Reacting to real-time data is too late

 

By David Musyj

During the lead up to the most recent provincial election and afterwards, we have heard plenty of discussions regarding “Hallway Medicine” and the need for it to end for the benefit of our patients, staff members and community.

There has been some instructive reports written about the causes and possible solutions to ending this issue by the Premier’s Council on Improving Healthcare and Ending Hallway Medicine.

One of the issues highlighted in the second report of the Council is the creation of a Command Centre that “uses real-time data, advanced algorithms, predictive analytics and adherence to operating procedures to ensure timely, seamless treatment for patients. The centralized team staffing the Command Centre are able to quickly address patient care delays in an efficient and coordinated way.”

Windsor Regional Hospital (WRH) is one of the largest community teaching hospitals in the province with approximately 575 beds divided between two hospital campuses.  In October 2017, WRH opened Command Centres at each of its two acute care campuses. The Command Centres are open 24/7 and coordinate all patient flow. Both campuses combined have fewer than 20 per cent private rooms and are home to some of the oldest infrastructure in the Province of Ontario. At least twice a day, and up to four times a day during influenza season, the clinical and non-clinical teams attend the Command Centres to discuss and address any real-time issues with the use of OTN but also, more importantly, use predictive data to plan for future patients who will require acute care in the next 12-24-36-48-96 hours and beyond. If we are addressing real-time patient flow issues, we are actually “too late”.

The Peter Drucker statement, “you can’t manage what you can’t measure,” is displayed at both Command Centres above the electronic displays. In 2016, Windsor Regional Hospital recognized the need to end Hallway Medicine and that it would not end without positive changes.

In 2016, each day, WRH was facing the following:

  • Twenty-four (24) “admit no bed” patients a day. These are patients who have been admitted but are waiting in the Emergency Department for a bed to become available;
  • Thirty-eight (38) patients a day being placed “off-service” even after moving to an inpatient floor;
  • In-patient beds remaining empty 5-12 hours after a patients were discharged;
  • Actual length of stay one day longer than expected;
  • Discharge rates on weekends a third lower than during the week; and
  • Time to inpatient bed after admission was 11 hours.

In order to tackle these issues, WRH not only created the Command Centres, but also examined prior patient data for each service to predict day-by-day, program-by-program, floor-by-floor, the exact number of admissions expected, be it medicine or surgical, elective or emergent, and the needs required by the system.

We also used simulation software and queuing theory to take the “magic” out of healthcare and the typical “we have no clue what is coming through our doors” explanation. Pretty much, we know how many patients to expect each day by the time of day, what they are going to present with and in some circumstances, the name of the patient expected to attend.

Key components was the creation of “assessment bays” to pull admitted patients from the ED to a temporary spot while they are awaiting the carbolization of their inpatient bed. The goal is to have the assessment bays empty.

In addition, we track what is called “grey days.” These are days that are tracked for any one of our approximate 600 patients who have their stays extended due to us not fulfilling an order for any testing (i.e. diagnostic or otherwise).

Twenty-four months after implementation, the current results show marked improvements:

  • The average number of “admit no bed” patients waiting in ED has been reduced from 24 to 4;
  • The average number of patients being placed “off-service” each day, even after moving to an impatient floor, has been reduced from 38 patients a day, to 5;
  • Inpatient beds, which used to remain empty for 5-12 hours after patients were discharged, are now carbolized immediately after discharge;
  • The average length of stay (LOS) for patients used to be 1 day above the expected LOS, is now actually at or lower than the expected LOS;
  • Discharge rates, which used to be a third lower on weekends have equalized; and
  • The average wait for an inpatient bed after admission has been reduced from 11 hours to 3.2 hours.

These results take a whole team effort and they will ensure WRH is prepared for any surges by not only allowing us to predict them in advance, but avoid or greatly reduce Hallway Medicine.

David Musyj is the President and CEO, Windsor Regional Hospital.