Published in the April 2009 issue of Today’s Hospitalist
A NEARBY EMERGENCY DEPARTMENT goes on divert or there’s a spike in flu-related admissions, and your patient volume surges. While that may put you at the center of a chaotic work day, it also puts you in the unique position of seeing where hospital systems break down “and where errors can be prevented.
While most physicians see only what’s going on in their own hospital department, hospitalists have a broader vantage point. That can make them key players in hospital efforts to prevent the negative effect of volume overload, says Alberta T. Pedroja, PhD, a researcher who’s investigating the relationship between volume and patient harm.
In a study published in the September/October 2008 American Journal of Medical Quality, Dr. Pedroja talks about a “tipping point.” She defines the term as that point at which a hospital’s systems are overwhelmed by patient volume, and the probability of provider error shoots up.
Dr. Pedroja says her goal is to help hospitals quantify that breakpoint so they can create early warning systems to alert staff and implement strategies that mitigate the threat to patient safety.
One big challenge, she admits, is figuring out which factors drive individual hospitals over the edge. Her research identified a number of factors, such as an unusually high volume of new admissions or of “add-on” (unscheduled) surgeries.
But perhaps just as significantly, Dr. Pedroja’s study found that capacity problems are made worse by a lack of communication. Errors increase when capacity surges in two or more areas of the hospital. But because departments don’t know when other divisions are overwhelmed, they’re not aware of the higher risk to patient safety that affects the entire hospital.
“One department doesn’t know another is busy unless people hear about it in the lunchroom,” Dr. Pedroja says. “It turns out the hospitalist is in a position to know.”
Finding the connection
To explore the connection between volume and patient harm, Dr. Pedroja took a two-pronged approach. She began by collecting anecdotal evidence from two hospitals in Southern California. She then collected data over 17 months from a 400-bed acute care facility in San Diego.
Using incident reports adjusted for harm to patients, she calculated a daily harm score by adding up the numerical value of each injury or near miss caused by errors. Then she examined whether trends in patient volume correlated with patient harm.
Dr. Pedroja concluded that high-volume days that could be linked to patient harm were uncommon; a volume-related error likely occurred on only 11 of the 515 days examined for the study. While that’s good news, it speaks to the challenges of pinpointing volume-related problems.
“It’s not obvious on a day-to-day level because it doesn’t happen very often,” says Dr. Pedroja, president of ATP Healthcare Services, a consulting firm in Northridge, Calif., that specializes in health care accreditation and performance improvement. “That’s why we miss it and need to look at it over the long term.”
The study found that hospital staff who cut across departments, such as those in engineering and housekeeping, were a bellwether in times of chaos, often becoming overwhelmed and showing signs of stress.
Breakdowns also occurred in other support systems that doctors and nurses rely on, such as lab, pharmacy and radiology.
According to Dr. Pedroja, every hospital has its own factors that drive it to the point where support systems are overwhelmed. In one hospital she studied, the “tipping point came when the ED had to handle more than five psychiatric admissions at once. But she noted that the volume indicator wasn’t a problem at another hospital in the study.
She says she would eventually like to see hospitals able to assign a capacity number to their own tipping point and to devise an early warning system, such as code orange and code red, when capacity is increasing the risk of patient harm.
However, Dr. Pedroja admits that quantifying that point is elusive. And preventing downstream patient harm at or beyond that point may require a fundamental shift in how hospitals approach capacity issues.
While the traditional approach to volume problems is to add more staff, she says, that’s not a good substitute for identifying “weak links in the system and shoring them up. The fact is that just adding staff who may not know what’s going on elsewhere in the system and don’t communicate well, or who perpetuate the same problems, may create even more obstacles.”
Because hospitalists interact with the ED and with surgery, they may be ideally suited to detecting bottlenecks and the risks of errors that stem from them. Hospitalists can then use those insights to develop surge plans to contain patient-safety risks.
Dr. Pedroja says that in one ED, the weak link was the inability to get specimens to the lab in a timely manner during the 4 p.m.-to-8 p.m. crunch. Because of that lag, the ED would need to redraw blood, and patients would be banked on gurneys when free beds were needed most. That hospital did opt for a staffing solution: adding a volunteer or student to make sure specimens got to the lab more quickly.
Other problems might require a more permanent fix. Dr. Pedroja found that when one med-surg floor was busy, information on patients who were being transferred from one room to another was not being entered into the computer right away. As a result, medications weren’t delivered to the right patient room.
When medications were slow to arrive, nurses would order them again, which led to duplicate orders being filled and a high level of stress for everyone. The solution was to implement a series of nurse follow-up phone calls to the pharmacy instead of issuing duplicate orders.
Hospitalists might be asked to pitch in, too. Dr. Pedroja says that surge plans may call on hospitalists to discharge earlier in the day or to assess patients earlier to determine if they are ready for discharge to free up beds.
Next: identifying measures
Ultimately, Dr. Pedroja would like to see hospitals create a clearinghouse in which individual departments would report critical-capacity indicators to a central location. The clearinghouse could then notify all hospital staff when any single department reached a yellow or red alert status and implement protective strategies.
Some hospitals have taken small steps to this goal, she says, by expanding bed control meetings to inform support services of hospital volume.
Dr. Pedroja is currently researching ways to identify which volume measures are the most sensitive predictors of patient safety problems. She’ll be looking at indicators like the number of no-code beds, the number of patients boarding in the ED and the number of patients in the ED at 7 a.m.
“Having that information can lead to appropriate fixes for areas susceptible to safety problems,” says Dr. Pedroja. “At the very least, it lets us know what may be the first to give under stress.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, III.