New bed configurations and discharge timing policies: A hospital-wide simulation.

OBJECTIVE: Optimising patient flow is becoming an increasingly critical issue as patient demand fluctuates in healthcare systems with finite capacity. Simulation provides a powerful tool to fine-tune policies and investigate their impact before any costly intervention. METHODS: A hospital-wide discrete event simulation is developed to model incoming flow from ED and elective units in a busy metropolitan hospital. The impacts of two different policies are investigated using this simulation model: (i) varying inpatient bed configurations and a load sharing strategy among a cluster of wards within a medical department and (ii) early discharge strategies on inpatient bed access. Several clinically relevant bed configurations and early discharge scenarios are defined and their impact on key performance metrics are quantified. RESULTS: Sharing beds between wards reduced the average and total ED length of stay (LOS) by 21% compared to having patients queue for individual wards. The current baseline performance level could be maintained by using fewer beds when the load sharing approach was imposed. Earlier discharge of inpatients resulted in reducing average patient ED LOS by approximately 16% and average patient waiting time by 75%. Specific time-based discharge targets led to greater improvements in flow compared to blanket approaches of discharging all patients 1 or 2 hours earlier. CONCLUSIONS: ED access performance for admitted patients can be improved by modifying downstream capacity or inpatient discharge times. The simulation model was able to quantify the potential impacts of such policies on patient flow and to provide insights for future strategic planning.

The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study.

AIMS AND OBJECTIVES: To determine presence of clinical complications related to dysphagia and to explore their operational outcomes. BACKGROUND: Dysphagia is a common complication of stroke. The management of poststroke dysphagia is multidisciplinary with nurses playing a key role in screening for dysphagia risk, monitoring tolerance of food and fluids and checking for the development of complications such as fever, dehydration and change in medical status. Dysphagia often results in further complications including aspiration pneumonia and the need for nasogastric feeding. Dysphagia-related complications have been shown to have a significant impact on morbidity and mortality, length of stay and cost of admission. DESIGN: Retrospective cohort study. METHODS: A total of 110 patients presenting with an ischaemic stroke were chart-audited. RESULTS: Aspiration pneumonia poststroke was found to be significantly associated with increased overall length of stay, poorer functional outcomes poststroke as well as being associated with a high risk of mortality. The presence of a nasogastric tube was also associated with reduced functional outcomes poststroke and increased risk of death. CONCLUSION: High prevalence and cost of complications associated with stroke highlight the complexity of providing nursing and allied health care to this patient population. This provides a snapshot of dysphagia-related complications experienced by stroke patients. RELEVANCE TO CLINICAL PRACTICE: This paper highlights that poststroke complications can significantly impact on patient outcomes and operational factors such as cost of admission; therefore, poststroke care requires a multidisciplinary approach to management. Furthermore, preventing and managing complications poststroke is a key element of nursing care and has the potential to significantly reduce incidence of mortality, length of stay and cost of hospital admission.

Management of swallowing in thrombolysed stroke patients: Implementation of a new protocol.

PURPOSE: There is a paucity of evidence regarding dysphagia management post-thrombolysis. The aim of this case-control study was to evaluate the impact of a dysphagia management protocol on patient outcomes. Thrombolysis has been completed at our metropolitan hospital since 2011 and a dysphagia management protocol was developed in 2012. METHOD: Chart auditing was completed for 83 participants in three groups: pre-protocol (n = 12) (2011), post-protocol (n = 28) (2012-2014), and non-thrombolysed stroke patients (n = 43). RESULT: Following the implementation of this clinical protocol, the average time patient remained nil by mouth reduced by 9.5 h, the percentage of patients who were malnourished or at risk reduced by 24% and the number of patients who developed aspiration pneumonia reduced by 11%. The cost of hospital stay reduced by $1505. Service compliance with best practice in dysphagia management in thrombolysed patients increased from 67% to 96% in the thrombolysed patient groups. CONCLUSION: The outcomes suggest that a clinical protocol for dysphagia management in thrombolysed patients has the potential to improve service outcomes, reduce complications from dysphagia, have financial benefits for the hospital and increase service compliance. Furthermore, the results lend support for speech pathology services to manage dysphagia on weekends.