge rates, and workloads for each hour of the day for every day of the week through calendar year 2013. Team 10 segmented this information based on various patient pools suggested by the Director of the AMOU. BackgroundThe AMOU at the UMHS is a medical unit in which patients are observed before being discharged due to uncertain health stability. Patients are either accepted or rejected by the AMOU based on a physician’s assessment on whether the unit can adequately treat a patient of that complexity or based on occupancy within the unit. Patients who are rejected from the AMOU are often sent to the MFH or other inpatient services within the hospital. However, the UMHS has set fourth a plan to expand the AMOU to consolidate treatment of all observation status patients to the AMOU service. The expanded AMOU service will draw patients from a larger patient pool in comparison to the current unit. The Medical Director of the AMOU classified the potential patient pools the expanded AMOU service could treat as Large, Medium, and. The Large patient pool includes all observations status patients treated by the UMHS. The Medium patient pool includes all observation status patients treated by non-surgical services or patients with complex needs such as intensive care, bone marrow treatment, or access to a ventilator. The Small patient pool excludes patients with complex needs and includes only observation status patients treated by Family Medicine (UFM), Medicine Faculty Hospitalists (MFH), General Medicine (GM) and the Medicine Observation Service (MOS), Medicine Dock (MDD), Medicine Francis (MF), Medicine Hewlett (MH), Medicine Newburgh (MN), and Medicine Sturgis (MS) services. According to the Medical Director of the AMOU, the average length of stay (LOS) of observation status patients in the AMOU is 24 hours. However, there is a lot of variability in LOS. The 2-Midnight Rule, a recently enacted policy change, has the potential to change the demand in the new AMOU service. Under the 2-Midnight Rule, patients who have stayed at the hospital for longer than two midnights will be considered inpatient status and transferred to an inpatient service. However, inpatient status patients who physicians believe will not require treatment longer than two midnights may be transferred to the AMOU II for the rest of their treatment. Additionally, if a physician believes an observation status patient will stay for longer than two midnights. the physician has the ability to have the patient transferred immediately to an inpatient service.Because of potential changes in patient demand due to the 2-Midnight Rule, the Medical Director of the AMOU classified an additional patient pool, Small with 2-Midnight Rule. The Small with 2-Midnight Rule patient pool consists of all patients treated by the Small patient pool services who stay in the hospital for less than two midnights.MethodsTeam 10 distributed surveys and conducted interviews to gather statistics related to workload and to become familiar with the AMOU. Next, the team worked with a UMHS Senior Management Engineer and an Industrial Engineer Lead to collect historical data to determine the potential demand, arrival rate, and discharge rate of observation status patients for the AMOU service. Using historical data and data collected from the surveys and interviews, the team determined the potential workload of the expanded AMOU service.Findings and ConclusionsThe UMHS treated 16,872 observation status patients in 2013. The AMOU treated only a quarter of this population, serving 4,212 patients. The increase in capacity from the expansion of the AMOU, will not allow the service to treat all observation status patients. As shown below in the full report, the service would have a median demand above the 41 bed capacity 100% and 99% of the week for the Large and Medium patient pools, respectively. Of note, the Small with 2-Midnight Rule patient pool has 35% more patients than the Small patient pool, but median demand for the Small with 2-Midnight Rule patient pool never exceeds the service capacity of 41 beds. Though this pool includes more patients, the length of stay (LOS) in the unit is shorter and less variable than the length of stay for the Small patient pool. The Small patient pool included 2717 patients who stayed greater than or longer than two midnights and 272 patients who stayed seven days or longer. Since average LOS is lower for the Small with 2-Midnight Rule patient pool, the occupancy of the service decreases significantly. The Medical Director has stated that two physicians and three NPPA’s will most likely staff the expanded AMOU service. If this five provider-staffing model is implemented, the expanded AMOU service would be able to sufficiently handle the peak workload from admits and discharges from the Small patient pool but would not be able to handle the peak workload associated with the Small with 2-Midnight Rule. RecommendationsThe number of patient arrivals and discharges as well as the workload and demand in the large patient pool are too large for the expanded AMOU to treat. Additionally, many of these patients would not realistically be treated by the AMOU because of complexity (i.e. ICU patients) or requirement of unavailable resources (i.e. ventilators, etc.), even if the AMOU had an unlimited capacity. The team recommends the AMOU service define the subset of observation patients they will treat in the expanded service as capacity restrictions prohibit the service from treating all observation status patients. For these reasons, Team 10 focused recommendations on the Medium and Small patient pools. Based on analysis, Team 10 recommendations the AMOU does the following:Reduce Services Treated by Expanded AMOUTo meet all demand without the risk of going over the capacity of the unitAdopt 2-Midnight RuleImplementation of the 2-Midnight Rule will lower peak occupancies Higher turnovers allowing more patients to be treatedGreater percentage of observation patients to be treated by AMOUHave providers specialize in admits or discharges Schedule the majority of the providers from 11:00 AM to 11:00 PM to cover the peak admit and discharge times Have one or two providers work the non-peak hours of 12:00-10:00 AMINTRODUCTIONThe Adult Medical Observation Unit (AMOU) at the University of Michigan Health System (UMHS) cares for patients who require additional observation before being discharged, or observation status patients. According to the Medical Director of the AMOU, the 18-bed unit has only been able to accept roughly 50% of observation status patients and often has to send patients to the Medicine Faculty Hospitalist (MFH) service to meet demand. ?The University Hospital (UH) would like all observation status patients to be treated by the AMOU, which led to a plan to expand the AMOU. ?This planned expansion will result in a two-location service. ?The current AMOU, AMOU I, will remain in its current location and will continue to be staffed by the Emergency Department (ED). The new location, AMOU II, will be located in the 4th floor of the previous C.S. Mott Children’s Hospital and will be staffed by MFH employees. AMOU II will include an additional 23 beds, such that the AMOU service will have a total of 41 beds. The Medical Director of the AMOU asked an IOE 481 student team from the University of Michigan, Team 10, to collect and analyze data of observation status patients to accurately determine the potential demand for the expanded AMOU service. The team analyzed historical data, distributed employee surveys, and conducted interviews to better understand observation status patient flow within the AMOU and the UMHS as a whole. From the team’s analysis, the team determined demands, arrival rates, discharge rates, and workloads for each hour of the day for every day of the week through calendar year 2013. Team 10 segmented this information based on various patient pools suggested by the Director of the AMOU. This final report describes the project methods, findings, conclusions, and recommendations.BACKGROUNDThe AMOU at the UMHS is a medical unit in which patients are observed before being discharged due to uncertain health stability. The complexity of treatment for observation status patients can range from the simple need of an IV, to observation of complex heart concerns. Patients are either accepted or rejected by the AMOU based on a physician’s assessment on whether the unit can adequately treat a patient of that complexity or based on occupancy within the unit. The current AMOU, AMOU I, has 18 beds; two of the beds are in isolation rooms while the other 16 are behind curtains. Patients who are contagious, antibiotic resistant, or could be disruptive to other patients require isolation rooms and may be rejected from the unit if both isolation rooms are filled, even if there are other beds available in the unit. Patients in the AMOU are treated by physicians, nurse practitioners and physicians assistants (NPPA’s), nurses, and technical nurses (techs).Patients who are rejected from the AMOU are often sent to the MFH or other inpatient services within the hospital. However, the UMHS has set forth a plan to expand the AMOU to consolidate treatment of all observation status patients to the AMOU service. Through this planned expansion, the AMOU will be adding an additional 23 isolation beds in the AMOU II to grow the service from 18 beds, with two isolation beds, to 41 total beds with 25 isolation beds. The Medical Director of the AMOU expects MFH employees to staff AMOU II. The expanded AMOU service will draw patients from a larger patient pool in comparison to the current unit. The Medical Director of the AMOU classified the potential patient pools the expanded AMOU service could treat as Large, Medium, and Small (see Graph 0). The Large patient pool includes all observations status patients treated by the UMHS. The Medium patient pool includes all observation status patients treated by non-surgical services or patients with complex needs such as intensive care, bone marrow treatment, or access to a ventilator. The Small patient pool excludes patients with complex needs and includes only observation status patients treated by Family Medicine (UFM), Medicine Faculty Hospitalists (MFH), General Medicine (GM) and the Medicine Observation Service (MOS), Medicine Dock (MDD), Medicine Francis (MF), Medicine Hewlett (MH), Medicine Newburgh (MN), and Medicine Sturgis (MS) services. Graph 0: The Potential Patient PoolsAccording to the Medical Director of the AMOU, the average length of stay (LOS) of observation status patients in the AMOU is 24 hours. However, there is a lot of variability in LOS. Many patients stay well beyond 48 hours. The 2-Midnight Rule, a recently enacted policy change, has the potential to change the demand in the new AMOU service. Under the 2-Midnight Rule, patients who have stayed at the hospital for longer than two midnights will be considered inpatient status and transferred to an inpatient service. However, inpatient status patients who physicians believe will not require treatment longer than two midnights may potentially be transferred to the AMOU II for the rest of their treatment. Additionally, if a physician believes an observation status patient will stay for longer than two midnights when they are initially admitted, the physician has the ability to have the patient transferred immediately to an inpatient service.Because of potential changes in patient demand due to the 2-Midnight Rule, the Medical Director of the AMOU classified an additional patient pool, Small with 2-Midnight Rule patient pool. The Small with 2-Midnight Rule patient pool consists of all of the patients in the Small pool with the addition of in-patients treated by the Small pool services that stay for less than two midnights and the subtraction of observation status patients in the Small pool that stayed in the hospital for two or more midnights. In other words, the Small with 2-Midnight Rule patient pool consists of all patients treated by the Small patient pool services who stay in the hospital for less than two midnights.KEY ISSUESThe following key issues drove the need for this project.? Treatment of observation status patients in non-observation services? Unknown patient demand for the expanded AMOU service? Unknown observation status patient arrival and discharge trends??Unknown staffing demands for the expanded AMOU service GOALS AND OBJECTIVESThe primary goal of this project was to validate the expansion of the AMOU service by characterizing the demands, arrival rates, discharge rates, and workloads related to observation status patients at UMHS. Team 10 determined these critical statistics for various patient pools and times to enable the Medical Director of the AMOU to set expectations for the expanded AMOU service. The team pursued these goals by addressing the following objectives:? Segmenting and interlinking data sets to properly represent relevant patient pools? Grouping patients by month, day of week, and time of day to understand seasonality, weekly trends, and daily trends? Determining appropriate distributions for demands, patient arrival, discharge rates and the associated workload PROJECT SCOPEThe scope of this project includes the examination of patient demands, arrival rates, and discharge rates of observation status patients in the UMHS and the associated staff workload. The team was asked to gather these statistics for four patient pools: Large, Medium, Small, and Small with 2-Midnight Rule. This project did not explore the routing of patients into AMOU I and AMOU II due to varying patient complexity and treated the expanded AMOU service as a cohesive unit during analysis. METHODSTeam 10 distributed surveys and conducted interviews to gather statistics related to workload and to become familiar with the AMOU. Next, the team worked with a UMHS Senior Management Engineer and an Industrial Engineer Lead to collect historical data to determine the potential demand, arrival rate, and discharge rate of observation status patients for the AMOU service. Using historical data and data collected from the surveys and interviews, the team determined the potential workload of the expanded AMOU service.SurveysTo better understand AMOU employees’ skill-sets and preferences, Team 10 developed a 21-question survey using Qualtrics and distributed it to the 21 physicians, nurse practitioners and physician assistants (NPPAs) currently employed by the AMOU. The survey allowed the team to better understand how much work each type of employee can complete in a shift, as well as preferences on length and day of week for shifts. The team collected 19 of the 21 survey responses and used the data to determine the number and types of employees required to treat patients at different times of the day. InterviewsThe team interviewed two physicians, three NPPAs, two nurses, and one tech from the evening shift on February 27th, 2014. In these interviews, each staff member recalled the minimum, average, and maximum time they spend on admissions, discharges, and hourly check-ups per patient. In addition to quantitative data, the interviews yielded information related to shifts regarding employee preference. Additionally, the team interviewed the department heads of the MFH to gain an understanding of how the ED and the MFH will be working together on the expanded AMOU service. Billing and Discharge RecordsTeam 10 determined the potential demand, arrival rates, and discharge rates of the expanded AMOU service from historical data. The team obtained billing and discharge records of all observation status patients and all inpatients that stayed at the hospital for fewer than two midnights over the 2013 calendar year. Team 10 utilized Microsoft SQL and Excel to segment patient data into the Large, Medium, Small, and Small with 2-Midnight Rule patient pools. The team segmented each patient pool by day of week, and then further segment by hour of day to estimate the mean demand, number of arrivals, and number of discharges for each hour of each day of the week.?The data segmented by the day of the week in each month was be used to determine whether demand changes due to seasonality. Many of the same steps were repeated for the Large, Medium, Small, and Small with 2-Midnight Rule patient pools. The following graphs, located in the findings and conclusions section, for admissions, discharges, and workloads are simplified. Rather than including lines for each day of the week, the team included lines for groups of days with similar trends. All lines that are grouped into multiple days of the week are based on averages of the grouped days. The data presented below is from the 2013 calendar year and the admissions, discharges, and workloads are all based on averages of the days of the week. Data from the interviews and surveys was used to determine how long admissions and discharges take in the AMOU. Using this along with the arrival and discharge rates found from historical data, the team also determined the workload for each hour of day for each day of week.FINDINGS AND CONCLUSIONS Team 10 determined the demands, arrival rates, discharge rates, and workloads for the Large, Medium, Small, and Small with 2-Midnight Rule patient pools. From interviews and surveys, the team found how long physicians spend on admissions and discharges as well as how long they spend checking up on patients per hour. To simplify analysis, the team used the following assumptions: The 2013 calendar year accurately predicts future years Workload is made up of only admissions and dischargesAdmissions take 90 minutes on averageDischarges take 60 minutes on averageWorkload can be evenly distributed over three-hour intervalsThe 2-Midnight Rule will be followed exactly by the definitionInpatient status patients were considered inpatients at discharge timeA patient is considered an admit once they arrive at the service, not the hospitalKey FindingsThe UMHS treated 16,872 observation status patients in 2013. There were no significant trends related to seasonality. The AMOU treated only a quarter of the observation status patient population, serving 4,212 patients. With the expansion from 18 to 41 beds, the AMOU service will more than double in capacity. This increase in capacity, however, will not allow the service to treat all observation status patients. As shown below in Table 1, the service would have a median demand above the 41 bed capacity 100% and 99% of the week for the Large and Medium patient pools, respectively. From interviews with department heads of the MFH, the team discovered that the expanded service expects to utilize a dedicated admissions team. Table 1, below, shows how many admission team staff members, and total staff members, the service would need to employ during peak hours to keep up with workload related to the demand of each patient pool. Table 1: Summary of Various Patient PoolLargeMediumSmallSmall with 2-Midnight RulePatients16,87212,2897,57610,229Staff required to treat peak demand8656Staff required to treat peak admit demand7433% time median demand exceeds capacity100%99%44%0%Of note, the Small with 2-Midnight Rule patient pool has 35% more patients than the Small patient pool, but median demand for the Small with 2-Midnight Rule patient pool never exceeds the service capacity of 41 beds. Though this pool includes more patients, the length of stay (LOS) in the unit is shorter and less variable than the length of stay for the Small patient pool. The Small patient pool included 2717 patients who stayed greater than or longer than two midnights and 272 patients who stayed seven days or longer. Since average LOS is lower for the Small with 2-Midnight Rule patient pool, the occupancy of the service decreases significantly. While the Small with 2-Midnight Rule patient pool will not require the AMOU service to reject as many patients as the Small patient pool due to capacity restrictions, the Small with 2-Midnight Rule may require a larger staff than the service has budgeted for. The Medical Director has stated that two physicians and three NPPA’s will most likely staff the expanded AMOU service. If this five provider-staffing model is implemented, the expanded AMOU service would be able to sufficiently handle the peak workload from admits and discharges from the Small patient pool but would not be able to handle the workload associated with the Small with 2-Midnight Rule. Large Patient Pool: All observation status patients treated by the UMHSThe UMHS treated 16,872 observation status patients in 2013; this shows that the current AMOU treats approximately 25%, 4212 patients, of observation status patients treated by the UMHS.Graph 1 shows that peak weekday arrivals occur between 6-7 AM and reach over six admits per hour. Graph 1 also shows that there are more arrivals on weekdays than weekends. Graph 1: Large Patient Pool, Patient Admits Per Hourn=16872, 2013 calendar yearDischarge trends for Saturdays are more similar to the weekday discharge trends and Monday’s discharge trends are more similar to discharge trends seen on Sundays. Graph 2 shows discharges broken into groups of Tuesday-Saturday and Sunday-Monday, rather than weekday and weekend. Graph 2 shows that there are virtually no discharges from 10PM to 6 AM. This is because patients are rarely discharged after dinner and before breakfast. Additionally, discharges peak every day from 12-2 PM with 5-7 discharges per hour. Graph 2: Large Patient Pool, Patient Discharges Per Hourn=16872, 2013 calendar yearGraph 3 shows that weekdays have the highest workload and that Sunday is the slowest day of the week. On weekdays, the peak workload occurs from 12PM-2PM and consists of 8-9 hours of work per hour. This means that there would need to be nine providers in the hospital from 12-2 PM to handle the work from all of the admissions and discharges.Graph 3: Large Patient Pool Workload Admits and Discharges Combined (Hours)n=16872, 2013 calendar yearHowever, even if the AMOU employed nine providers to work on admits and discharges to account for the nine hours of work at peak times, there would not be enough beds to accommodate all of the patients. Graph 4 illustrates the census by day of week and time of day for the Large patient pool. The low horizontal line on the graph is the current number of beds, 18, in the AMOU. The higher horizontal line is the total number of beds, 41 that the expanded AMOU service will have. The lower curved line is the median number of patients that the service would see on a given day of the week at any given time. The highest line is the maximum patient demand that was observed in the 2013 calendar year. Graph 4 shows that the number of the beds in the expanded AMOU service does not meet the median demand, even during the slowest time of day on the least busy day of the week. To illustrate, on Sundays at 6PM, the expanded AMOU will still have to turn away at least nine patients on over 50% of the Sundays. This data shows that the expanded AMOU is still not large enough to treat all of observation status patients at the UMHS.Graph 4 Large Pool Peak Demand Censusn=16872, 2013 calendar yearMedium Patient Pool: All observation patients treated by the UMHS excluding Surgical, Ventilation, Intensive Care, and Bone Marrow Services The Medium patient pool has 12,289 patients and excludes all patients treated by surgical services and patients with complex needs such as intensive care, bone marrow treatment, or access to a ventilator. This exclusion removes 4,583 or 27% of patients from the Large patient pool.Graph 5 shows that peak weekday arrivals, similar to the Large patient pool, occur between 6-7 AM and reach almost four admits per hour. Graph 5 also shows that there are more arrivals on weekdays than weekends. Graph 5: Medium Patient Pool, Patient Admits Per Hourn=12289, 2013 calendar yearGraph 6 shows that once again, the Medium group is similar to the Large Group. Saturday discharge patterns are more similar to the weekday trends and Monday is more similar to Sunday trends, in terms of discharges per day. As such, discharges are better broken into groups of Tuesday-Saturday and Sunday-Monday, rather than by weekday and weekend. From Graph 6, one can see that there are virtually no discharges from 10-PM to 6 AM. Additionally, discharges peak every day from 12-2 PM with 3-5 discharges per hour from Tuesday through Saturday and 2.5-3 for the Sunday and Monday grouping.Graph 6: Medium Patient Pool, Patient Discharges per Hourn=12,289, 2013 calendar yearTeam 10 determined that Sunday is the slowest day of the week in terms of workload for the Medium pool and the rest of the week is consistent. This is due to the discharge related workload on Sundays. From Monday to Saturday, the peak workload occurs around 5 PM and consists of six hours of work. Additionally, for Monday through Saturday, there is a steady increase in workload from 5AM-5PM, and a steady decrease in workload from 5PM-5AM.Graph 7: Medium Patient Pool Workload Admits and Discharges Combined (Hours), n=12,289, 2013 calendar yearSimilarly to the Large pool, the Medium pool contains more demand than the capacity of the expanded AMOU service, even if there were enough employees to handle the workload from admits and discharges. As Graph 8 shows, only on Sundays at 7PM, the least busy hour of the week, can the 41-bed capacity of the unit meet the demand of the Medium patient pool. This means that 99% of the time the unit cannot meet the median demand. Graph 8: Medium Census of Weekn=12,289, 2013 calendar yearSmall Patient Pool: Observation status patients treated by the MFH, MOS, UFM, MDD, MN, MH, MS, and MF services (Also excluding Surgical, Ventilation, Intensive Care, and Bone Marrow Services)The Small patient pool, like the Medium patient pool, excludes patients with complex needs such as intensive care, bone marrow treatment, or access to a ventilator but includes only observation status patients who were treated by the MOS, MFH, UFM, MDD, MN, MH, MS, and MF. The small patient pool includes 7,576 patients, 45% of all observation status patients. If the expanded AMOU service could serve this entire patient pool, it would serve less than 50% of all observation status patients. Unlike the Large and Medium patient pools, there is no patient arrival spike from 6-7 AM on weekdays; instead, arrival rates rise beginning around 11 AM. Additionally, arrival rates for weekends and weekdays are more closely correlated than in the Large or Medium patient pools. Peak arrivals from the various days of the week occur in the evening around 6-7 PM and can reach as high as 1.8 arrivals per hour. However, as shown in Graph 9, the weekday average does not exceed above 1.6 admits per hour.Graph 9: Small Patient Pool, Patient Admits per Hourn=7576, 2013 calendar yearFor discharges, the Small patient pool follows the trends of the Medium and Large patient pools. Peak discharges occur from 12-5PM and vary from 2-3 discharges per hour. Once again, as shown in Graph 10, Sunday and Monday have slightly lower discharges than the rest of the week. Graph 10: Small Patient Pool, Patient Discharges Per Hourn=7576, 2013 calendar yearThe Workload created by the admissions and discharges in the Small patient pool is shown below in Graph 11. Workload is relatively low and constant throughout the week from 12AM-12PM. From 3-5PM during weekdays, the workload peaks at slightly over four hours of admission and discharge related work. The Medical Director of the AMOU has stated that two physicians and three NPPA’s will most likely staff the expanded AMOU service. If this is the case, these five providers will be able to handle the workload created by the admits and discharges in the Small patient pool. Graph 11: Small Patient Pool Workload Admits and Discharges Combined (Hours) n=7576, 2013 calendar yearThe demand for the Small patient pool is shown below in Graph 12. As one can see, the median demand for the Small patient pool oscillates near 41, the maximum capacity of the expanded AMOU service. Graph 12 illustrates that the appropriate patient pool for the expanded AMOU service may fall somewhere between the Small and Medium patient pools, as the median demand for the Small patient pool is often below 41.Graph 12: Small Patient Pool Census of Weekn=7576, 2013 calendar yearSmall Patient Pool w/ 2-Midnight Rule: Observation and in-patient status patients treated by the MFH, MOS, UFM, MDD, MN, MH, MS, and MF services that stay less than two midnights (Also excluding Newborns, Pediatrics, ICU and Expired patients)The implementation of the 2-Midnight Rule drastically changes the sample size, average length of stay, maximum length of stay, and standard deviation of the length of stay for patients in the Small patient pool. Table 2 summarizes the differences in theses key statistics for the Small patient pool when the 2-Midnight Rule is implemented.Table 2: Changes in Small Patient Pool with the Implementation of the 2-Midnight RuleSmall PoolSmall with2-Midnight Rule PoolSample Size (Patients)757610229Patient Percent IncreaseN/A35%Median Length of Stay (Hours)25.4822.48Maximum Length of Stay (Hours)1432.6246.62Standard Deviation for Length of Stay (Hours)63.658.06Average Length of Stay (Hours)45.8322.33Since the number of patients in the Small patient pool is 35% greater after the implementation of the 2-Midnight Rule, the workload required to handle the admissions and discharges has also increased. Graph 13 shows that the peak workload for the Small patient pool with the 2-Midnight Rule still occurs from 3-5PM on weekdays. However, the peak workload is now six hours instead of four and a half hours. This is a 33% increase in peak workload from the Small patient pool without the implementation of the 2-Midnight Rule.Graph 13: Small w/ 2-Midnight Rule Patient Pool Workload Admits and Discharges Combined (Hours), n=10229, 2013 calendar yearIf the AMOU can staff the service with enough providers to cover this peak workload, the unit will not have to turn away as many patients as they will if they serve the Small patient pool. While 2-Midnight Rule increases the number of patients in the Small patient pool by 35%, it significantly decreases the average length of stay and variability (standard deviation), which allows for a greater throughput of patients. Graph 14, shows this decrease in peak demand. The decreases in the variability and average length of stay as a result of the 2-Midnight Rule allow the AMOU service to not only treat a larger patient pool, but the unit will not have to reject as many patients due to capacity. Graph 14: Small w/ 2-Midnight Rule Census, n=10229, 2013 calendar yearRECOMMENDATIONS As shown in the previous analysis, the number of patient arrivals and discharges as well as the workload and demand in the large patient pool are too large for the expanded AMOU to treat. Additionally, many of these patients would not realistically be treated by the AMOU because of complexity (i.e. ICU patients) or requirement of unavailable resources (i.e. ventilators, etc.), even if the AMOU had an unlimited capacity. The team recommends the AMOU service define the subset of observation patients they will treat in the expanded service as capacity restrictions prohibit the service from treating all observation status patients. The Medical Director of the AMOU has confirmed these conclusions and recommended focusing on the Medium and Small patient pools. For these reasons, Team 10 focused recommendations on the Medium and Small patient pools.Census Recommendations Redefine Services Treated by Expanded AMOUAfter examining the occupancy rates for each of the patient pools represented, the team believes that an accurate representation of the census for the expanded unit falls within the Medium and Small patient pools. With this in mind, it is clear from Graph 12, Small Census of Week, that even the Small patient pool’s median occupancy rates, which represents a lower bound for patients treated, are very close to the 41 bed capacity of the expanded AMOU. To meet all demand without the risk of going over the capacity of the unit, the team recommends to further limit the services that the expanded service will potentially treat. The expanded service could reduce the number of patients from General Medicine services and focus primarily on MOS, UFM and MFH services.Adopt 2-Midnight RuleTeam 10 recommends that the expanded AMOU service follow the 2-Midnight Rule as closely as possible. The implementation of the 2-Midnight Rule will allow the expanded service to potentially treat 35% more patients compared to the small patient pool and additionally will lower the median occupancy rates so that less patients are turned away due to capacity. If the expanded unit choses to strictly follow the guidelines of the 2-Midnight Rule, the AMOU will accept all in-patients with expected length of stays less than two midnights and reject all observation status patients with expected stays longer than two midnights. Successful implementation of the 2-Midnight Rule would result in an increase in the number of patients but a decrease in length of stay and variation of length of stay (Table 3). This will allow the median occupancy rates for the small pool to decrease below the overall capacity of the expanded unit (Graph 12). The expanded unit would have higher turnovers allowing more patients to be treated. However, the data used for the Small group with 2-Midnight Rule was taken from 2013 and the 2-Midnight Rule may affect the future observation status demand at the UMHS. It is difficult in practice to predict the final length of stay of patients, which will affect the final demand, arrival rates, and discharge rates.Workload and Staffing RecommendationsThe Medical Director of the AMOU requested information to determine how having providers specialize in admits or discharges would affect staffing models. If this type of staffing model is to be implemented, the team recommends having different schedules for each of the provider types, admit specialist and discharge specialist, to account for the varying peak arrival and discharge times. The number of providers required to cover the workload of weekday and weekend shifts are shown in tables 3 and 4. Table 3: Admit Provider Shift Schedule?WeekdaysWeekends12PM-9PM328PM-5AM224AM-1PM22Table 4: Discharge Provider Shift ScheduleWeekdayWeekends1AM-10AM119AM-6PM445PM-2AM12The Small with 2-Midnight Rule patient pools requires staffing more providers than the Small patient pool because the providers would have to admit and discharge more patients. Furthermore, assigning dedicated admit and discharge teams does not allow providers to split partial hours of admit or discharge work between teams. For example, if peak discharge workload reached 1.25 hours per hour in a shift and peak admit workload reached 2.25 per hour hours in a given shift, the service would have to employ 2 discharge providers and 3 admit providers rather than 4 general providers. However, the team believes that quality of patient care and efficiency of work would rise to outweigh these potential adverse outcomes. FUTURE WORKTeam 10 has determined essential inputs by determining the demands, arrival rates and discharge rates for multiple potential patient pools. The next step of this project will be to input the statistics determined by the team into a simulation program to develop a staffing model. Additionally, future 481 project teams and the Director of the AMOU will be able to use this data for justification for the expansion of the AMOU. SimulationsSimulations can be run based on the demands, arrival rates, and discharge rates determined by Team 10. Multiple simulations can be run as the data are segmented by the month of the year, the day of the week, and the time of day. Simulations can also be run using the patient pools segmented by observation status patients who are treated by various services. 2-Midnight RuleDue to the uncertainty surrounding the introduction of the 2-Midnight Rule and the changes it will bring to how patients are treated, Team 10 recommends that future analysis be done after the 2-Midnight Rule has been fully implemented. Specifically, examining when patients will be transferred from the observation unit to an inpatient unit once they exceed two midnights. To accurately represent the patient pool, the effects of the 2-Midnight Rule must be fully examined once enough data is available.Additionally future teams may need to determine if assigning providers to specialized admission and discharge teams makes them more efficient in their work. Specifically, future teams may wish to examine if dedicated admission providers can complete admissions in fewer than 90 minutes and discharge providers can complete discharges in fewer than 60 minutes. If this is the case, the number of the providers per shift may be reduced. Financial ImpactThe critical statistics determined by the team can also be used to analyze the financial impact that the expansion of the AMOU will have on the hospital. The analysis shows the additional number of patients who are expected to be treated by the expanded AMOU service. Additional analysis can be conducted to show the financial implications that correspond to more observation status patients being treated by the AMOU service, in particular the financial implications of strictly adhering to the 2-Midnight Rule.EXPECTED IMPACTTeam 10’s analysis, specifically the census data collected, provides validation of the planned expansion of the current AMOU from 18 to 41 beds. If the AMOU chooses to use the team’s findings when developing a staffing model, the model will provide an accurate representation of the potential demand, arrival and discharge rates for the expanded unit. Appendix A: Large Patient Pool Discharge WorkloadAppendix B: Large Patient Pool Arrival WorkloadAppendix C: Medium Patient Pool Arrival Workload Appendix D: Medium Patient Pool Discharge Workload Appendix E: Small Patient Pool Arrival Workload Appendix F: Small Patient Pool Discharge Workload Appendix G: Workload with Two Midnight Rule Appendix H: Small Patient Pool w/ 2-Midnight Rule, Patient Admits Per Hour Graph I, n=10229, 2013 calendar yearAppendix I: Small w/ 2-Midnight Rule Patient Pool, Patient Discharges Per Hour Graph I, n=10229, 2013 calendar yearAppendix J: Survey ResultsAppendix J: Survey Results (Continue)Appendix J: Survey Results (Continue)Appendix J: Survey Results (Continue)Appendix J: Survey Results (Continue)Appendix J: Survey Results (Continue) ................
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