“We continue to experience an increase in patient demand for services in our hospitals. This is why patient flow, which is about placing the right patient in the right bed at the right time, is so important,” says Dr. George Pylypchuk, Acting Unified Head of the Department of Medicine and co-lead of a Physician Guiding Coalition that began meeting at Royal University Hospital (RUH) in October 2015.
The coalition was created to engage physicians in problem-solving and joint ownership of patient flow in Saskatoon Health Region’s three acute care hospitals. A cross-functional working group, comprised of physicians and leadership from all areas (e.g., cardiology, emergency department, medicine, psychiatry, surgery) is meeting to implement both short- and long-term plans that will better meet demand and provide safer services for patients.
The need for a coalition became evident in the fall of last year, when the Region’s predictive model, which calculates daily admissions and discharges to RUH and St. Paul’s Hospital (SPH), forecasted peaks in demand in mid-November 2015 and January 2016.
A 15% increase in the Region’s population over the last five years is the primary reason for the increase in emergency department visits and acute care admissions and discharges. Last year, a total of 150,985 people visited the Region’s three acute care emergency departments, an increase of more than 4,700 people in the previous year. The last two years has also seen an increase of 1,154 patients admitted to and discharged from the hospital.
A hospital stay costs an average of $20,000 per patient. These costs increase significantly for patients who require intensive or specialty care.” – Jean Morisson, President and CEO of SPH and Dr. Pylypchuk’s co-lead on the Physician Guiding Coalition
The short-term objective of the coalition is to appropriately reduce the average length of stay for patients admitted to the acute care medicine units at RUH and SPH by 0.25 days or six hours. The average length of stay for patients is 9.3 days at RUH and 11.5 days at SPH.
“Literature suggests that reducing a patient’s length of stay by six hours would free up approximately 20 beds,” says Dr. Pylypchuk. “Reducing length of stay will also decrease patient waits in the emergency department, allowing us to have the right patient in the right bed at the right time. For example, patients requiring specialized care beds such as observation units will be able to access them quicker, thus leading to safer patient care.”
Three initiatives have been undertaken to reduce patients’ length of stay and provide safer services for patients: a review of observation unit protocols, a reduction in discharges that occur later in the day and the implementation of a chronic obstructive pulmonary disease (COPD) order set.
Observation unit protocols (led by Dr. Kempe Gowda and Bryan Witt)
Observation units are for patients who require more intense nursing care. Currently, the average wait time for an observation bed is 21.91 hours at RUH and 16.37 hours at SPH. Each day, approximately five patients wait for an observation bed at RUH and three wait for a bed at SPH.
The goal of Dr. Gowda, Respirologist, and Bryan Witt, Acting Director of General Internal Medicine, is twofold. The first is to ensure that 100% of patients who are referred to an observation bed truly require observation unit level care.
The second is to ensure that 100% of patients in observation beds are re-assessed daily by 10 a.m. to determine if they require observation for an additional 24 hours or can be moved to another unit, and to clearly indicate on the patients’ charts the reason they require more observation. “Physicians have been rounding each morning, trying to see all patients by noon,” says Witt. “We’re hoping to meet our target of 10 a.m. shortly.”
To assist physicians in assessing patients, Dr. Gowda and Witt are developing guidelines for patients who require observation unit beds. They are also working on a predictive model to determine whether the Region has enough observation beds in the system and to better prepare through prediction when observation bed needs may surge.
Discharge time of day (led by Dr. Raviqubal Basi and Jenny Bartsch)
In order for a patient to be discharged home, significant preparation by the entire healthcare team is required. If the care team is made aware of the plans on the day of discharge only, the patient often leaves late in the day or is unable to leave until the following day while preparations are being made. Currently, less than 40% of medicine and clinical teaching unit (CTU) patients at RUH and SPH are discharged before 2 p.m.
The goal of Dr. Basi, Internist and Clinical Teaching Unit Chief, and Jenny Bartsch, Director of Heart Health and Critical Care, is for 75% of medicine and CTU patients at RUH and SPH to be discharged home by 2 p.m.
During the second week of January 2016, the team began trialing an improvement project on the CTU at RUH. On this unit, physicians are being asked to predict their patient discharges on the day prior to discharge by no later than 5 p.m. and to inform the patient’s charge nurse by text or phone of the potential discharge. Based on the information received from the physician, the patient’s charge nurse, primary care nurse and other members of the care team are using standard work to prepare the patient and family for the potential discharge.
“It’s great to see this seemingly simple change create an improvement in communication among the care team,” says Bartsch. “It’s another step in our journey to continuously improve quality of care for our patients.” The team’s next steps are to replicate the process on the medical units at SPH.
COPD order set (led by Dr. Robert Skomro and Kelly Johnson)
Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease that makes it difficult to breathe. COPD is one of the most common reasons for admission to hospital, and COPD patients commonly have an increased length of stay of 1.0 days at SPH and 0.8 to 2.3 days at RUH.
The goal of Dr. Skomro, Respirologist and Head of the Division of Respirology, and Kelly Johnson, Kaizen Operation Team Lead, is to implement a COPD order set for patients that will standardize care and increase efficiencies. The first step in the process is to try and condense a seven-page COPD order set to one page. The order set is meant to be completed by physicians when a patient is admitted to and discharged from hospital, but because it is so long, the form is often being filled out incorrectly, incompletely or not at all.
The second step is to ensure that all patients who are discharged are referred to the Region’s LiveWell Chronic Disease Management Program, which is offered to individuals and their families who have chronic conditions like COPD.
The team is in the process of engaging with stakeholders such as pharmacy to review the COPD order set and to involve COPD nurse educators from the LiveWell program. It is also working to ensure that the order set is standardized so that it can be used at both RUH and SPH.
Long-term patient flow initiatives
The coalition is also in the planning stages of implementing long-term patient flow initiatives, which include a restorative care program, psychiatric enhancements, cardiology improvements and rural remote emergency department coverage to help rural physicians treat patients in their own communities. Stay tuned for more on these initiatives in the coming months.
Glossary of terms
Length of stay – the length of time that a patient stays in the hospital from admission to discharge
Patient flow – placing the right patient in the right bed at the right time
Predictive model – forecasts daily admissions/discharges for Royal University Hospital and St. Paul’s Hospital