Safely Enhancing Surgical Ward Patient Flow in the Bed Shortage Era by a Modified “Safer red2green” Multi-Disciplinary Board Round. A Quality Improvement Research Report

BackgroundAcute hospital bed shortage is a serious concern worldwide, constantly involving high-dependency units (HDU), where the non-availability of postoperative beds results in surgery cancellation. In the acute medicine context, the SAFER Red2Green initiative has shown to enhance patient flow.Local problem At the Royal London hospital, in 2016, hospital-initiated cancellations peaked at over 50% weekly due to the inability of high dependency Units (HDU) to discharge step-down patients to the general surgical wards, where bed occupancy was close to 100% and the average length of stay was stable on average close to 7 (+/- 8.6) days.MethodsThis was a service improvement research to enhance patient flow which adapted the SAFER Red2Green model to a surgical ward (SAFER Surgery Red2Green). This before-after study involving all 2017 digestive surgery admissions was divided into a three-month feasibility phase followed by a nine-month pilot phase, versus the year 2016 (pre-intervention). Outcome measures: weekly discharges, length of stay (LOS), surgery cancellations, feasibility of a “theatre go” policy, HDU step-downs, 30-day readmissions.Interventions1) Systematic communication of key care plan from the afternoon ward rounds by surgical teams to the nurse in charge; 2) 10 AM Monday-to-Friday multi-disciplinary senior-team daily board round, addressing updated key care plan aimed at early discharges, appropriateness of each inpatient day, causes of delays; 3) hospital and site managers weekly attendance. ResultsAt three months: +67% discharges/week (p=0.001), -20% LOS (p=0.023), +21% HDU step-downs, (p=0.205). At one year: +10.7% HDU step-downs (p=0.197), increased probability of earlier discharge (p=0.023), -60% hospital-initiated cancellations from 38 to 15 (p>=1), a “Theatre go” policy has been active since month 6. Failed discharges kept at 1.3 %. The MDT board round staff satisfaction rate was over 80%, with key actors’ attendance over 75%. ConclusionsThe Barts SAFER Surgery R2G model safely enhanced patient flow and reduced cancellations and unnecessary nurse staff time. It requires senior medical and nursing commitment, however, is designed for any surgical specialty, and has proven sustainable. It warrants further validation.