Humans or widgets?

Mary Clare Egberts in happier times at PECMH with members of the hospital auxiliary.

Hospitals relying more upon standardized methods of care

In her challenge to Quinte Healthcare Corporation (QHC) patients, to “adjust their attitude” board memberKaren Baker was echoing a theme thathas been repeated across Ontario for thepast decade, as the healthcare system grapples with increasing pressures froman aging population, a greater relianceupon expensive technology and the everincreasing costs of human skills.

At least part QHC’s response has beento move patients in and out of bedsquicker. Turning over beds faster means more efficient use of nurses, staff and other resources. They can do more with less. Thus the focus over the past decade of shortening hospital stays, particularlyfor those who might be cared for equallywell in another setting.

This isn’t just forthe benefit of the hospital’s bottomline—there aregood reasons why patients shouldn’tlinger in a hospital bed.

“Patients do bet-ter when they areable to get up and out of the hospital,” said Dr. Elizabeth Christie, head of the Prince EdwardFamily Health Team (PEFHT). “Theyhave less risks of pneumonia and otherinfection. They get up and move about.There are statistics that show that a dayin a hospital bed means three days to re-turn to full mobility.”

RACE TO DISCHARGE
But does the rush to move patients outof a hospital bed become a race in whichpatients’ needs, as individuals, are determinedby external measuresand “best practices”?

practices”?“Is it a race to get peo-ple out of a hospitalbed?” asked Dr. Christie. “Yes it is. But if it works, it’s great. It is good forthe patient and the hos-pital resources.”

One of the tools QHCand other hospitals useto accelerate turnover ofhospital beds is known asclinical pathways. In simple terms, a clinical path-way seeks to define care,including length of hospital stay, for a menu of ailments, including congestive heart failure and chronic obstructive pulmonary disease (COPD)—two common diagnoses in this community.

WHO DECIDES?
Is there a risk that too great a reliance on clinical pathways could lead to patients going home too soon?

Both Dr. Christie and QHC administrator Mary Clare Egberts clearly say no.

“The physicians in Prince Edward County are dedicated, excellent, clinicians,” said Dr. Christie. “They are not going to say it’s okay to send a patient home before they are able to go home.”

Mary Clare Egberts added that “the patient’s physician is the only one who can make the decision to discharge a patient.”

Yet both acknowledge limitations and safeguards.

“Clinical care pathways are guidelines—evidenceinformed guidelines,” said Dr. Christie. “If, however, the patient comes in with a COPD exacerbation but they also have an underlying dementia and they have Type 2 diabetes and congestive heart failure that happens to have gotten worse because of the COPD exacerbation—there is a pretty good chance running them through the COPD clinical pathway isn’t going to get them out the door in the prescribed amount of time. There are often confounding factors—but that isn’t a reason to aim for evidence-informed best practices. There is no one answer.”

Mary Clare Egberts comes at the issue from a systems approach, saying her organization monitors certain metrics to ensure the quality of care isn’t impacted by shorter hospital stays indicated by the clinical pathway.

“One of our key indicators is 30-day readmission rates,” she said. “When patients are being discharged from the hospital, how many need to be readmitted within the next 30 days? That would be a key indicator that physicians are discharging patients too soon and the other supports in the community weren’t in place to care for that patient. Our 30-day readmission rates have not increased.”

Dr. Christie says the pressure to move patients out of hospital beds will increase. And while this may be a good thing for many patients—borrowing management techniques from an MBA texbook and applying them in a hospital setting bears risk that must be monitored.

“We can just speak the words patientcentred care,” said Christie. “Health care is about actually caring about human beings. Patients should never be discharged from hospital until that patient is ready to be discharged from hospital. Whether we’ve failed to tick off a box on chart because they have more than one thing wrong with them— therefore justifying another day in hospital—that is a separate issue.

In Picton, we see overflows in our beds—precisely for that reason. We will not discharge patients until they are ready to be discharged. I am more comfortable putting up with that situation— even if it means overflows in our beds—than I am sending patients home when they shouldn’t be sent home.”