A shortage of nurses and other workers will continue to erode hospital financial performance throughout 2022, according to a Healthcare Quarterly report from Moody’s.
Two of many challenges loom in the year ahead: nursing staffing shortages and reducing costly readmissions and average lengths of stay – issues present even before the pandemic.
Fortunately, healthcare information technology can help tackle these challenges.
Dr. Darin Vercillo is a board-certified and practicing hospitalist and chief medical officer and co-founder of About Healthcare, a vendor of technology that aims to help hospitals and health systems operate as one connected network of care.
We spoke with him recently to explore how IT can help with staffing shortages, improve healthcare access and patient-care coordination, and enable quick, efficient transfers.
Q. You say that to help cut down on costly readmission penalties, it is vital for hospitals to be properly staffed. Why is this, and what can hospitals do in the realm of information technology to combat staffing shortages?
A. We are facing an unprecedented staffing shortage now, and unfortunately, it is worsening. As a practicing hospital-based physician working in a large health system in the Salt Lake City area, I have witnessed that it is not just limited to nurse staffing, but in other areas of both hospital and outpatient practices.
Certainly, the greatest impact that we are seeing is with nurse staffing, and I have seen estimates that it may take as long as a decade for us to catch up.
That is why many capacity issues we have seen at hospitals are based on staffing, not available beds. At the same time, we are seeing an increase in demand with the COVID-19 pandemic. The question becomes, where do you put these patients?
Because hospitals are short-staffed, sometimes patients who would normally be admitted to a cardiology ward get admitted to a medical-surgical space where there are typically fewer nurses. Then, what is the domino effect of that? If we are boarding patients in the ER, potentially for days before they can come into the hospital, or boarding them in another hospital before we transfer them, what is the effect on patient outcomes?
There is going to be a higher percentage of patients with complications who come back after they are discharged because they did not do as well as they would have otherwise.
The way health IT can help ease these shortages is to create visibility across these organizations, even across competitive systems so they can better work together and load-balance patients to the appropriate places. If we are short-staffed in one location, we should immediately look at the hospital across the street, across town – or even across the state – that may have nursing staff to spare.
Take a look at what the state of Arizona did in creating the Arizona Surge Line, where they created real-time situational awareness across the entire state. When one location was showing shortages of capacity, which were largely nursing-based, they were able to route patients to other areas and kept everything load-balanced across the entire state.
Not only across the state but balanced across numerous traditionally competitive healthcare organizations by getting them all to work together. They brought visibility into everybody’s capacity in one centralized location.
The Arizona Surge Line is still going strong with the most recent Omicron wave and has been invaluable in aligning patients with the appropriate level of care so they can be attended to appropriately and have better outcomes. By extension, with promptly delivered care in the appropriate facility, readmissions drop and penalties go away.
Q. How does, as you suggest, improving healthcare access and patient-care coordination across the entire care continuum empower health systems to shorten average length of stay and deliver safer, more effective care across care settings? What is health IT’s role here?
A. Coincidentally, I had a personal experience with this recently. Apart from having done this for 15 years as a hospital-based physician and my work as a consultant, I had to manage a transfer for an elderly family member in Southern California who had a cardiac arrhythmia and was sent to the hospital after his pacemaker malfunctioned.
The hospital prescribed medications and sent him home, but unfortunately, he was readmitted. It was determined that he needed a cardiac ablation. Due to his heart failure issues, physicians wanted to transfer him to a major academic medical center in the Los Angeles area that would have the resources in case of a severe complication during the procedure.
So, for the next 17 days, my family member sat in this hospital, every day being told, “Maybe it will be tomorrow, maybe it will be tomorrow,” and he cannot go home because he is on IV antiarrhythmic medications.
Meanwhile, he is starting to accumulate the typical complications of being in a hospital for that length of time, such as deep-vein thrombosis in his arm, a sore on the back of one of his feet and issues with deconditioning just from being in bed for so long. I finally asked this hospital, “Have you attempted to transfer him potentially to some of the other hospitals in the area?”
There are multiple major tertiary and quaternary care centers in the area that are more than capable of managing this patient. And, of course, they had not contacted anybody except this one health system. So, our family contacted the other major academic medical centers in the area, and within about 36 hours, they had him transferred and admitted and had his ablation procedure completed.
The upshot of the whole thing is that he spent more than two weeks waiting around for a transfer to take place because the people doing the transfer did not have the resources to assist them. We could have shaved 17 days off his length of stay just by coordinating this better.
Similarly, when there is not a solid care access and orchestration strategy in place, you have ER doctors who are calling sometimes a dozen or more hospitals trying to place a patient from their ER. If an ER doctor is spending time calling a dozen or more hospitals, obviously that is taking them away from other patients within the ER.
One of the other important duties within a patient access and orchestration center is to work on getting patients safely transferred out of the hospital to a post-acute-care facility.
Again, these facilities are seeing some of the same capacity-constraint issues that hospitals are, so the hospital’s case manager who is placing a patient in a skilled nursing facility is making phone calls one by one, or faxing records one by one to these various locations. It can take several hours to hear back from them, which then spills over into the next day.
Instead, technology is readily available with curated networks of post-acute-care facilities that allow you to broadcast a transfer need automatically with the click of a button. That request may go out to 10 different skilled-nursing facilities all at once that can then respond immediately and approve an admission.
A tech-enabled automated process shortens the patient’s length of stay, frees up resources and decompresses the bottleneck – whether in the ER, the post anesthesia care unit or from another inpatient hospital bed.
This is something where healthcare organizations sometimes miss the value of what they could accomplish with a robust access and orchestration strategy. Right now, I don’t know if there are many hospitals looking to get more patients into their overloaded facilities.
So, an access and orchestration center can help alleviate the burden being shouldered by ER docs needing to transfer patients out. All they need to do is say, “I have a patient we cannot admit. Can you find a place?” They have the networking and the capabilities, and they can find the destination so the ER doctor can go back to seeing patients again.
Q. What are a couple of health IT best practices for quick, efficient transfers that, not only save time and hassles for referring physicians, but also have the potential to improve outcomes when specialty care is needed emergently?
A. Answers are never found in IT alone, but with great processes and IT side-by-side. As I mentioned, with a well-designed access and orchestration center using the best industry processes and technology together, you will efficiently find capacity and staff for the patient you want to admit or transfer out.
All this needs to be accomplished according to a standardized process that walks clinicians through each step to achieve maximum efficiency. Your technology should then give you visibility into the physical resources across the organization, great communication tools and an understanding of available provider resources.
Together, it can ensure the whole transfer is done in as little as 15 minutes, as opposed to taking multiple hours or days.
When it comes to process, a question to ask is where we can automate and where we can cut down on the number of people involved in decision-making? IT can certainly help automate and streamline, but where do you start?
By looking at data, we can ask questions such as, “Under what circumstances are we saying ‘yes’ to a transfer 100% of the time?” Because if we are, we can automatically start the team preparing the patient in these scenarios, and then have the physicians consult while preparations are being made.
Moving to a SPA model, which stands for single provider acceptance, you begin to transform the organization’s culture to empower either the subspecialist or the hospitalist, intensivist, etc., to approve the transfer.
Within the technology, we have workflow protocols, agreements, communication capabilities and documentation so the entire team shares information and the process is not slowed by requiring multiple physicians to approve it.
Here is a real-life example. As a hospital-based physician, I once tried to transfer a patient out of my hospital who had an unstable dissecting carotid aneurysm. In this case, I had five different specialties: neurosurgery, neurology, vascular surgery, a hospitalist and a critical-care physician all weighing in, but none of them wanted to be the one to approve the admission.
You can imagine my frustration as the referring physician watching my patient decompensate while I got passed around from doctor to doctor. Fortunately, the patient was eventually transferred, the procedure was performed in time, and she had a good outcome. But it could have been far worse.
In the ideal model, the technology will guide the agent in the access center to gather initial information so when the appropriate accepting physician is called, all the relevant context is shared, and the care team can hit the ground running.
Under the SPA model, that physician can confidently accept that patient, and the referring doctor is now off the phone and back to taking care of the patient. As the referring physician, I will feel even better about my patient being taken care of by this organization and that it has been a very efficient process for me as well.