Introducing a structured daily multidisciplinary board round to safely enhance surgical ward patient flow in the bed shortage era: a quality improvement research report

Hospital bed shortage is a worldwide concern. Their unavailability has caused elective surgery cancellations at our hospital peaking in spring 2016 at over 50%. This is often due to difficult patient step-down from intensive care (ICU) and high-dependency units (HDU). In our general/digestive surgery service admitting approximately 1000 patients yearly, ward rounds were run on a consultant firm basis. We report quality improvement (ISRCTN13976096) after we introduced a structured daily multidisciplinary board round framework (SAFER Surgery R2G) adapted from the ‘SAFER patient flow bundle’ and the ‘Red to Green days’ approaches to enhance flow. We compare 2016–2017, when our framework was applied for 12 months. We used a Plan–Do–Study–Act (PDSA) methodology. Our intervention consisted in (1) systematically communicating the key care plan after the afternoon ward rounds to the nurse in charge; (2) 30’ 10:00 hours Monday-to-Friday multidisciplinary board rounds, attended daily by the senior team and weekly by hospital and site managers, revising the key care plan to aim at safe, early discharges, assessing the appropriateness of each inpatient day and tackling any cause of delay. We measured patient flow by average length of stay (LOS), ICU/HDU step-downs and operation cancellations count, monitoring safety through early 30-day readmissions. Compliance was assessed by board round attendance and staff satisfaction rate surveys. After 12 months of intervention (PDSA-1-2, N=1032), compared with baseline (PDSA-0, N=954) average LOS significantly decreased from 7.2 (8.9) to 6.3 (7.4) days (p=0.003); ICU/HDU bed step-down flow increased by 9.3% from 345 to 375 (p=0.197), surgery cancellations dropped from 38 to 15 (p=0.100). 30-day readmissions increased from 0.9% (N=9) to 1.3% (N=14)(p=0.390). Average cross-specialty attendance was 80%. Satisfaction rates were >75%, regarding enhanced teamwork and faster decisions. The SAFER Surgery R2G framework has increased patient flow in the context of an enhanced multidisciplinary approach, requiring senior staff commitment to remain sustainable.

[1]  G. Orengo,et al.  A new model to prioritize waiting lists for elective surgery under the COVID-19 pandemic pressure , 2020, The British journal of surgery.

[2]  Isaac Tranter-Entwistle,et al.  Introduction and validation of a surgical ward round checklist to improve surgical ward round performance in a tertiary vascular service. , 2020, ANZ journal of surgery.

[3]  T. Guzzo,et al.  Improving Operating Room Efficiency , 2019, Current Urology Reports.

[4]  M. Gagnon,et al.  Patient prioritization tools and their effectiveness in non-emergency healthcare services: a systematic review protocol , 2019, Systematic Reviews.

[5]  S. Banerjee,et al.  Factors affecting patient flow in a neurosurgery department. , 2020, Annals of the Royal College of Surgeons of England.

[6]  Stella L. Smith,et al.  Improving the patient discharge process: implementing actions derived from a soft systems methodology study , 2018, Health systems.

[7]  G. Luscombe,et al.  Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation , 2018, Journal of hospital medicine.

[8]  N. Gilliland,et al.  Ward round template: enhancing patient safety on ward rounds , 2018, BMJ open quality.

[9]  A. Darzi,et al.  Savings from reducing low‐value general surgical interventions , 2018, The British journal of surgery.

[10]  A. Darzi,et al.  “The Longest Way Round Is The Shortest Way Home”: An Overhaul of Surgical Ward Rounds , 2017, World Journal of Surgery.

[11]  A. O'dowd Doctors condemn need for Red Cross to step in to aid NHS in “humanitarian crisis” , 2017, British Medical Journal.

[12]  Peri Rosenfeld,et al.  Early Discharge Planning and Improved Care Transitions: Pre-Admission Assessment for Readmission Risk in an Elective Orthopedic and Cardiovascular Surgical Population , 2016, International journal of integrated care.

[13]  A. Kothari,et al.  Cross-sector Service Provision in Health and Social Care: An Umbrella Review , 2016, International journal of integrated care.

[14]  J. Boyle,et al.  Discharge timeliness and its impact on hospital crowding and emergency department flow performance , 2016, Emergency medicine Australasia : EMA.

[15]  Sasha Shepperd,et al.  Discharge planning from hospital. , 2016, The Cochrane database of systematic reviews.

[16]  Wilton C Levine,et al.  Optimizing Operating Room Scheduling. , 2015, Anesthesiology clinics.

[17]  F. Davidoff,et al.  SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. , 2015, Canadian journal of diabetes.

[18]  S. J. Martin,et al.  Lowering levels of bed occupancy is associated with decreased inhospital mortality and improved performance on the 4-hour target in a UK District General Hospital , 2015, Emergency Medicine Journal.

[19]  A. Steuer,et al.  Four Simple Ward Based Initiatives to Reduce Unnecessary In-Hospital Patient Stay: A Quality Improvement Project , 2015, BMJ quality improvement reports.

[20]  P. Weston,et al.  A cost-benefit analysis of twice-daily consultant ward rounds and clinical input on investigation and pharmacy costs in a major teaching hospital in the UK , 2015, BMJ Open.

[21]  G. Fried,et al.  Systematic review of outcomes used to evaluate enhanced recovery after surgery , 2014, The British journal of surgery.

[22]  A. Darzi,et al.  Surgical Ward Round Quality and Impact on Variable Patient Outcomes , 2013, Annals of surgery.

[23]  Rachel Pollock,et al.  Delay in discharge and its impact on unnecessary hospital bed occupancy , 2012, BMC Health Services Research.

[24]  Erik Demeulemeester,et al.  Operating room planning and scheduling: A literature review , 2010, Eur. J. Oper. Res..

[25]  L. Aitken,et al.  What factors influence suboptimal ward care in the acutely ill ward patient? , 2009, Intensive & critical care nursing.

[26]  Barbara Quinn,et al.  Daily Rapid Rounds: Decreasing Length of Stay and Improving Professional Practice , 2009, The Journal of nursing administration.

[27]  Florence M. Simmons,et al.  CEU: Hospital overcrowding: An opportunity for case managers , 2005 .

[28]  S Burton,et al.  Implementation of collaborative practice through interdisciplinary rounds on a general surgery service. , 1997, Nursing case management : managing the process of patient care.

[29]  Florence M Simmons,et al.  Hospital overcrowding: an opportunity for case managers. , 2005, The Case manager.

[30]  G. Agnew The Shortage of Hospital Beds. , 1942, Canadian Medical Association journal.