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Let it Flow: Efficient Transitions Elevate Care

By Don Sadler

There are few things that can cause more problems in hospitals than poor patient flow in the perioperative setting. Perioperative services is one of the most interconnected units in a hospital, so inefficient flow of patients through the perioperative area can cause disruptions that ripple throughout the entire organization.

“Efficient patient flow means that each individual patient moves through the surgical experience as planned,” says Erin Kyle, DNP, RN, CNOR, NEA-BC, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN). “Each individual patient’s movement is in harmony with the movement of other patients.”

A Seamless Transition

Kristin Ray MSN, RN, CPN, NE-BC, director of nursing for pre-admission testing at Children’s Mercy Kansas City, describes efficient patient flow as “a seamless transition between phases of care throughout the surgical journey.”

“With efficient patient flow, bottlenecks and unnecessary wait times for patients are minimized through thorough pre-operative coordination of care,” says Ray. “Streamlined communication between perioperative team members and appropriate and timely signaling to the next phase of care when the patient is ready to advance also help improve patient flow.”

When patient flow through the perioperative area is smooth, “patients with higher acuity who need more resource utilization don’t interfere or compete with other patients’ needs at the time of preoperative preparation, surgery and recovery,” says Kyle.

“Every patient receives the undivided attention of physicians, perioperative RNs and all members of the perioperative team,” Kyle adds.

Conversely, poor or inefficient patient flow can lead to a number of negative consequences, says Desiree Chappell, MSNA, CRNA, associate editor and U.S. lead, TopMedTalk. “This includes confusion among patients and their families, which can impact HCAP and patient satisfaction for the hospital and providers.”

Other problems associated with poor patient flow include OR backlog, increases in call time and overtime pay, increasing PACU holds, and issues with discharge for outpatient and bed utilization throughout the rest of the hospital, says Chappell.

“Unforeseen and last-minute surgery cancellations are extremely costly because they create empty OR block time,” says Ray. “Staffing cannot be adjusted in advance to match the empty OR time and decreased case load.”

“During high hospital census, patients who have met the criteria to move on to the next phase of care can be held in the OR or PACU. Holding a patient in these high acuity areas for a long period of time comes at an increased cost to the patient,” Ray adds.

Factors That Impact Patient Flow

According to Kyle, patient flow can be impacted by a number of different things that are out of the hospital’s control. These range from manpower or personnel issues to scheduling and activity sequencing, equipment and supplies, and patient concerns.

“Also, health care workers are human and have human needs,” Kyle adds. “Sometimes they’re ill and can’t come to work. Or maybe they come to work sick and are less productive, or they have to leave work early due to personal or family issues.”

Chappell believes that a lack of team communication and a lack of education are key contributors to inefficient patient flow. Kyle agrees.

“When any of these issues are coupled with poor communication, the loss of efficiency is magnified exponentially,” Kyle says.

Ray lists a number of other contributors to inefficient patient flow, including the following:

  • Space constraints
  • Budget restrictions for equipment needs
  • Inpatient post-op bed availability
  • Last minute schedule changes
  • The redesign of space to support LEAN methods and strategies
  • Block time rearrangements to accommodate emergent and urgent cases

What Smooth Patient Flow Looks Like

So what does efficient patient flow look like? Kyle lists a number of characteristics of a perioperative services area with smooth patient flow:

  • Surgery scheduling allows for cooperative use of resources with effective planning. “For example, overlapping procedures needing the same equipment are not scheduled simultaneously,” she says.
  • Patients arrive for surgery with adequate time to effectively prepare for surgery.
  • Every member of the perioperative team has been given a clear assignment, which allows them to be prepared for all aspects of each assigned patient’s needs.
  • The surgeon arrives in advance of the surgical procedure to perform preoperative duties and is not interrupted with competing demands on his or her time.
  • Every member of the perioperative team has the supplies, equipment, time and support needed to move efficiently through the day. “In other words, they don’t have to waste time searching for missing items,” says Kyle.
  • The post anesthesia care unit can admit and discharge patients when they’re ready for admission or discharge. “This unit shouldn’t be serving as a holding space due to a lack of resources or space in the receiving unit,” says Kyle.
  • Disruptions that are common in the management of surgery schedules are anticipated and handled in such a way that the schedule is not disrupted. “There should be a plan for common add-on procedures and emergency procedures that doesn’t disrupt scheduled procedures or surgeons’ schedules,” says Kyle.

Steps to Improving Patient Flow

According to Chappell, patient flow can be improved via enhanced education of health care providers at all levels. “They need to be educated not only about their specific jobs, but also about their role in the efficiency of patient flow,” she says.

Ray recommends using an electronic tracking board to communicate each patient’s current destination and readiness for each stage in the perioperative process. “You should also perform daily readiness and safety huddles at the start of each day and designate a surgical observation unit specifically for patients who require a short stay after surgery,” she adds.

Kyle says that improved patient flow starts with two main things: preparedness within all phases of perioperative care – including patient, supply and equipment, team availability and competency, and environmental – and correct scheduling.

“These two concepts are closely related and interdependent,” Kyle says.

“However, improved patient flow is sustained when an organization uses data to inform decisions, fosters a culture of safety, maintains appropriate staffing levels, and provides the resources needed by staff to perform their jobs correctly,” Kyle adds.

How ERAS Can Improve Patient Flow

Chappell believes that Enhanced Recovery After Surgery (ERAS) can play a significant role in improving patient flow through the perioperative continuum.

“A basic tenant of an ERAS program is standardization through protocols and pathways,” says Chappell. “The benefit of standardization is that everyone is on the same page and throughput improves.”

Chappell points out one caveat to using ERAS to improve patient flow: the steep learning curve during implementation, especially if implementation is unorganized and there’s a lack of education during the process.

“But it all circles back to managing expectations, education and communication,” she says.

According to Kyle, there are great resources for improving the efficiency of patient flow in the AORN Perioperative Efficiency Toolkit. “The toolkit includes practical strategies for optimizing perioperative patient flow,” she says.

For more information, visit to order a copy of the AORN Perioperative Efficiency Toolkit. The resource is free to AORN members and costs $11 for non-members.



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