Purpose : Efficient patient care depends on close communication between the trauma team, other surgical providers, nursing, physical therapy, and discharge planners. Communication is hampered by the number of services involved, the workload of each service, and the institution’s training mission. We hypothesized that daily multidisciplinary “discharge rounds” would improve patient flow and increase readiness.
Methods : A senior trauma center physician leads discharge rounds, focusing on each patient’s plan of care, including surgeries, diagnostic tests, and anticipated date of discharge or transfer. Present at rounds are the fellows leading each trauma team; an orthopedic surgeon; the hospital bed manager; the unit’s discharge planner; the unit nursing staff; and physical, occupational, and speech therapists.
Results : Discharge rounds cover 90 inpatient trauma service beds in approximately 60 minutes each day. Discharge rounds have had a dramatic effect on patient flow. While maintaining the daily census, we have seen a 36% increase in patient volume and a 15% decrease in length of stay. “Bypass” status—inability to accept admissions—has been virtually eliminated. This effect has been sustained.
Conclusion : By providing a forum for clear communications among all providers, discharge rounds have streamlined the care of complex trauma patients. As health care resources become ever more constrained, this sort of multidisciplinary effort is a viable option for senior physicians to directly impact hospital performance.
Rising costs and falling reimbursements are producing stress throughout the health care industry. 1–4 Trauma care is disproportionately affected because of the high costs associated with severe injuries and the rising number of patients with inadequate insurance coverage. 1,4–9 Many hospitals, especially in urban areas, have elected not to care for trauma patients because the revenue generated does not support the associated cost. 4,6,7,9 Other hospitals are overwhelmed by the volume of trauma they see, and are forced to limit care or reduce quality in response to inadequate resources. 10
One solution to this problem is increased operational efficiency. 11–13 Reducing the average patient’s length of stay on the trauma service can have a profound impact on hospital finances, particularly when the hospital is being reimbursed on a capitated “per-admission” basis. 5,12,14–21 Reduced length of stay means a reduced consumption of resources by each individual patient, freeing those resources for use on others. This is especially important in systems where space or personnel is limited and the number of trauma patients seen is restricted by the capacity of the system.
Barriers to rapid flow of patients through a trauma system include the complex nature of traumatic injuries, a limited supply of physical resources, the inexperience of residents and fellows, and limited postacute beds. 5,19,11,22 Trauma patients frequently have multiple injuries, necessitating specialized care by a number of different physician services. Trauma patients must compete for operating room or radiologic procedure time already allocated to other patients, potentially increasing length of stay. In many university hospitals, interservice communication is left to residents, who lack training in the intricacies of trauma and coordinating multiple specialties.
There is also a tendency for each consultant service to focus only on their own portion of care, without regard to other injuries and illness. Communication through the medical record is often relegated to junior team members, with a time lag—often measured in days—between message transmission (“Patient is cleared by neurosurgery,” “orthopedic procedures are complete”) and the next step (patient discharge). This tendency is exacerbated on consultant services with heavy workloads and inexperienced house officers.
Regional variation is substantial, but most acute trauma services discharge patients to a variety of rehabilitation centers, nursing homes, and specialized recovery programs both within and outside their university network. 14,19 Untangling the maze of discharge options created by the combination of a given patient’s injury and their insurance status is beyond the capacity of most house officers, especially junior residents who might have only a short exposure to the trauma system. The inefficiency of inexperienced providers in making financially sensitive discharge decisions is an obvious cost of graduate medical education, but is seldom discussed specifically. 22 Professional assistance is required, and most hospitals employ a large staff of discharge planners, social workers, and rehabilitation specialists. Once again, communication becomes essential to efficient operations: discharge planning requires both the knowledge that the patient is medically ready for discharge and the energy and expertise of the planners.
The R Adams Cowley Shock Trauma Center (STC) of the University of Maryland Medical System is a specialized hospital for the care of injured patients. Although receiving some state support, the STC must generate most of its revenue (>95%) from fee-for-service. It has not been immune to the national trends discussed above. 1,4,6,9 Expenses have risen substantially in recent years, driven largely by the costs of recruiting and retaining nursing staff. At the same time, the number of underinsured patients has also increased, with a consequent decrease in revenues. By 1998, the STC had reached a crisis point. Resources were sufficiently constrained that new admissions could not always be accepted, and “bypass status” became a relatively frequent event.
In response to these problems, efforts were undertaken to increase operational efficiency. Daily multidisciplinary rounds were established in 1999, with the purpose of improving communications, shortening length of stay, and increasing trauma center readiness. To test the effectiveness of rounds in meeting these objectives, and to assess the impact of efficiency measures on the quality of patient care, we retrospectively reviewed the STC’s performance for the year before the inception of discharge rounds and the 3 years that followed.
From the R Adams Cowley Shock Trauma Center (R.P.D., C.C., A.J., S.L., M.E.K., T.M.S.) and the Departments of Anesthesiology (R.P.D.), Surgery (C.C., T.M.S.), and Orthopedic Surgery (A.J.), University of Maryland School of Medicine, Baltimore, Maryland.
Submitted for publication November 12, 2002.
Accepted for publication August 8, 2003.
Poster presentation at the 61st Annual Meeting of the American Association for the Surgery of Trauma, September 26–28, 2002, Orlando, Florida.
Address for reprints: Richard P. Dutton, MD, MBA, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201; email: firstname.lastname@example.org.