University College London, London, UK
Barts and The London NHS Trust, London, UK.
BMJ Open Qual. 2023 Mar;12(1). doi: 10.1136/bmjoq-2021-001669.
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.
医院床位短缺是一个全球性的问题。在我们医院，由于从重症监护病房（ICU）和高依赖病房（HDU）转出的患者难度较大，导致 2016 年春季择期手术取消率达到 50%以上。我们普外科/消化科每年收治约 1000 名患者，采用顾问制进行查房。我们报告了一项质量改进（ISRCTN13976096），即在引入结构化每日多学科委员会查房框架（SAFER Surgery R2G）后，该框架改编自“SAFER 患者流动包”和“从红到绿日”方法，以增强流动。我们比较了 2016 年至 2017 年，当时我们的框架应用了 12 个月。我们使用了计划-执行-研究-行动（PDSA）方法。我们的干预措施包括：（1）在下午查房后，系统地向主管护士传达关键护理计划；（2）每周一至周五上午 10 点进行 30 分钟的多学科委员会查房，由高级团队和医院及站点管理人员每天参加，修订关键护理计划，以实现安全、早期出院，评估每个住院日的适当性，并解决任何延误的原因。我们通过平均住院时间（LOS）、ICU/HDU 转出和手术取消次数来衡量患者流量，通过早期 30 天再入院来监测安全性。通过委员会出席率和员工满意度调查来评估合规性。干预 12 个月后（PDSA-1-2，N=1032），与基线相比（PDSA-0，N=954），平均 LOS 从 7.2（8.9）天显著下降至 6.3（7.4）天（p=0.003）；ICU/HDU 床位转出流量增加 9.3%，从 345 张增加到 375 张（p=0.197），手术取消率从 38 次降至 15 次（p=0.100）。30 天再入院率从 0.9%（N=9）增加到 1.3%（N=14）（p=0.390）。跨专业平均出席率为 80%。员工满意度>75%，认为团队合作得到了加强，决策速度加快。SAFER Surgery R2G 框架在增强多学科方法的背景下增加了患者流量，需要高级员工的承诺才能保持可持续性。
