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Figure 1. 2008-2009 hospital bed capacity by country
Listen to AnnMarie Papp
Figure 2. U.S. hospital bed capacity and costs
Each of the techniques would serve to get patients out earlier on what is arguably the most costly day of their stay. “Hospitals generally lose money on the last day of a patient’s stay,” Dr. Wilson says. “When appropriate from a patient care standpoint, discharging your patient and getting the bed ready for the next patient sooner is definitely an advantage for the hospital, and for the next patient.”
Dr. Bachman says one of the main hurdles to that process is no single provider “has clear responsibility and oversight. … It’s this diffuse responsibility.” That’s where Dr. Howell and colleagues thought ABM would work well. At Hopkins Bayview, hospitalists staffed an active bed-management program that rounded twice daily in ICUs and visited the ED regularly. The hospitalist on the 12-hour shift had no other duties, a luxury that HM pioneer Robert Wachter, MD, MHM, described at the time as “freeing him or her up to act as a full-time air traffic controller for all medical patients.”
The intervention reduced ED throughput for admitted patients by 98 minutes, to 360 minutes from 458 minutes. It also cut the amount of time the ED diverted ambulances because of overcrowding—the so-called “yellow alert”—by 6%, and the amount of time ambulances were diverted due to a lack of ICU beds—“red alert”—by 27%. Dr. Howell, an SHM board member, says the results showed how hospitalists can lead throughput change through institutions but that more work needs to be done to focus on early-day discharge.
“The hospital medicine side may be incentivized for early discharges,” he says, “but the hospital systems may not.”
Dr. Howell pushes for “2-by-10,” shorthand for identifying two patients daily who could be discharged by 10 a.m. because “the ED doesn’t necessarily need more beds for 24 hours. They need more beds early in the day.” But in keeping with the ABM model, Dr. Howell believes fiscal and personnel resources have to be dedicated to the problem to expect results. In the Hopkins Bayview intervention, Dr. Wachter, professor and associate chairman of the Department of Medicine at the University of California at San Francisco, chief of the division of hospital medicine, and chief of the medical service at UCSF Medical Center, estimated the annual costs of ABM at close to $1 million a year, given the likely need for four to six full-time equivalent hospitalists, according to a post on his Wachter’s World blog (www.wachtersworld. com) after the report was published.
One idea Dr. Howell suggests to push earlier discharges is restructuring physician workweeks, setting aside certain days for admission and certain days for follow-ups. If two shifts of follow-up days are scheduled after two days of admissions, it’s likely a hospitalist could follow a patient through their entire stay, he says. “You have to structure the doctor’s day to focus on discharges first,” he adds.
Dr. Howell also believes multidisciplinary rounds are key to earlier discharges. At Wayne Memorial Hospital and other places that have instituted such teams, discharge usually is just one byproduct of a construct ultimately aimed at quality improvement. Wayne Memorial’s Dr. O’Boyle says that since the team approach was initiated in September 2009, the hospital’s LOS has dropped by 0.75 days and patient satisfaction scores have risen about 25%. Those metrics will be key data points in the years to come as discharges and readmissions become tied to reimbursement via healthcare reform (see “Value-Based Purchasing Raises the Stakes,” May 2011).