AT BAYLOR SCOTT AND WHITE All Saints Medical Center in Fort Worth, Texas, hospitalist medical director Ijeoma Carol Nwelue, MD, lists ways in which the problem of having no empty beds in her hospital keeps getting worse.
For one, the hospital last year started a residency program—and length of stay has since increased. The medical center is also pursuing sicker patients by setting up more advanced GI, cardiology and oncology services. “There is a plan to build a new tower,” says Dr. Nwelue. “Until then, the hospital is working to shift departments and administrative staff around to make room for more beds.”
Like just about every other hospital, Dr. Nwelue’s is full. With studies showing that inpatients have longer lengths of stay as census grows, many programs are calling it a win if they can just keep length of stay stable. But Dr. Nwelue and her colleagues—like hospitalists around the country—are charged with improving throughput and reducing length of stay.
“Throughput, length of stay—they are all measures of how well a system is working.”
~ Ijeoma Carol Nwelue, MD
Baylor Scott and White All Saints Medical Center
“Throughput, length of stay—they are all measures of how well a system is working,” she says. Here’s a look at what her hospital and others are doing to move patients through as safely and quickly as possible.
All hands on deck
For many, the key has been finding ways to bring more team members in to solve problems around discharge. And throughput problems are so entrenched that they require taking a very broad view. In Charlottesville, George Hoke, MD, a hospitalist leader at the University of Virginia Medical Center, says that what started as his center’s length of stay coalition has since morphed into what’s now called the patient progression coalition.
“It was a nod to the fact that to improve hospital capacity, you have to look at a lot more than inpatients,” Dr. Hoke points out. “You need to look at how patients move through the ED, how outpatient services can prevent hospitalizations, how efficient your observation unit and ancillary services need to be.” That coalition is now so large that it’s been broken down into six or seven subcommittees to tackle discharge barriers in different service lines and settings.
Today’s Hospitalist often runs stories on discharge management. Click here to read about automated texts post discharge, SNF discharges, early discharges and more.
Dr. Nwelue and her colleagues likewise launched a capacity management steering committee in early 2022 that now has many subcommittees.
One initiative that has already proved successful: a project to get admitted patients from the ED to the floor more quickly by speeding up notifications to floor nurses. “They have improved the percentage of patients who make it to the floor within 60 or even 30 minutes from 20% to 50%,” says Dr. Nwelue. “That’s been a great improvement.”
Escalating problems up the chain
Dr. Nwelue also worked on an initiative for the Baylor system to overhaul multidisciplinary rounds.
“To improve hospital capacity, you have to look at a lot more than inpatients.”
~ George Hoke, MD
University of Virginia Medical Center
“Those looked different in every hospital and on every floor,” she points out. “We are working to standardize them and to have everyone focus on the expected discharge date and any discharge barriers.” Baylor also started bringing physical therapists and pharmacists on rounds so everyone knows when a patient is having trouble walking or can’t afford a medication at discharge.
“We now know these complications days in advance,” says Dr. Nwelue. “That gives us time to develop a plan to address them.”
In Amarillo, Texas, hospitalist Sheryl Williams, MD, medical director of quality at Baptist St. Anthony’s Hospital, says multidisciplinary discharge rounds were redesigned to make them more rapid fire.
And instead of having front-line hospitalists attend discharge rounds, the hospitalist medical director attends half of them (three floors’ worth) while Dr. Williams attends the other half. She then brings the information she and the hospitalist director have learned back to the front-line hospitalists so they know what they need to do to keep discharges on track.
She also creates a spreadsheet with color coding to indicate length of stay problems: red is patients in the hospital three days over their expected discharge date, orange is for those one or two days over, and so forth.
“I go into that sheet and literally write in what’s keeping a patient here, such as waiting on a wound vac or a post-acute bed,” Dr. Williams explains. “I then escalate that daily report up the chain to all the unit directors and executive team, including the CMO, who can start making phone calls if necessary.” Such calls, for instance, might be to a subspecialist who isn’t scheduling a needed procedure for several days while a patient sits in the hospital.
“In the end, it all comes down to relationships.”
~ James Manning, MD ECU Health
“That doctor,” says Dr. Williams, “will be asked to move that procedure up.”
Discharge experience counts
At ECU Health, in Greenville, N.C., hospitalist medical director James Manning, MD, says that all eight hospitals in his system have likewise redesigned discharge rounds, which are called progression of care rounds. Those changes, which took place in 2018, included putting a nurse in charge of running the rounds, not doctors.
“Physicians do a very thorough job of presenting cases, and there’s a time and place for that,” Dr. Manning says. “Progression of care rounds aren’t the time or place.” As in Dr. Williams’ hospital, the rounds are tightly formatted to be completed in 45 minutes or less.
Another big change: Those rounds typically include a senior physician who could be the hospitalist director or one of the hospital medicine co-directors. That clinician reviews all the care decisions being made during rounds and suggests alternatives for a faster discharge.
Those doctors may, for instance, recommend outpatient therapies or oral alternatives to IV medications so patients can go home. Or they may urge physician colleagues to rethink calling in another consultant.
“What these seasoned clinicians during rounds really establish is the tone and urgency for discharge,” Dr. Manning points out. “They encourage the whole team to think of creative ways to get patients out of the hospital.”
Radiology, PT/OT work queues
Those same clinician leaders fill another key role. In an intervention launched in 2019, Dr. Manning helped create a long length of stay unit with 22 beds. That unit draws the academic center’s most experienced physicians and case managers.
“We now have evidence to support which service lines are responsible for longer lengths of stay.”
~ Sheryl Williams, MD
Baptist St. Anthony’s Hospital
“The patients don’t require a lot of time but they do need someone who’s creative and aggressive with discharges,” Dr. Manning points out. Plus, the case managers working that unit are dedicated to it. “It’s a badge of honor for them to work there and safely discharge the really tough patients.”
In Charlottesville, Dr. Hoke says that he and a colleague looked before the pandemic at which patients accounted for their excess length of stay days. One-half turned out to be patients with very long length of stay. (See “Tackling outliers.”) The other half were patients in the hospital a day or two past their expected discharge date. To help whittle those down, Dr. Hoke revamped patient progression rounds last year.
In addition to crafting a script to keep rounds tightly focused on discharge problems, “we’re using the information exchanged during rounds to create work queues for radiology and for PT and OT,” he explains. “When patients are within 48 hours of discharge and have an outstanding order for one of those services, they are prioritized and go to the front of the line.”
Are the rounds effective? “Our length of stay for the last few months has been basically flat, where it had been rising before,” says Dr. Hoke. “Perhaps that’s progress. It feels like we’re doing a better job with patients who used to stay a day or two past their expected discharge.”
Staying longer on units
The interventions that ECU Health put in place led to a reduction of 0.7 days in length of stay. But then covid hit, staffing fell short and length of stay soared. During the pandemic, the progression of care rounds on general floors were discontinued and were reinstated only in October 2022.
Part of why they were suspended, says Dr. Manning, is that staffing was so unstable. (That has improved since.) But when interventions peter out, “it’s often because they aren’t going that well to begin with. I think many clinicians and team members felt the rounds weren’t value-added when everyone was pressed for time.”
How have the rounds been tweaked to improve their value? “If you’re just rotating through a unit for one week, you tend not to build great relationships,” Dr. Manning says. He and his program decided to keep clinicians working on specific units for at least three months so they’ll continue holding progression of care rounds with the same team members. So far, he points out, the feedback he’s received is positive.
“With more time, hospitalists will build better relationships and improve communications with nursing staff,” he points out. “In the end, it all comes down to relationships.”
Owning what you control
In Amarillo, Dr. Williams says that she—as well as the hospitalist medical director, C-suite members and the head of case management—make up the length of stay committee, which meets every two weeks. For each meeting, she prepares PowerPoints that break down length of stay by service and sub-service line.
“I developed the slides,” Dr. Williams says, “so we wouldn’t all be sitting around the table, with me and the hospitalist director being asked, ‘Why are hospitalists’ patients staying here so long?’ We now have evidence to support which service lines are responsible for longer lengths of stay and which have shown improvement. We can also see which individual physicians have the longest lengths of stay and number of avoidable days, allowing for individual counseling and mentoring.”
In Fort Worth, Dr. Nwelue says she likewise makes sure that hospitalists are held responsible only for throughput delays they can actually do something about. “We focus on when is a patient medically stable to leave instead of when does that patient actually leave,” she says. “The discharge date may not be in our full control.”
To back up that position, Dr. Nwelue asks each hospitalist every weekday to list all the patients on that physician’s census who are medically stable enough for discharge. She makes sure that rounding list makes its way through hospital leadership.
“We want to call out the difference between hospitalists keeping patients too long and all the other factors that interfere with discharges,” Dr. Nwelue says. “When I hear, ‘Your doctors had only 10 discharges today,’ I can reply, ‘Well, we expected 25, and here are the reasons the hospitalists listed for why the rest of those patients are still waiting to leave.’ ”
Phyllis Maguire is Executive Editor of Today’s Hospitalist
IN CHARLOTTESVILLE, George Hoke, MD, a hospitalist program leader at the University of Virginia Medical Center, says that he and a colleague a few years ago looked into their discharge data to find out which patients accounted for all their excess length of stay days.
As Dr. Hoke explains, one-half turned out to be patients staying a day or two beyond their expected discharge date. But the other half were long length of stay outliers. “Their lengths of stay were multiples of what you’d expect,” he says. “If they were expected to stay five days, they were staying 20-plus.”
Not surprisingly, those were patients dealing with intractable problems: dementia, addiction, homelessness and mental illness, as well as social determinants of health and comorbidities. To learn how other hospitals managed those challenges, he and his colleague reached out to about a dozen other academic centers around the country and brought several approaches they heard about back.
Guardianship was one of those. “Some hospitals partner with outside law firms to do their guardianship work,” Dr. Hoke says. One county in Ohio created a board to help local hospitals deal with such cases. His own center started working with a local group that provides free legal services. “UVA Health is also talking about whether we should hire an attorney specifically to help these patients and their families,” he adds.
They are also exploring another idea: providing extra resources at a specific skilled nursing facility to take patients who are behaviorally impaired. “We may provide a geriatric psychiatrist or psychologist to that facility to do consults,” says Dr. Hoke. “We’re also considering supplying addiction medicine consults there so the facility can care for patients with opioid use disorder.”
What works and what to try
REDUCING LENGTH OF STAY and improving throughput take an all-hands-on-deck approach to ferret out bottlenecks in each department and service line. When it comes to hospital medicine, here are some interventions that sources have either tried and had success with or believe hold out promise:
• Disease-specific pathways: George Hoke, MD, a hospitalist leader at the University of Virginia Medical Center in Charlottesville, Va., says that he and his colleagues have tackled reducing length of stay for some conditions. For pancreatitis, for instance, “evidence shows that keeping these patients NPO is no longer recommended,” says Dr. Hoke. “Getting patients to eat and drink sooner might shorten their length of stay.” Pneumonia has been another target to reduce how long patients take antibiotics.
Hospitalist Sheryl Williams, MD, medical director of quality at Baptist St. Anthony’s Hospital in Amarillo, Texas, says her facility has launched a pilot using learning modules provided by QURE Healthcare. Clinicians work their way through presented cases, then go over responses in group discussions. The goal: improve care for (and the length of stay of) sepsis and heart failure patients.
• Dedicated case management: Dr. Hoke notes that his program has not pulled off geographic assignments and rounding. That means hospitalists over the course of a day may have to talk to six different case managers about discharge problems.
To be more efficient, “we transitioned to a model where one case manager was assigned to two hospitalist teams,” he says. “Each hospitalist would ideally have all of his or her patients with one case manager, and that case manager would have only two hospitalists to communicate with.”
But staffing is key to keeping that model afloat. “When we’re fully staffed, we can pull that off,” Dr. Hoke points out. “When we’re not, it falls apart.”
• Get patients out of bed sooner: In Amarillo, Dr. Williams says that her hospital’s biggest discharge challenge is finding post-acute beds. To help, she and her colleagues want to start a mobility pilot program that would include an ambulatory evaluation on bed day 1 for all patients to get them up and walking.
“That may prevent some patients from needing post-acute care,” she says. But it is still undecided whether nurses or physical therapists will head up that project, and staffing shortages continue. As a result, that pilot has yet to be launched.
• Check your coding: Dr. Williams also recommends looking through as much billing and discharge data as possible. At her hospital, that process led to this reveal: “Our coding wasn’t optimal, and some patients admitted for sepsis were somehow being coded with congestive heart failure. Those DRGS have totally different geometric mean LOS.” Her hospital has now signed on with a new coding company, which is “going back and reviewing some of those DRG assignments.”
• Early discharge: Many groups include this metric in their incentive plan, although some physicians feel the focus on early discharge actually makes length of stay longer. Ijeoma Carol Nwelue, MD, hospitalist medical director at Baylor Medical Center Ft. Worth in Texas, says that every rounding team on her service is asked to identify one or two patients who can leave by 10 a.m.
“We’re really pushing the idea that the identification of those patients can’t happen on the day of discharge,” she points out. “We’re planning two days prior to make sure all consultants have signed off and patients have all their prior authorizations and scripts.”
• A discharge hospitality lounge: Dr. Nwelue’s hospital got such a lounge off the ground, giving patients an area to go over their discharge instructions and wait for their transportation, all while getting them out of their hospital bed.
“It’s basically its own nursing unit,” she points out. Having the lounge has improved the time it takes for patients to leave the floor. Moreover, “it’s been great for catches. Patients may be missing a script or they’re not sure how to change a wound dressing, so the nurses there can have very detailed discussions with patients and their caregivers.” Dr. Nwelue also credits the lounge for a bump up in the hospital’s HCAHPS scores on care transitions.
Published in the January/February 2023 issue of Today’s Hospitalist