Volume 28 • No. 11
N E W S I T E M S
The Perfect Storm
by: LAWRENCE M. SHUER
"There's a certain amount of denial in swordfishing. The boats claw
through a lot of bad weather and the crews generally just batten down
the hatches, turn on the VCR, and put their faith in the tensile strength
of steel. Still, every man on a sword boat knows there are waves out there
that can crack them open like a coconut É. Once you're in the denial
business, though, it's hard to know when to stop."
- from The Perfect Storm by
Sebastian Junger
(W.W. Norton Co., 1997), p. 95.
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There are many differences between swordfishing and practicing hospital medicine, but the dilemmas fishermen face during a freak and deadly storm still offer us some poignant lessons about how to plan when the challenges are greater than the sum of their parts.
In The Perfect Storm, Junger's nonfiction study of a 1991 disaster, the captain (played by George Clooney in the more fictionalized film of the same name) of the Gloucester, Mass., fishing boat Andrea Gail forged ahead to his boat's Atlantic fishery despite a peculiarly vicious storm. The skilled crew had plans for each component of risk, but a rare convergence of wind and seas suddenly made the risks greater than the sum of their parts. The six fishermen on the boat drowned. Nature had changed the rules.
At Stanford Hospital we are facing similar conditions wrought in our case by economic, political and social conditions more often than nature. Like the crews of those fishing boats who survived the 1991 Perfect Storm, we must plan prudently for conditions that are larger and less predictable than their component parts.
One significant component locally is the closing of San Jose Medical Center, until recently one of Santa Clara County's three trauma centers. Our hospital has vowed to help take up the slack, and this will bring in an estimated 800 more trauma patients to our Emergency Department each year. Nevertheless, we are expected to manage challenges of this sort.
But there are more waves surging and winds blowing from other directions. A carefully planned building and program development effort at SHC has created an elective surgery schedule that fills our operating rooms regularly. On top of this, our transfer center acts on ever increasing numbers of requests from outlying hospitals wishing to send patients here to receive the latest technology. (And this doesn't even count the trauma and other patients we received after the San Jose Medical Center was closed because of financial difficulties.) The failure in November of Proposition 67, which would have supported our emergency rooms through a phone tax, will surely not help an already stressed financial picture on the frontlines of hospital intake in our region.
Now we are entering the season where historically we have admissions for influenza as well as other flu-like illnesses, and Packard Hospital will be dealing with the usual outbreak of RSV. We could be facing some very busy times for both hospitals, and in this case nature will be a contributing factor.
Additionally, our urgent and acute care population increasingly is the focus of our hospital, and this makes managing patient census far more volatile than in past years, when elective or chronic care was an inpatient staple. Put simply, we have a daily dance for bed space. Although we have increased the number of acute care beds, we nonetheless have already faced times when patients could not be brought here because beds were unavailable.
We do have plans to increase operating room capacity, and we also have contingencies to increase the number of critical care beds. But none of these "plans" are close to operational now. If we reach the point where surgical cases must be cancelled because we lack available operating rooms or intensive care beds, then patients and their physicians will surely be frustrated. Surgical procedures have been cancelled at Stanford because of a lack of beds, and I believe these cancellations will increase as they already have at Packard since the winter flu season began.
We absolutely must strive toward efficient use of all of the resources at our disposal. As I discussed in my February 2004 chief of staff's column, we must manage these precious resources wisely. Hospital administration put a high priority on improving operating room functions so that cases can be completed in a timely fashion. We as physicians need to do our part to facilitate the appropriate transfer of patients from critical care beds to regular beds. Then we must also make the discharge process occur as early in the day as feasible to make sure the bed can be "turned around" to accommodate the next patient. Your creativity can help with this process. Please forward your suggestions on this either to Nancy Lee at nlee@stanfordmed.org or to me at lshuer@stanford.edu.
In general, we cannot be lulled into thinking that the problem of hospital crowding is a good problem to have because it loudly proclaims we have a strong patient base, are building clinical programs and are providing an environment patients generally prefer for their care. We are doing a good job of providing care and services as recent surveys and our experiences in the Cancer Center have shown. Patients do want to come here. But remember this is only one part of the picture. We cannot let our success and competence lure us into a dangerous storm where we find no adequate protection.
Let's continue to improve and look creatively to meet the relentless challenges that impact how we care for patients, because we are no longer - if we ever really were - in control of the overarching circumstances that impact our operation in often unpredictable ways. We need to be realistic, think strategically and act creatively.
As the Gloucester fishermen who did survive the 1991 storm remember, prudence, intelligence and creativity will allow us to plan or at least protect ourselves from the Perfect Storm.
As we see another calendar year come to a close I wish to thank each and every one of you for all the fine work that you do each day in providing excellent care for our patients and helping us continue to be successful. The challenges of volume and space are a testament to the reputation that our underlying quality has spawned. And behind that excellence is your spirit, enthusiasm and creativity.
And may we all find a safe harbor - I
hope that you are able to have a very Happy Holiday Season and a very
healthy New Year!
