SGH Internal Medicine tests new clinical practice which frees up beds, cuts length of stay and lowers costs.
By Goh Sai Luan, Lighter Notes
This article was first published in LighterNotes, stories of SGH Campus, with the title "Autonomy + Integration = Rapid care and early discharge".
SGH Internal Medicine tests new clinical practice which frees up beds, cuts length of stay and lowers costs.
Average length of stay cut by 2.4 days. 20% savings from average patient bill. 5 beds saved per day. These improvements were made possible by a new work model practised in SGH’s Acute Medical Ward (AMW).
In 2013, a study by the Internal Medicine (IM) department found that 45 per cent of its admissions were for infection-related conditions such as pneumonia, cellulitis, etc. Admitted from A&E, some of these patients were not critically ill, yet not well enough to be sent home. 76 per cent of this group of patients were hospitalised for three or more days.
Convinced that it is possible to stabilise many of these patients with rapid assessment and discharge them within 72 hours, IM set up the 67-bed AMW in Ward 73 in February 2015 to pilot a new care model.
Empowered for rapid action
A workgroup comprising members from different disciplines re-engineered the work process to reduce waste of time in waiting for each profession in the team to be activated.
“Each profession brings a different expertise to the patient’s journey and all are equally important.”
“We developed 6 clinical care pathways for the most common conditions to standardise practice. These helped to reduce over-reporting to doctors, and empowered nurses, pharmacists, therapists and medical social workers to act with greater autonomy,” said Dr Tharma Balakrishnan, Consultant in the IM department.
Nurses in the team were able to identify patients who needed escalation and trigger action, using a system modelled after the UK Royal College of Physicians’ National Early Warning Score. If the patients are still clinically unstable, they are transferred to the Intermediate Care Areas or Intensive Care Unit. Patients who require longer stay will be transferred out to general ward after 72hours in AMW.
A team that rounds together
To enhance communication within the care team, the department introduced daily “Multi-Disciplinary Team Rounds” which involve all the professions. This is a nurse-led discussion and unique to AMW.
“Such face time is important because it allows the entire care team to discuss the needs of each patient in detail, thus leading to more accurate and timely discharge and referrals,” explained Dr Tharma, who was tasked to set up AMW.
“Introducing this new model of care was not easy because it involved a complete rework of workflow and processes. But once it was proven to be beneficial for our patients, everyone came on board,” said Rosie Kwan, Senior Nurse Manager.
The nurses made AMW possible, said the doctors.
“Through this project, we doctors have grown closer to our nursing colleagues. They were the ones who got going and made the changes happen,” said Dr Lim Wan Tin, Associate Consultant.
“We also had the support of colleagues from Emergency Medicine, who had to learn to identify suitable patients to admit to AMW. And the active participation of administrators such as the Admission Office was invaluable,” she added.
Associate Professor Wong Kok Seng, Head and Senior Consultant of the IM Department, attributes the success of the ward to teamwork: “Each profession brings a different expertise to the patient’s journey and all are equally important.”
Adding value beyond delivering treatment
For Dr Tharma, setting up AMW has been a steep learning journey, totally unlike her clinical training in providing treatment and care.
“Through this project, I was exposed to many Quality Improvement concepts. I gained new perspective to things, learning a lot about how a hospital is run, the financing model, etc. It involves knowing the whole system. I am grateful for all the guidance and support from Prof Wong.
“We are a service organisation. It is important to look at how to organise ourselves better, to deliver care better. It makes a difference to our patients, saving them a lot of appointments or longer stays,” said Dr Tharma.
Average length of stay cut by 2.4 days. 20% savings from average patient bill. 5 beds saved per day.
Since the AMW started operations, it has seen over 9,000 patients. Discharged patients are scheduled for outpatient review in Early Ambulatory Clinic (EAC) within a week to ensure that they are stable after their discharge.
SHQSA Best Team – the multi-disciplinary AMW workgroup.
The project has won recognition by the Institute for Healthcare Improvement, which accepted 3 posters on AMW from our IM doctors. The AMW workgroup also won the Best Team – Clinical Practice Improvement Award at the Singapore Health Service Quality Awards 2017.
This article was first published in LighterNotes, stories of SGH Campus, with the title "Autonomy + Integration = Rapid care and early discharge".
