Published in the January 2013 issue of Today’s Hospitalist
IN MOST HOSPITALS, hospitalists spend their days frantically ordering tests, talking to consultants, creating care plans and preparing for discharge. But that hustle often comes to a halt around 6 p.m. or 7 p.m., when the day shift prepares to hand off patients to the night team.
As a result, any major decisions about patient disposition often are put off until the next morning. And after-hours staff in the evening may be not be doing much to help improve throughput and streamline the discharge process.
The realization that nighttime staff could be doing more, combined with perennial logjams in the emergency department and telemetry units, prompted the hospitalist service at Geisinger Medical Center in Danville, Pa., to reengineer its traditional evening huddle. The idea was to experiment with giving hospitalists some new tasks in the evening to help solve the hospital’s capacity problems.
“Our evening huddle had tended to function like check-out rounds,” says hospitalist Sashikanth Kodali, MD, who is part of Geisinger’s clinical innovations department as medical director for inpatient clinical decision support. “We go over the to-do list, get ready for the next day and prepare for the hospitalists’ sign-out. But we realized that the huddles don’t do much to improve patient flow, so we decided to see if we could leverage the after-hours period to improve that flow.”
One big problem that Dr. Kodali hoped a re-designed huddle might solve was the bottleneck in telemetry. “We’re quick to put patients on those floors, but not to take them off,” he notes. “That means that patients often stack up in the ED at night.”
Optimizing “after hours”
The huddle redesign came after Geisinger had tried several other throughput initiatives. In recent years, for instance, hospitalists have been charged with documenting patients’ expected discharge day in the electronic health record. Choices include today, tomorrow, or two days or more.
“We struggled to get people to do this,” Dr. Kodali explains. “Hospitalists were good about documenting the patients ‘leaving today’ more than 80% of the time. But the ‘discharge tomorrow’ was a real toss-up.” Geisinger has 20 full-time hospitalists and operates both a teaching and nonteaching service on 12-hour shifts. Combined, the services cover an average of 120 patients and make extensive use of physician assistants on the night shift.
In fall 2011, Dr. Kodali devised and piloted the reengineering project. That entailed adding three tasks to the evening huddle for daytime physicians. First, the huddle began to retriage all patients on the service, with an eye on identifying telemetry or ICU-step-down “special care” unit patients who could be moved to either a lower or higher level of care.
The team also began anticipating and planning for “tomorrow” discharges and handling associated tasks. And third, it started doing preliminary medication reconciliation for pharmacist review for patients expected to be discharged the next day.
The biggest difference from the status quo, Dr. Kodali explains, is that triage has traditionally been done only once a day during morning rounds. The hope was that doing a second assessment might lead to quicker disposition decisions. That in turn might help free up telemetry beds during evenings and nights when the demand for those beds spikes.
“There may be patients whose clinical status has improved by the time of the evening huddle,” he points out. “If our hospitalists are here for 12 hours, we may have more information available from the tests ordered during the day. So why not triage those patients again?”
Enlisting nursing and pharmacy staff
The other two new tasks “med rec and discharge planning “used to be crammed into the morning hours between 8 a.m. and 11 a.m., when hospitalists’ activity level is already high. During that period, any number of issues could crop up and delay the discharge, from a prescription not being available to a transportation problem.
“The hypothesis was this: If we have the nighttime nursing and pharmacy staff handle some of these planning issues when things are quieter,” Dr. Kodali says, “we would be able to improve patient flow.”
Geisinger implemented the three-month reengineering pilot in September 2011, following two weeks of talking over the planned changes with the hospitalists and other staff.
Although the daytime hospitalists weren’t pleased about having more work to do at the end of an already jam-packed day, Dr. Kodali says they went along with the program “because they recognized the value of it.” They also understood that doctors on the pared-down night team, which includes one hospitalist working with two physician assistants and residents, are generally too busy putting out fires to take on the reassessment.
Although the reengineering is still a work in progress, Geisinger now has enough data to figure out what worked, what didn’t and where to focus the project’s next efforts.
One success? Retriaging has increased the number of patients being moved to a lower care level during the evening. According to Dr. Kodali, between three and eight patients are moved to lower care levels some nights.
But results have been more mixed for early medication reconciliation and tasks around next-day discharge. “The medication reconciliation has proved cumbersome because it can take an extra 10 minutes of physician work,” he notes.
He also points out that the redesigned huddle didn’t improve tomorrow-discharge prediction rates. Those stood at roughly 45% accuracy both before and after the pilot.
Part of the challenge is that the hospitalists are coming up with those predictions without input from a multidisciplinary team.
“That’s one of the things we’re going to try to address with a phase 2 implementation,” says Dr. Kodali. “But we’re encouraged at this point by the results we’ve seen, and we’re inclined to move forward with the reengineering process.”
Bonnie Darves is a freelance health care writer based in Seattle.