WHILE THROUGHPUT in hospitals has always been king, it is now—with staffing shortages, an aging population and consistently high volumes—more critical than ever. To meet that challenge, clinicians and staff at St. Mary’s Medical Center in Huntington, W. Va., the largest of the four hospitals in the Marshall Health Network, have in the past year put in place a series of throughput innovations.
As Rob Hayes, MD, MHA, chief of the hospital-based specialties division and medical director of the hospitalist service, points out, that suite of innovations has cut length of stay in the observation unit, increased throughput and is helping tamp down inpatient length of stay as well.
Here is a breakdown of specific throughput innovations the hospital has put in place.
• Multidisciplinary rounds: For years, the hospitalists at St. Mary’s met in the morning with a case manager. That case manager was then supposed to report all information out to other disciplines including social work and nursing.
But that process wasn’t necessarily well-defined, says Dr. Hayes. That’s why he and his team designed a much more robust process for multidisciplinary rounding. Since last fall, each hospitalist in the morning meets in a conference room with case management, physical therapy and pharmacy, as well as with charge and bedside nurses. They spend between 30 and 60 minutes going through patient lists to get everyone on board with discharge planning.
“We’ve reduced our observation unit length of stay by about 24 hours.”
Rob Hayes, MD, MHA
St. Mary’s Medical Center
But before those meetings could begin to take place, Dr. Hayes says, “we realized there was no way to do such rounds in our size of hospital”—413 beds—”without first going to geographic physician assignments.”
That innovation was “a major undertaking,” he admits, with doctors keeping between 80% and 85% of their patients on one floor. “My opinion of geographic rounds is that they create almost as many problems as they solve. But otherwise we could not have implemented such a multidisciplinary and highly inclusive approach. I would do it again.” Physicians rotate their geographic assignments every quarter.
• Observation unit with nurse-driven care maps: Hospitalists and their NPs/PAs supervise the patients in St. Mary’s observation unit. But late last fall, Dr. Hayes with case management and nursing leadership drew up “care maps” for common diagnoses seen in that unit. The nurses there are in charge of implementing those.
As Dr. Hayes explains, the care maps detail what an ideal workup (and workup timeline) should look like for any given differential. “Nurses who know that an observation patient needs an echo can see from a care map that an echo is supposed to be read within 24 hours—but that the patient has been there 12 hours and the echo hasn’t happened yet. They know they need to reach out to the echo department and call for a high-priority one.”
Driving the care maps helps empower the nurses. Moreover, the use of those maps has, says Dr. Hayes, “reduced our observation unit length of stay by about 24 hours. We were running between 72 and 80 hours, and we’re now right around 50.”
• Faster admission orders: Hospitalists now have committed themselves to putting in admission orders within five or 10 minutes after speaking with an ED physician about a patient.
“Some people may go eyeball a patient real fast first and then put the order in,” Dr. Hayes points out. “But a lot just put the order in and trust what the ED physician says.”
Before, he notes, hospitalists often didn’t place an admission order for an hour and a half after speaking with the ED. “Now, they understand there is a potential opportunity with respect to flow.”
Some hospitalists worried that they would be placing admission orders on patients who would leave the ED before a hospitalist could see them or that a patient being admitted to the floor might really need ICU-level care instead. “But,” says Dr. Hayes, “we have not seen those scenarios happen on any dramatic scale.”
• Preparing discharge orders the afternoon before: Giving hospitalists the time to work on patients’ discharge paperwork the day before their expected discharge is predicated on keeping daily census reasonable.
“We’ve tried to staff in such a way,” Dr. Hayes says, “that physicians have an opportunity to look at patients again at the end of the day and to follow up on any abnormal labs or talk to any consultants and prepare discharges.” At the same time, the hospitalist group does not maintain any set targets for morning discharges.
“We avoid setting hard limits,” he says. “When you have a certain number of discharges as your goal, people may be incentivized to hold patients until the next day to meet it. We just encourage people to be rational and engaged, and we have since seen discharge times shift toward the morning.”
• NEDOCS score: Earlier this year, St. Mary’s began using the NEDOCS scoring system (from the National Emergency Department Overcrowding Study).
That score, says Dr. Hayes, “assesses the hospital very comprehensively in terms of predicted flow,” with staff and clinicians very aware of the hospital’s score. “It’s announced overhead three times a day and there’s an LED sign in the physician parking garage.”
When that score is high, several interventions are supposed to kick in. For one, hospitalists maintain a whiteboard in their conference room they use to list patients they expect to discharge the next day along with any potential barriers to that discharge. During times with high NEDOCS score, they are expected to fill those entries in.
Hospitalists are also supposed to re-round virtually (through the EHR) on their patients to see if any can be discharged and speak again with case management. They also review all patients who are ER holds “to see if they can be discharged. Same with observation patients.”
While many hospitalists can usually leave at 5 p.m., they understand that their days may be longer when the hospital’s NEDOCS score is running high. “It’s an objective way of determining if we’re in a low state of flow,” Dr. Hayes says. “It’s an objective way for doctors to know to reround and do some extra work instead of administration just making demands.”
Other innovations
In terms of potential other innovations, Dr. Hayes points out that the hospitalists may design some compensation incentives around throughput measures. He favors incentivizing only those factors that doctors have some control over, such as completing discharge paperwork.
It helps that the entire hospital has fostered a culture of greater efficiency, with Dr. Hayes again singling out the echo department. “They know to prioritize echoes for people about to be discharged,” he says. “The likelihood of that department bumping a critical echo for a patient being discharged is not very likely, and everyone is on board.”
As a result, inpatient length of stay at St. Mary’s has been trending down. But it has also been affected, Dr. Hayes says, by the hospital’s ongoing struggle to place patients for post-acute care, a reality nationwide. “Social work staffing has been up and down,” he notes. “We’re now about to be fully staffed with respect to social work, so I anticipate that our inpatient length of stay will drop in the near future.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Read how other groups are redesigning healthcare in their hospitals.
NEDOC score sounds interesting. I would like to point out that none of the above articles addressed the number of patients on each Hospitalist’s service. Where I work in South Carolina, I consistently have 22 to 24 patients. [Please elaborate on] how would the NEDOC score help, not exactly clear to me.