Redesigning intensive care unit flow using variability management to improve access and safety.

Background: Poor flow of patients into and out of the ICU can result in gridlock and bottlenecks that disrupt care and have a detrimental effect on patient safety and satisfaction, hospital efficiency, staff stress and morale, and revenue. Beginning in 2006, Cincinnati Children's Hospital Medical Center implemented a series of interventions to "smooth" patient flow through the system.

Methods: Key activities included patient flow models based on surgical providers' predicted need for intensive care and predicted length of stay; scheduling the case and an ICU bed at the same time; capping and simulation models to identify the appropriate number of elective surgical cases to maximize occupancy without cancelling elective cases; and a morning huddle by the chief of staff, manager of patient services, and representatives from the operating room, pediatric ICUS, and anesthesia to confirm that day's plan and anticipate the next day's needs.

Results: New elective surgical admissions to the pediatric ICU were restricted to a maximum of five cases per day. Diversion of patients to the cardiac ICU, keeping patients in the postanesthesia care unit longer than expected, and delaying or canceling cases are now rare events. Since implementation of the operations management interventions, there have been no cases when beds in the pediatric ICU were not available when needed for urgent medical or surgical use.

Discussion: A system for smoothing flow, based on an advanced predictive model for need, occupancy, and length of stay, coupled with an active daily strategy for demand/capacity matching of resources and needs, allowed much better early planning, predictions, and capacity management, thereby ensuring that all patients are in suitable ICU environments.