Timing it right: UTMB inpatient units focus on appropriate length of stay, planning for safe discharge

Nov 20, 2017, 11:17 AM by KirstiAnn Clifford
UTMB’s Acute Care for Elders (ACE) Unit discusses patient care plans during their daily Progression of Care Round.
Every morning between 8 and 9 a.m., groups of interdisciplinary teams meet at all inpatient units in Galveston, League City and Angleton Danbury to discuss each and every patient in the hospital.

They’re called “Progression of Care Rounds,” or POCR (pronounced “poker”) rounds, and for the past year, they have been making a difference in both patient outcomes and length of stay, which is the period of time (in days) that spans from a patient’s admission to the hospital to the time they are discharged.

“No matter how good the view is in Jennie Sealy Hospital, our patients would rather be at home than in the hospital,” said Deb McGrew, vice president and chief operating officer of UTMB Health System. “The main goal of the rounds is for care teams to come together to talk about each patient’s plan for the day, plan for the stay and the plan for the way back to their home or community.”

She emphasized that the focus of POCR rounds is to improve coordination of care and ensure appropriate length of stay for each patient to help support the best possible outcome.

“It’s about providing Best Care,” said McGrew. “We don’t want to shorten length of stay to the point that we have unplanned readmissions, because that’s not good for the patient. But we also don’t want to keep patients in the hospital longer than is medically necessary. It’s a balancing act.”

Included in the rounds are the patient’s primary nurse, case managers, social workers, utilization review nurses, a patient care facilitator and, depending on the hospital unit, physical/occupational therapists, physicians, pharmacists, nutritionists, respiratory therapists and speech therapists.

By getting all care team members together, Dr. Josette Armendariz-Batiste, director of patient care services and assistant chief nursing officer, said coordination of care has gone from a fragmented system to a well-oiled machine, with improved communication and proactive planning for patient discharge.

“Nurses are expected to present on their patients in two minutes, so these rounds are quick and very focused,” said Armendariz-Batiste. “Length of stay is in the back of team members’ minds, absolutely. But nobody sits there and says, ‘Well, this patient has been here for 10 days, so we need to get them out of here.’ It’s truly more about the challenges our patients face and what we can do to deliver more efficient care while also focusing on their safety and well-being.”

The POCR rounds have also helped identify delays in the system that have affected patient length of stay. For example, some routine radiology services were only available on weekdays, which meant patients who were admitted on Friday may have had to wait until Monday for imaging diagnostics. After further examination, Health System leadership decided to make more imaging services available seven days a week so patients didn’t have to spend excess days in the hospital.

In addition to POCR, three part-time physician advisors to the Care Management Department have been put in place to help determine each patient’s status, assist with clinical documentation to support continued stay, and focus on resource utilization.

Dr. Leah Low, an assistant professor of Internal Medicine and lead physician advisor, has traveled to all three campuses to educate physicians on appropriate patient status (inpatient or outpatient) and how that impacts length of stay. These sessions also have provided front-line physicians an opportunity to voice concerns and highlight additional opportunities to improve efficiency, quality of care and patient experience. For patients who are at a high risk for readmission or require complex care following discharge, physician advisors take part in a review process to ensure patients have an appropriate plan of care and to help remove obstacles to being safely discharged.

“We have put in a lot of leg work up front, but we are making progress and seeing results,” Low said. “It’s a culture change, but if we can make things better for our patients, we have done our job.”

Length of stay makes up half of the “efficiency” domain in the national Vizient Quality and Accountability Study. Since the Best Care initiative began, UTMB has gone from an efficiency ranking of 98 to 27. Through UTMB’s targeted efforts to provide appropriate care and remove barriers, the average length of stay has been reduced by .84 days, resulting in more than $5 million in savings. Additionally, during this same time period, the inpatient satisfaction scores have climbed to the 99th percentile.

“At the same time we have reduced length of stay, we haven’t seen an uptick in readmissions—which means we are planning more effectively and making sure the plans we make for each patient’s discharge are appropriate and aren’t causing them to come back to the hospital too soon,” said Dr. David Marshall, chief nursing and patient care service officer. “We’ve come a long way. It’s been an institution-wide effort and we aren’t done yet.”