Tackling patient flow during COVID-19

An expert offers six tips to achieve early discharges.

Having enough beds available is critically important for hospitals during the COVID-19 pandemic. But the best way to do that is to increase efficiency, according to Katherine A. Hochman, MD, the associate chair for quality for the department of medicine at New York University (NYU) Langone Health.

When asked about NYU Langone's planning and strategy for a potential second wave, she said, “We can't build any more units; it's too expensive. We absolutely do not want to cancel elective surgeries; no one can afford to do that. We've lost hundreds of millions of dollars.”

Dr Hochman
Dr. Hochman

Dr. Hochman participated in a panel discussion on patient flow strategies at the Virtual Summit on Health System Recovery from the COVID-19 Pandemic, an online conference held in June by Global Health Care. She and other hospital leaders emphasized the importance of two interventions: initiating early-discharge protocols and “smoothing” elective surgery schedules across five days per week.

In recent years, Dr. Hochman helped her department of medicine improve its rate of discharges before noon from the single digits to up to 45%. Prioritizing this metric before the pandemic hit helped with eliminating boarding in the ED, improving bed capacity, she said. “I think we really have to get back down to the basics of inpatient medicine because we're all intertwined. . . . Surgery is completely dependent on medicine and vice versa, and same with the ED.”

Dr. Hochman, who also directs the hospitalist program at Tisch Hospital, part of NYU Langone, in New York City, shared her playbook for building capacity by increasing efficiency. (For an example of how tackling throughput helped one medical director develop a problem-solving framework, see Perspectives article also in this issue.)

Create geographic wards

Hospitals with geographic wards are able to have more efficient communication because teams are consolidated on the same unit, said Dr. Hochman. “When I'm the hospitalist on my team on 17 West, I make it a very small experience. . . . All the nurses I know, all the patients I know, I have my own care manager, my own social worker, and my team is all on that one unit,” she said. “I'm not bouncing around, going to six or seven other units.”

Ask four questions

Dr. Hochman outlined four questions that all members of the team, including the patient, must answer in order to achieve an early discharge. “The patient has to be at the center of this,” she said.

First, why is the patient here? Typically, securing a diagnosis can take a while, although COVID-19 might be an exception. “We had a one-DRG hospital for a while: We were COVID,” she said. “You've got to know the diagnosis, and don't be telling me shortness of breath. That is not a diagnosis. You have to know what you're talking about.”

Second, why is the patient still here? For example, if the patient was admitted for pneumonia, maybe he is still requiring oxygen and febrile, she said.

Third, what has to happen for the patient to leave? In this example, he needs to be off IV antibiotics and no longer on oxygen.

Finally, when and where is the patient going to be discharged? Maybe the answer is home before noon tomorrow, but everyone needs know that, said Dr. Hochman. “You have to do safety huddles where in the morning, people know who's up for discharge, and you have to be able to mine your EMR such that you get all this information up front,” she said.

Mind your metrics

Dr. Hochman said that when she hires hospitalists at her metric-driven organization, she gives them a report card every three to six months. Report cards measure such metrics as observed-to-expected length of stay and discharge-before-noon rate, which ultimately demonstrate a clinician's skills in teamwork and use of care management, social work, and consults, she said. They also show how well hospitalists are anticipating what might happen next.

“Like I always tell my team, ‘Let's play chess, not checkers.’ I don't want you to think one step ahead; think two or three steps ahead. Have contingency planning in place,” said Dr. Hochman.

Lower scores on these metrics can call attention to fixable problems that can hold up discharge, such as calling consults with nebulous questions or getting a late start in the morning, she noted. “Just like you diagnose a patient, you can diagnose a . . . hospitalist who may not have the greatest discharge performance metrics.”

Get teams on the same page

Hospitalists aren't the only ones on the hook for metrics. “We made it clear not only to the hospitalists, but to the . . . different medicine teams—the care managers, the social workers, the nurses—all these metrics are up for everybody,” said Dr. Hochman.

In addition, as they would in a morbidity and mortality conference, the teams dissect and try to understand cases where, unexpectedly, the patient isn't discharged before noon, she said. “If somebody spikes, of course that's understandable. . . . [But] I always tell my team, ‘Guys, a Wednesday afternoon discharge is always better than a Thursday morning one. Don't be hanging onto patients overnight to get the [discharge] in the morning, because I'll see that in the O/E [observed-to-expected] length of stay. Your O/E ratio is going to go up.’”

Remember the purpose of early discharge

To get teams to pay more attention to discharging before noon, it's important to convey why patients should leave the hospital earlier—and it's not about money, said Dr. Hochman. “It's for the patient. Who wants to stay any second longer in the hospital, especially now with a COVID hospital, than they have to?”

For example, an earlier discharge time gives patients more time to fill their medications, “so you're not coming back because you haven't filled your pain medication,” said Dr. Hochman. “That happened [before the early-discharge initiative], and people were coming back to the ED because they were discharged so late, they didn't pick up their pain meds, and then they were back in pain again.”

Keep looking for results

Everyone came together during the first phase of the COVID-19 pandemic to get the job done, but the work isn't finished, Dr. Hochman said. “We need to keep that and have that carry over into this next phase. . . . I worry that we're going to get another big fall surge, but we have to be prepared and ready,” she said.

Now is the time to keep striving for results, using existing resources to improve patient flow, said Dr. Hochman. “We have to make do with our current resources. We have to work smarter, not harder.”