Despite many hospital's efforts to reduce readmissions, penalties for excessive readmissions reached an all-time high this year. The Centers for Medicare & Medicaid will levy fines to 2,610 hospitals in its third year of a program aimed to prevent patients from returning to the hospital within a month of discharge.
FierceHealthcare has reported this year on the many steps hospitals take to address readmissions, including coordinating care after discharge, scheduling follow-up appointments for patients and creating medical adherence plans.
But the problem with all of these initiatives is that they focus on how patients exit the hospital, Eugene Litvak, Ph.D., president and CEO of the Institute for Healthcare Optimization in Newton, Massachusetts, told me during an exclusive interview.
Until hospital leaders address how patients enter their facilities, he says, they will never solve the readmission problem.
How patient flow leads to readmissions
Litvak (pictured) says it's the flow of patients through the hospital--and the resulting peaks and valleys in that flow--that typically leads to overburdened staff members on peak days and to increased readmissions. Smoothing the flow reduces the peaks and thereby reduces not only readmissions but medical errors, infections and mortality rates.
The real problem, he says, begins with staffing levels. Hospitals typically staff based on an average, below the peak of bed occupancy. As a result, when staffing levels are too high, hospitals waste resources. But when they are too low--which happens frequently during the peak of patient flow--clinicians and resources are stretched too thin.
"So what does that mean? Multiple studies and leading medical journals show that when nurses or physicians overloaded, quality care and patient safety is diminished ... So we cannot staff to the peak because we simply cannot afford it. When we staff below the peak, then we have negative consequences," he says.
Stagger surgeries, admissions
The solution, he says, involves taking a hard look at what causes the peaks and valleys in patient flow. Although many believe the problem begins in the emergency department, Litvak says that the main cause is scheduled elective admissions. When patient admissions are scheduled for the same day, there is an artificial peak in the demand for beds. The demand increases when a patient in the emergency room needs surgery or must be admitted as an inpatient.
Therefore, hospitals must work with surgeons to stagger scheduled admissions and procedures, he says. This is a difficult conversation for many administrators, who fear the change in scheduling may cause a surgeon who enjoys the convenience of scheduling operations whenever he or she wants, to move to a competitor's hospital to retain that flexibility.
But, Litvak says, this isn't the case. The actual result is that hospitals can decrease operating room waiting time while increasing surgical throughout--and save millions of dollars.
"One hospital in Canada sent us a letter that by separating scheduled and unscheduled admissions and leaving room for an unscheduled emergency, actually reduced patient lengths of stay and saved the lives of 40 patients a year," he says.
Avoid premature discharges
Hospitals must also consider what happens to the patient after surgery, according to Litvak. If bed occupancy is high, hospitals will put the patient wherever there is a space on a floor. For example, if a cardiac patient underwent successfully surgery, but is placed in an oncology unit where there is an available bed, the nurses there aren't trained on how to properly administer medication for a cardiac patient.
In order to free up beds, hospitals may sent emails to all units to discharge whoever possible as fast as possible. As a result, during peak times for in-patient volume, there is a far greater likelihood that patients will be discharged prematurely--and thus will likely be readmitted to the hospital, according to Litvak.
"If you see that in the ICU there is somebody who should stay another day but is more or less in stable condition and you have somebody in terrible condition, who will get the bed? Obviously, the person in the better condition ready for discharge is likely to be discharged and replaced with someone who has a more urgent need. And that's where we create a basis for future readmission," he says.
Rethink staffing ratios
In addition to the planned admissions and premature discharges, Litvak hospitals must also consider another reason for smoothing patient flow: nurse to patient staffing ratios.
"What happens to the patient who has a nurse who is caring or eight patients instead of four? Can they provide a proper level of care? Is that patient, who did not have an adequate level of care, at a greater likelihood or readmission after discharge? Yes."
Litvak says that even if every hospital in the country had successful interventions in place to reduce readmissions, overcrowding and hospital-acquired conditions, it isn't enough to solve the problem.
Those interventions are necessary, he says, but they aren't sufficient.
"As long as patient flow is ignored, you will not achieve an adequate level of readmissions, mortality rates or solve overcrowding. You will be at square one as long as the healthcare facility is under stress," he says. "As long as you have excessive patient volume and an excessive workload, you are going nowhere."
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