Wednesday, June 22, 2011

Raise your hand if you want a shiny, new hospital ward!

Twenty-five years ago, when I was an intern on the surgery service, the dreaded part of the day was the late afternoon.  That was when all the patients were admitted to the hospital.   For surgery the next day.

Yes, you heard me right - admitted the day before scheduled surgery.  Sounds crazy, huh?

Interns were expected to document the medical history, examine the patient, arrange lab testing, obtain consent for surgery, and discuss the case with the attending surgeon.  There could be dozens of scheduled admissions in an afternoon.  I'm not telling you this to gripe about the workload in the "good old days", but to point out that nowadays, if any surgeon planned to admit all patients to hospital the day before surgery, he/she would be pilloried.  It would be rightly noted as wasteful of resources as well as being a needless discomfort for patients.

But, back then, there were many reasons why it had to be so:

  • Patients needed a history and physical completed
  • Nurses had to do preop teaching
  • Patients couldn't be trusted not to eat or drink after midnight (i.e. NPO for surgery/anaesthetic)
  • Preop sedation had to be administered to prevent undue preop anxiety
  • Patients couldn't manage their own bowel prep (powerful laxatives used prior to colon surgery)
  • Patients had to "acclimatize" to the hospital (I never understood that one, but accepted it because the staff surgeon said it with great conviction.)

That's just the way it was done for everything from an aortic aneurysm repair to tonsillectomy.

Well, there were exceptions.  I remember admitting a local GP who was having hemorrhoid surgery the next day.  He patiently submitted to the routine, having served as an intern in the same hospital several years previously.  After being "admitted", he asked if he could go home on an "overnight pass" - highly irregular!  His surgeon agreed out of professional courtesy.  He returned the next morning and underwent uneventful surgery, even without being "acclimatized".

Then, the chief of surgery decided that we would do things differently.  Based on day surgery practices at other hospitals, he lead the development of a system that allowed patients to be operated on and discharged on the same day for "minor" procedures, and admitted to hospital on the day of surgery for "major" cases.  I can only imagine the consternation this caused when first proposed, even though it was a proven and established practice in many other centres.  Now, day surgery is standard practice for many conditions.

I've taken you down Memory Lane because it seems to me that the past is repeating itself.  Thinking about changing deeply entrenched practices remains a jarring experience.

At a meeting this week, I learned that there are plans to renovate a currently unused floor at our hospital.  This new unit will be designated for surgery patients and will expand surgical bed capacity.  The impetus for this expanded capacity is the Saskatchewan Surgical Initiative (SkSI).  As part of SkSI's mandate to reduce surgery wait time, the health regions are increasing the volume of surgery they perform.  As some patients will require a postop hospital stay, and surgical wards are currently usually full to capacity, increasing the surgical volume means we need more beds for patients to stay in postop.  That's simple math.

But, as a friend of mine likes to say "For every complicated problem, there's a simple solution.  And, it's wrong."

Renovating a new hospital ward will be expensive, but simple.  Simple, in the sense that there are prescribed building codes, architectural principles and construction practices that can be applied.  If we sign the cheque (Whaddaya figure? Over $1M, at least?), a contractor will deliver a shiny new surgical floor.  Everyone will be pleased.  Photo-ops will abound.

And, the status quo will be cemented.

I believe that building extra inpatient bed capacity is not only the wrong solution, but will actually be a harmful solution.

The solution to a mismatch of demand (number of surgeries requiring hospitalization X number of days spent in hospital) and capacity (number of bed-days available) involves reducing demand, increasing capacity, or creating a better balance of demand and capacity.

Here's some ways to increase capacity:

1) A new surgical ward increases capacity.  It's relatively easy to do (see above) and gives fairly quick results (within a year?).  But, it's expensive, and taking this route reinforces the notion that we don't need to change our processes, as long as we can throw enough money at a problem.

2) New capacity for surgical patients can also come from existing hospital capacity.  "Medical" patients also occupy hospital beds, and there is always a tension between medical and surgical services over bed usage.  To an outsider, it may seem petty that surgeons and medical specialists covet hospital resources that are intended for patient care, but each physician wants to ensure that his/her patients have access to a bed when needed.  Medical patients tend to be acutely ill when admitted, often presenting to the emergency department.  That means that there is little choice other than to have them stay in a hospital bed.  Elective surgical patients, in contrast, are generally in reasonable health when they come to the hospital (although the surgery they undergo upsets that condition to varying degrees).  However, if there is only one bed available, it will be assigned to the acutely ill "medical" patient, and the person expecting to have their elective (sometimes urgent) surgery performed will be sent home and have the procedure rescheduled.

Surgeons love to demonize medical specialists around bed usage.  We surgeons flatter ourselves that we're diligent in preparing our patients for prompt discharge, assessing them early in the morning so that necessary preparations can be made, and even developing care maps that anticipate the date of discharge.  At our meeting earlier this week, it was pointed out that most of Saskatoon's surgical services have average length of postop stays at or below national averages.  So, perhaps our surgeons have the right to feel smug about this.

We're convinced that, if our medical colleagues could implement similar discharge planning practices, their patients' average length of hospital stay could also be shortened.  As hospital beds are a global resource, any reduction in length of stay means increased bed capacity for all services, medical and surgical.

Surgeons have multiple incentives to help their patients recover promptly and return home in good condition as soon as possible.  Of course, the main reason is that this is good patient care - our prime objective.  But, we also have a responsibility to the next patient who is scheduled for surgery.  If there are no available beds, then their surgery will be cancelled.

Medical specialists share the same mandate to provide good patient care.  But, if a new, acutely ill patient comes into the emergency department, a bed will be found for that person.  Perhaps they will be assigned to a "surgical" bed, or they may stay in the emergency room overnight.  Either way, they will not be sent home.  That means there's relatively little incentive for medical specialists to hasten discharge of recovered patients.

This issue raises much rancour in surgical meetings.  However, because it crosses the boundaries between surgery and medicine, it's a difficult conversation to have.  As such, we come up with work-around solutions, like "protected" surgery beds (no medical patients allowed, even if the bed isn't needed by a surgery patient), or adding more beds to the hospital.

Managing demand is more challenging.  Here are some options:

1) Do more surgery on an outpatient basis.  At a conference earlier this month, SkSI hosted representatives from the health system of South Devon in the UK.  One of their presentations was about "enhanced recovery", essentially helping patients get better more quickly after surgery.  One part of this talk surprised - even shocked - me.

At the start of the presentation, they showed their traditional list of procedures suitable for day surgery.  I noted that there were several urology procedures on the list: circumcision, bladder tumor removal, ureteroscopy - all procedures we already do on a day surgery basis.  I began compiling a mental list of urology procedures that could never, ever be done on a day surgery basis.  My intent was to think of ways that all other procedures could be changed from inpatient to day surgery cases.  The list of never, ever procedures was pretty clear: cystectomy, prostatectomy and laparoscopic nephrectomy - respectively, removal of the bladder, prostate and kidney.

Then, the South Devon team showed their current list of procedures considered suitable for day surgery.  Laparoscopic nephrectomy was on the list!

I had already closed the door on the possibility of doing that procedure as day surgery, yet surgeons from South Devon had achieved it.

They used a combination of anaesthetic and surgical techniques - all accessible and fairly low-tech, but applied rigorously and consistently - to achieve this.  But, the real power of their approach was that they improved the entire process from family doctor to home care support after discharge.  As soon as the family doctor thought that surgery might be required, they supplied the patient with consistent information about the entire process including expectations around pre-op medical optimization, hospital stay and at-home recovery.  Nurses followed patients with at-home visits and phone calls.

The South Devon team was careful to point out that the processes they use are easily accessible in developed countries, but implementation requires coordinated will over the entire system.  Our current "silo view" of surgery makes this difficult to achieve.

2) Help patients recover more quickly, so they can achieve their discharge goal sooner.  Again, the South Devon team challenged us with their approach.  They showed the wide variation in hospital stays for patients undergoing colon surgery.  By adopting the best practices from centres with shorter hospital stays, they were able to likewise help patients recover more quickly.  They emphasized that their goal for patients was always "Better, quicker", and not just earlier discharge.  The fact that patients went home more rapidly was just a reflection of their more rapid recuperation.

During discussion at our surgical meeting this week, it was pointed out that we're already meeting, or exceeding, national benchmarks around expected length of hospital stay.  This demonstrates the danger of benchmarking!  These benchmarks are national averages, and the philosophy they tacitly encourage is "Let's be mediocre!" That is, as long as we're average, we can excuse ourselves from trying any harder.  Surely, if we're going to use benchmarks, we should choose the best performers and try to match their results.

And now, back to the potential hazard of spending millions of dollars to add surgical bed capacity rather than do the more challenging work of process redesign.  Adding capacity reinforces the notion that the status quo is fine - we just need more of it.  Adding capacity carries a huge opportunity cost.  Imagine how much system-wide change $1M would support.  Adding capacity takes away the incentive for providers, managers and leaders to have the difficult conversations about turf protection and changing habits.

Our patients trust us not only to provide care, but to constantly improve that care.  They rely on us to seek out the possible and think beyond the traditional.  Henry Ford, when commenting on the invention of the automobile, said,  "If I had asked people what they wanted, they would have said faster horses."

A shiny, new hospital ward will be welcomed by patients, staff, administrators and politicians.  It's what we want.

But, not what we need.


  1. Completely buy the message here! We in Victoria implemented a colon care pathway, where really all we did was standardize the care that patients get. Things like pre-op bowel prep (stopped doongit), doing more MIS, early feeding, removal of drains, and good pre-op teaching. We educated the nurses on best practices, and empowered them through better designed care plans, we halved our time in hospital, and in one year saved over 300 hospital days. Cost: way less than one million.

  2. Kishore VisvanathanJune 23, 2011 at 9:26 AM

    Kishore said:

    Ahmer! Great to hear from you. Thanks for leaving this encouraging comment. So, it's not just my imagination - it can be done! I hope we have the opportunity to learn from your success.

  3. Kishore,
    You have identified a crucial principle that applies everywhere in our health care system: increasing capacity should be the solution of last resort, not first. This applies not only to hospitals, but to family medicine. Recently we learned that Saskatchewan has "only" about 750 family doctors, and this is widely assumed to be a shortage. The number translates to 1 family doctor for every 1400 residents. Group Health Cooperative in Seattle, a fabulous system serving 650,000 patients, centres its entire system around primary care. It has 1 family doctor for every 1800 patients.

    The real question is why decision-makers allow these capacity-expanding non-solutions before exhausting all avenues for quality improvement. In a strange way, abundance is the enemy of creativity. You've raised the issue very compellingly.

  4. Kishore, once again you have hit the nail on the head. Maybe we need the "sieve" for approving requests for any more space/people/machines to be having first completed the process redesign and improvement.

  5. Hello again from South Devon! I really enjoyed the visit to Saskatchewan.

    I agree with you Kishore.

    While I dont know he exact circumstances of your hospital, it has to be wrong to be increasing beds. We do >75% of all our electives as day surgery (<12 hour stay - usually <2 hours). Lengths of stay for the rest are reducing all the time.

    This is greatly facilitated by having a dedicated ambulatory unit - maybe a better thing to do with your money? We have reduced and reduced beds while increasing activity.

    PS - only telephone follow up the next day - no home visits by nurses unless for very specific reasons.

    It was good to meet you all and share practice. The lap nephrectomies are going well as day cases - along with all the rest. You can find suggested day case rates in the BADS Directory of Day Surgery at - needs to purchsed but v cheap! It gives realistic rates rather than best practice so for some procedures is not particularly ambitious.
    The electronic version comparing your own performance to the directory is more expensive but also a bargain!

    Good luck - suggest you might like to consider whether a better use of the money might be to temporarily fund additional operating lists and create a day surgery environment to bring waiting times down without creating more infrastructure?

    Best wishes

    Kerri Jones

  6. Thanks for the comment, Kerri. Knowing that enhanced postoperative recovery has been so successful elsewhere is a real boost to our efforts here in Saskatchewan.


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