Hannah J. Wong

Electronic inpatient whiteboards: Improving multidisciplinary communication and coordination of care

OBJECTIVES Effective and timely communication of information is essential for quality patient care. Information and communication technology tools have the potential to transform and enable health care processes to be more accurate, timely, and integrated. This study describes the development, implementation, and evaluation of an electronic whiteboard in a General Internal Medicine (GIM) inpatient unit of an acute care hospital. METHODS The development, implementation, and evaluation of the inpatient whiteboard included scope discussions, workflow analyses, communication and training, and issues and enhancement reporting, all managed through a central project team. Evaluation of the whiteboard was two-fold: a survey given to allied health, nursing and physician disciplines (n=120), and an audit performed on whiteboard usage. RESULTS The whiteboard displays relevant, real-time patient information, in a single, highly visible, user-friendly display. With a quick glance at the whiteboard, one can get an accurate snapshot view of the current patient activity in the unit. Approximately 71% of survey participants believed that the whiteboard improves and standardizes communication within the care team. Further, approximately 62% of the participants agreed that the whiteboard saves them time when searching for information on a patient and their care plan. In addition, the whiteboard has had an impact on the work practices of many GIM care providers, and it along with its users has acted together as agents for positive change. Whiteboard utilization has significantly increased since its implementation. CONCLUSIONS The success of the whiteboard is in part due to overall change management methodologies through collaborative development throughout the project development lifecycle and subsequent continuous improvement initiatives. The multidisciplinary care team embraced the tool, took ownership of it, and tailored it to meet their needs.

How much do operational processes affect hospital inpatient discharge rates

BACKGROUND The objective of this study is to determine the effect of day of the week, holiday, team admission and rotation schedules, individual attending physicians and their length of coverage on daily team discharge rates. METHODS We conducted a retrospective analysis of the General Internal Medicine (GIM) inpatient service at our institution for years 2005 and 2006, which included 5088 patients under GIM care. RESULTS Weekend discharge rate was more than 50% lower compared with reference rates whereas Friday rates were 24% higher. Holiday Monday discharge rates were 65% lower than regular Mondays, with an increase in pre-holiday discharge rates. Teams that were on-call or that were on call the next day had 15% higher discharge rates compared with reference whereas teams that were post-call had 20% lower rates. Individual attending physicians and length of attending coverage contributed small variations in discharge rates. Resident scheduling was not a significant predictor of discharge rates. CONCLUSIONS Day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge rates. Introducing greater holiday and weekend capacity as well as reorganizing internal processes such as admitting and attending schedules may potentially optimize discharge rates.

Smoothing inpatient discharges decreases emergency department congestion: a system dynamics simulation model

Background Timely access to emergency patient care is an important quality and efficiency issue. Reduced discharges of inpatients at weekends are a reality to many hospitals and may reduce hospital efficiency and contribute to emergency department (ED) congestion. Objective To evaluate the daily number of ED beds occupied by inpatients after evenly distributing inpatient discharges over the course of the week using a computer simulation model. Methods Simulation modelling study from an academic care hospital in Toronto, Canada. Daily historical data from the general internal medicine (GIM) department between 15 January and 15 December for two years, 2005 and 2006, were used for model building and validation, respectively. Results There was good agreement between model simulations and historical data for both ED and ward censuses and their respective lengths of stay (LOS), with the greatest difference being +7.8% for GIM ward LOS (model: 9.3 days vs historical: 8.7 days). When discharges were smoothed across the 7 days, the number of ED beds occupied by GIM patients decreased by ∼27–57% while ED LOS decreased 7–14 hours. The model also demonstrated that patients occupying hospital beds who no longer require acute care have a considerable impact on ED and ward beds. Conclusions Smoothing out inpatient discharges over the course of a week had a positive effect on decreasing the number of ED beds occupied by inpatients. Despite the particular challenges associated with weekend discharges, simulation experiments suggest that discharges evenly spread across the week may significantly reduce bed requirements and ED LOS.

Excellent Hospital Care for All: Open and Operating 24/7

ABSTRACTNights and weekends are the times when most people are admitted to the hospital. They are also synonymous with reduced staffing levels and fewer specialized diagnostic, procedural, and treatment options. Indeed, there is increasing evidence suggesting that patient care is compromised during these times. Equally important is the inefficient use of capital investments during nights and weekends, and inappropriate utilization of hospital beds caused by poor weekend discharge flexibility. We believe that these findings should be of concern not just to hospital care providers, but across care settings and to the general public. In this perspective article, we highlight how our current office-hours system of running hospitals threatens the lives of our sickest, most vulnerable patients, describe solutions currently implemented in hospitals that may alleviate this disparity, and discuss challenges to wider scale implementation.

Using System Dynamics Principles for Conceptual Modelling of Publicly Funded Hospitals

This paper examines the long-standing operational issue of patients boarding in the emergency department (ED), who have been admitted to hospital (inpatient ‘boarders’). From this analysis we design a conceptual model that provides a roadmap to create sustainable improvements in ED waiting times. The conceptual model is built using system dynamics methodology, and illustrates the use of system archetypes, a set of common causal feedback loops that illustrate how well-intended decisions have unintentional side effects. This paper outlines the journey taken by one large academic health centre to address these issues, and highlights the larger implications and recommendations that are applicable to other publicly funded hospitals.

Use of Imaging in the Emergency Department: Physicians Have Limited Effect on Variation

PURPOSE To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level. MATERIALS AND METHODS This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit. Physician-specific random effects were estimated to articulate (by odds ratio) and quantify (by intraclass correlation coefficient [ICC]) interphysician variation. RESULTS Patient- and visit-level factors found to be statistically significant predictors of imaging use included measures of ED busyness, prior ED visit, referral source to the ED, and ED arrival mode. Physician-level factors (eg, sex, years since graduation, annual workload, and residency training) did not correlate with imaging use. The remaining amount of interphysician variation was very low (ICC, 0.97% for low-cost imaging; ICC, 1.07% for high-cost imaging). These physician-specific odds ratios of imaging estimates were moderately reliable at 0.78 (95% confidence interval [CI]: 0.77, 0.79) for low-cost imaging and 0.76 (95% CI: 0.74, 0.78) for high-cost imaging. CONCLUSION After careful and comprehensive case-mix adjustment by using hierarchical logistic regression, only about 1% of the variability in ED imaging utilization was attributable to physicians.

An evidence-based case for the value of social workers in efficient hospital discharge.

A study was undertaken to make an evidence-based case for the value of social workers in efficient discharge of patients from acute care hospitals and to assist hospital managers in making informed staffing decisions. Hospital administrative databases from March 1 to November 30, 2008, were used for the analysis of inpatient discharges on days when social workers were on vacation compared with days fully staffed with social workers. Two performance measures, daily discharge rate and average length of stay, were evaluated. During the study period, 1825 patients were discharged from the General Internal Medicine inpatient service. Team discharge rates were significantly lower on social work vacation Fridays versus regular Fridays. In contrast, the average length of stay for patients discharged on social work vacation Fridays was significantly shorter than that for patients discharged on regular Fridays. It was concluded that daily discharge rate better quantified the role of social work in patient discharge. More generally, these results provide preliminary support for the need for adequate social work staffing in timely and efficient patient discharge.

Real-time operational feedback: daily discharge rate as a novel hospital efficiency metric

Background Part of delivering quality care means providing it in a timely, efficient manner. Improving the efficiency of care requires measurement. The selection of appropriate indicators that are valid and responsive is crucial to focus improvement initiatives. Indicators of operational efficiency should be conceptually simple, generated in real time, calculated using readily available hospital administrative data, sufficiently granular to reveal detail needed to focus improvement, and correlate with other valid indicators of operational efficiency. Discussion In this paper, the authors propose daily discharge rate as a novel real-time metric of hospital operational discharge efficiency and compare it with average length of stay. The authors also suggest the use of control charts as an effective way to present daily discharge rate data to clinicians and managers in real time to prompt actionable improvements in discharge efficiency. Conclusion The authors conclude that daily discharge rate has the potential to drive timely improvements in the discharge process and warrants consideration and further study by others interested in improving hospital operational efficiency and the delivery of quality care.

Conceptualizing type 2 diabetes and its management.

Type 2 diabetes is growing worldwide due to population growth, increased rates of obesity, unhealthy diet, and physical inactivity. Risk assessment methods can effectively evaluate the risk of diabetes, and a healthy lifestyle can significantly reduce risk or prevent complications of type 2 diabetes. However, risk assessment alone has not significantly improved poor adherence to recommended medical interventions and lifestyle changes. This paper focuses on the challenge of nonadherence and posits that improving adherence requires tailoring interventions that explicitly consider the social determinants of health.

Goals of care discussions among hospitalized long‐term care residents: Predictors and associated outcomes of care

INTRODUCTION There are limited data on the occurrence, predictors, and impact of goals of care (GOC) discussions during hospitalization for seriously ill elderly patients, particularly for long-term care (LTC) residents. METHODS The study was a retrospective chart review of 200 randomly sampled LTC residents hospitalized via the emergency department and admitted to the general internal medicine service of 2 Canadian academic hospitals, from January 2012 through December 2012. We applied logistic regression models to identify factors associated with, and outcomes of, these discussions. RESULTS Overall, 9.4% (665 of 7084) of hospitalizations were patients from LTC. In the sample of 200 patients, 37.5% had a documented discussion. No baseline patient characteristic was associated with GOC discussions. Low Glasgow Coma Scale, high respiratory rate, and low oxygen saturation were associated with discussions. Patients with discussions had higher rates of orders for no resuscitation (80% vs 55%) and orders for comfort measures only (7% vs 0%). In adjusted analyses, patients with discussions had higher odds of in-hospital death (52.0, 95% confidence interval [CI]: 6.2-440.4) and 1-year mortality (4.1, 95% CI: 1.7-9.6). Nearly 75% of patients with a change in their GOC did not have this documented in the discharge summary. CONCLUSION In hospitalized LTC patients, GOC discussions occurred infrequently and appeared to be triggered by illness severity. Orders for advance directives, in-hospital death, and 1-year mortality were associated with discussions. Rates of GOC documentation in the discharge summary were poor. This study provides direction for developing education and practice standards to improve GOC discussion rates and their communication back to LTC. Journal of Hospital Medicine 2015;11:824-831.