I concluded my February column entitled "Winter Surge 2014 – Lessons Learned," noting that our crowding issue during the winter surge gave us "an opportunity to rethink our standard work." I predicted "the 'problem' wouldn't go away" and the crowded state would become "our new normal." And it has. ED and OR volumes are up 10.8 percent; ambulatory visits are up 9.7 percent; and inpatient discharges are up 3.4 percent.
Despite this growth, quality indicators and patient satisfaction scores continue to improve. Sepsis, patient safety, CLABSI and CAUTI rates are all moving in favorable directions. Patient satisfaction scores in the ED, Cancer Center and the inpatient setting are rising or above goal and holding steady. In the ED, the new team approach to evaluation of psychiatry patients has resulted in decreased time in the ED and improved placement. Congratulations to all staff, nurses and physicians on these improvements. We have also made excellent progress on our discharge before noon target, which has improved steadily from near 10 percent to around 30 percent today. But we need to do even better, and we need your participation.
As a colorectal surgeon I know well, almost on an hourly basis, how my patient should behave after a laparoscopic right hemi-colectomy. Similarly, the outstanding nurses on E3 know what to expect on an hour-to-hour basis from a patient who had a routine laparoscopic right. Yet, when it comes to coordinating patients' care, anticipating a discharge need or a radiograph evaluation, for example, it can seem like we have never taken care of a patient after a colectomy before. There is often little or no coordination. Physical therapy may show up when the patient is off the floor for a scheduled test. Discharge expectations can be confusing, with conflicting messaging from nurses, residents and attendings. We can do better and we plan to.
We have launched a very exciting effort in Orthopedic Surgery with the help and leadership of Bill Maloney and James Huddleston. It is a pilot patient flow study, led by Marlena Kane in Performance Excellence, which utilizes tools from the Hospital Operations Center, a new program led by Rudy Arthofer. In this new pilot program, we are breaking down each step of the patient experience with elective hip and knee procedures, from the patient's preoperative visit, to perioperative care and hospital admission, to post-operative follow up at six weeks. We are examining the work and workflow of every individual involved in the patient's care experience to characterize the work and evaluate it for efficiencies.
Our goal is to provide patients and family members with a discharge date and time pre-operatively so they know exactly when the patient is expected to leave the hospital. This will allow us to schedule necessary physical therapy and imaging studies, so that on the patient's day of discharge, any necessary rehabilitation and imaging can be completed, and the patient can get home in a timely manner. This will also allow us to level-load the discharge process. We don't have enough nurses and support staff (escorts) to discharge everyone by 11 am. Rather our preference would be to get patients who have to travel a long distance discharged early in the morning, with those who are only traveling to Atherton home later in the day.
Elective orthopedic knees and hips are just the beginning. We will expand this program hospital-wide, program by program. While you are waiting for "us" to get to your service line, we need you to be thinking about your practice. And we need you to realize our numbers demonstrate continued growth with no NEW beds until late 2017. Our hospital bed utilization cannot continue in its current fashion. We have to start thinking differently now.
As many are aware, we have had difficulties accepting some patients who would be appropriate for transfer because we do not have available beds. For many of us, this is not a problem created by someone else, but a problem created by ourselves. We need to think hard about appropriateness of transfer—can we really help the patient? Or would they be better served remaining near family and loved ones in a regional hospital? Some, Gary Steinberg for example, are very good at having those conversations with families and referring MDs. The referring MDs feel supported and families appreciate not having to travel a great distance only to hear that nothing more can be done. Further, the next patient that we can help may then be transferred and receive leading-edge care because a bed is available.
As I said in February, you have created this wonderful "problem" by delivering the type of innovative medical care that many can only receive at Stanford. Innovation in care delivery and resource utilization is equally beneficial to patients and society. I look forward to hearing your ideas.