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Managing Precious Resources
by: LAWRENCE M. SHUER
Based
on patient occupancy, Stanford University Medical Center is becoming a
victim of its own success. Recently we have had to cancel both surgeries
and admissions because a high census at Stanford Hospital has led to a
bed shortage in critical care and other units. (The problem began even
earlier and persists at Lucile Packard Children's Hospital.)
We are faced with this resource allocation problem, ironically, because we built strong clinical programs that have brought increasing patients to our facilities. Consequently, our census has risen above 90 percent occupancy, a volume that creates patient flow challenges. Operating rooms are being impacted as well as beds.
Think of this in human terms: Physicians and their patients are frustrated when both learn on the day of surgery that an elective procedure has been cancelled because a bed cannot be found. Think of the physician who cannot accept a referral patient - sent to him or her because of unique expertise - because bed space is lacking. Instead the patient is sent to another physician at one of our competing institutions!
Yes, these are trying times. Certainly, we have faced a "full house" before, but these have always been temporary situations, such as a flu season or a busy, predictable elective surgical schedule coinciding with school vacations, etc. In those cases, there was light at the end of the tunnel. Now, however, we seem to be in a mode where we have many clinical programs in medicine and surgery that are rising in activity, creating a persistent shortage of space begging for a strategic solution. This time we can't simply wait for flu symptoms to disappear or vacations to end. Are there inefficiencies in our system that could be corrected to help alleviate the dilemma? Yes, most definitely! Here is one step:
For the past year we have been working toward an earlier discharge time for patients. The data I've seen indicates we can make improvements leading to an earlier departure for patients. Broadly stated, we need to change our work habits so that we can improve patient flow. Specifically, we have many services where the discharge orders are not being written until after rounds have been completed. Our goal is to have those discharge orders in the system ready to receive a final OK during morning rounds. Localized rules or practices often work against this seemingly simple efficiency. For instance, some services will not discharge a patient until the attending rounds are completed, and this may not happen until the afternoon. Some of the surgical services will not discharge patients until the people responsible for the patient finish their day's work in the operating room. Some patient discharges are being held up awaiting a lab result or a radiologic procedure. We need to come to an understanding as to how we can change all these practices to get better patient flow.
Resource pressures go beyond space and patient beds. Precious resource allocation also includes the blood that is available for our patients' use in our blood bank. In the not too distant past we had a critical shortage of blood, not only in our institution, but nationwide as well. We had to cancel surgeries because of our inability to guarantee sufficient supply of a needed blood type. At the same time we had some patients who seemed to be utilizing blood at an extraordinary rate in situations where their prognosis for survival seemed poor.
We need to manage resource allocation more effectively. So with that in mind I am going to pull together into a special committee some of the physician leaders from critical care, the operating room, transplant services, medicine, trauma, etc. I believe this will be an effective peer-driven mechanism to communicate to physicians when resource limitations require canceling admissions and surgical cases. We are also brainstorming about how to improve patient flow - the prerequisite for efficient bed utilization. Eventually we may need to look further at expanding the hospital so that we will have more critical care and med/surg beds.
I welcome any and all suggestions about how to improve patient flow and better utilize our precious resources. A solution to this problem cannot be achieved without the informed, thoughtful and constructive input of our users - those of us who are working in the trenches (including me part of the time) and understand our complex system. Please e-mail me at
