Is mismanaging patient flow a medical error?
RRTs used to often to fix flow problems
ED wait times have been the traditional headline grabbers. But more and more, people are looking at throughput and seeing a different monster altogether the OR. And more and more people are saying the solution for wait times is to smooth your OR scheduling, and wait times and the patient safety implications therein will go away.
"There are two sources of medical errors. One source is clinical. The other is due to the peaks in patient flow. And if you ask which number is greater, I don't know anybody who can answer that question. Yet, the second cause is completely overlooked," says Eugene Litvak, PhD, president and CEO of the Institute for Healthcare Optimization and adjunct professor in operations management in the department of health policy & management at the Harvard School of Public Health.
Litvak recently penned a commentary in the Journal of the American Medical Association "Rethinking Rapid Response Teams" along with Peter Pronovost, MD, PhD, an intensive care specialist physician at Johns Hopkins Hospital; professor at the Johns Hopkins University School of Medicine in the departments of anesthesiology and critical care medicine, and surgery; and medical director for the Center for Innovation in Quality Patient Care.
The takeaway from the commentary? "Let me be very specific," Litvak says, "because people were trying to misinterpret our piece in different ways. You ask whether a rapid response team is needed. The answer is yes. I want to be very clear about that. I also want to be clear about something else. That the frequency of using the rapid response is a reflection of our ability to manage patient flow.
"What does that mean? It means that very frequently we are using rapid response teams to correct our own mistakes in patient misplacement," he says.
He says the suggestion that hospitals don't have enough beds is incorrect because there is not a "steady-state pattern." "In the vast majority of cases, we don't have the right bed periodically... Why on Wednesday do we have a shortage of ICU beds that you don't have on Tuesday? Is it that God makes patients sicker on Wednesday?"
The reason, he says: the scheduling of elective admissions. If there is a peak in those admissions, then beds are held up and patients are diverted and rapid response teams are sent "to correct the mistakes" of suboptimal bed placement, Litvak says. "So we are frequently endangering patients' lives and then successfully correcting our own mistakes." Suboptimal placement, he says, occurs when the bed is not in the unit where the patient should be or staffing is not optimal.
Scheduling predictable admissions evenly, he says, can fix the problem of poor bed management. The ED is in "a more or less steady-state manner," he says. Ask any ED physician if there is a significant difference in patient volumes between Tuesday or Wednesday, or whether he or she expects that four weeks from now it will be different on that Wednesday.
"Now, you go to the operating room and ask how many surgeries are going to be performed four weeks from now, and the answer would be, 'Who knows?' That's exactly upside down," he says.
The approach Litvak proposes is the "variability methodology" created by the Institute for Healthcare Optimization (see box). In working with several hospitals, most centers saw about 700 surgical bumps a year that is, a scheduled surgery is cancelled because of an emergent situation. After implementing the methodology, the bump rate decreased to a total of about 60, instead of 2,100.
"Part of our methodology," he says, is "separating scheduled and unscheduled surgeries physically. We're using mathematical tools to determine how many rooms we need for urgent and nonurgent surgeries so that the waiting time would not exceed the waiting time that clinicians believe is right."
The biggest portion of OR scheduling is elective about 80%-plus, he says. "They now may have a very high utilization rate because they are no longer being interrupted by urgent cases, which would be done in a different room."
In this way, he says, you can control wait times for urgent and nonurgent surgeries, increase your throughput of elective scheduled surgeries because you can afford higher utilization rates, and floors don't have to be left open in case an urgent case comes through the doors.
Litvak worked for six years with Cincinnati Children's Hospital. The results? The hospital reported a boost in capacity that equated to a $100 million, 100-bed expansion, and increased income from treating more patients. (To see a detailed account of the changes made by the hospital, visit www.ihoptimize.org, select "knowledge center" and then case studies, and click "Cincinnati Children's Hospital Medical Center.)
Reference
- Litvak E, Pronovost PJ. Rethinking rapid response teams. JAMA. 2010 Sep 22;304(12):1375-6.
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