Many days we are at or near patient capacity at SHC (and for that matter Packard hospital). Patients in great numbers want to come here for their care and the services you provide.
But finding a bed for our patients has become more complicated as we seek to match individual patients with the increasingly specialized nursing expertise and equipment they need. So it’s no surprise that the hospital faces challenges to use our patient beds as efficiently as possible.
Put simply, many of the capacity pressures stem from bottlenecks. Too often patients wait for an earlier patient to be discharged and then for housekeeping to ready an appropriate bed. Postoperative patients wait in a recovery room, while patients awaiting admission from the Emergency Department must stay in that busy, currently crowded, corner of the hospital. Outpatient clinic patients too often must sit in a chair in admitting; needed or comforting treatment is delayed until after their bed is located.
Some patients never get the care here they need or even get here at all. Surgeries are postponed or canceled when an appropriate “acuity bed” is not available. And the hospital is heavily impacted whenever the Transfer Center too frequently must deny taking patients from other facilities for specialized care at SHC because we have no appropriate place for them.
Over the years we have had a number of initiatives to try to relieve the bottlenecks. I am sure many of you will remember our campaign to complete patient discharge by 11 a.m. Meeting this deadline has been a continual struggle for various reasons despite our best efforts, which have included such measures as increasing the number of ICU and telemetry beds, and as many of you have heard, transforming the inpatient rehab unit on C1 into acute care inpatient beds.
But until a new hospital is constructed in the coming years, we’ve gone about as far as we can go toward finding more beds.
Meanwhile, If we are going to continue to try and build new clinical programs without turning away patients or frustrating everyone involved, we must utilize our beds more efficiently and effectively.
First, we must work constructively with the hospital to figure out ways to speed up the discharge process for those patients we know are ready to leave. This will involve re-engineering many of our procedures, or put another way, we may need to do some things differently. This process has started. We are fast tracking labs and radiologic tests that physicians need to make discharge decisions.
Nurses on each unit are gathering information about potential discharges each day to help predict bed availability each morning. That planning should help plan ICU transfers, operating room cases and potential Transfer Center admissions throughout the day. Nurses also report when problems appear to hold up an anticipated discharge. That information will help us track trends and plan corrective strategies.
Now its time for physicians at SHC to take some steps:
Communicate potential discharge timing to patients, their families and the nursing staff, so patients won’t have to stay in a bed just because no one had a heads up to seek an appropriate outpatient placement.
Whenever possible perform lab tests or procedures crucial to a discharge decision the night before the anticipated departure. Tests not crucial to a discharge decision can be performed later as an outpatient procedure and then put into the patient record.
Write discharge orders conditionally the day or night before departure. These orders can be activated with a phone call the next day or aborted if needed by letting them expire. This process may help you practice more efficiently, because you won’t be asked to break free from your clinic or procedure to write discharge orders.
The hospital is doing its part. Currently we are beta testing use of a Medical Control Officer (MCO) to help break the logjam.
The MCO — myself during the pilot stage — is a medical staff member working with a team including nursing leadership, case management and physician colleagues to accommodate incoming patients and maximize the number of patients the organization can admit safely, comfortably and efficiently. The MCO’s day-to-day tasks include problem solving to help facilitate timely discharges. The MCO will also lead or support strategic projects to streamline the overall discharge process and optimize scheduled admissions.
So if in the near future you receive a call from me asking you to write your discharge orders on a patient, you will understand where this is coming from.
Meanwhile, if you have ideas about how we can accommodate more of our patients in an efficient and safe manner, please contact me at lshuer@stanford.edu or call me at (650) 723-5371.
