SickKids works to help bring kids home sooner

Going home after a hospital stay can bring to the surface a complex mix of emotions for children and families: relief and happiness, combined with nervousness about whether the timing is right and the necessary supports and resources are in place. For health-care providers, providing excellent care and equipping families with the tools for a successful discharge, while ensuring that health care resources are used appropriately and effectively by reducing unnecessary prolonged hospitalization, are always at the forefront.

As part of its continuous efforts to provide safe, efficient, coordinated, evidence-based and high-quality care for each patient, The Hospital for Sick Children (SickKids) has made it an organizational priority to reduce the average length of stay for patients whenever possible by eliminating unnecessary waits or delays in care and treatment caused by inefficiencies in the way care has traditionally been provided. The Length of Stay initiative aims to restore children to health as quickly as possible and move them to an environment where they can be surrounded by family, friends and the comforts of home; to provide inpatient care for more children who need it by freeing up beds; and to reduce costs associated with the unnecessary time a child spends in hospital.

“Children shouldn’t have to stay in the hospital any longer than they need to. We are very focused on providing a family-centred care environment; however, we recognize that it’s stressful for families to have a child in a high-tech, incredibly busy hospital setting,” says Marilyn Monk, Executive Vice-President, Clinical, and Executive Sponsor of the Length of Stay Task Force at SickKids. “The longer children remain hospitalized, the more they are exposed to risks associated with handoffs, hospital-acquired infections, and other known risks of hospitalization.”

Through a series of projects piloted on a number of units across SickKids, the average length of stay has dropped from 6.82 days in 2013-14 fiscal year to 6.63 in 2014-15, surpassing a target of 6.75. This improvement equates to more than 2,600 patient days with the volume of patients seen in 2014-15 at SickKids.

“We have already made great strides in this area: reducing the duration and costs of unnecessarily prolonged admissions, while expanding our capacity to admit and care for growing numbers of very ill children coming through the emergency department or through direct transfers from community hospitals,” she adds.

One of the most significant Length of Stay transformations took place on the surgical inpatient unit, where clinical staff were constantly balancing the higher level of care required for children with more acute or complex medical needs, along with those who had undergone less complex surgeries and were expected to have more straightforward recoveries.

Through the creation of a surgical short stay area, patients from seven surgical specialties whose length of stay was anticipated to be under two days were grouped together in one section of the unit. This enabled staff to develop an environment and culture tailored to the needs of this specific group of patients, with a dedicated nursing team. New workflows and standardized checklists have been developed to improve the coordination of care, including discharge planning, and follow-up resources. Families are now provided with educational material in a variety of languages through AboutKidsHealth, and receive post-discharge follow-up phone calls to address any questions they may have after returning home.

The creation of the surgical short stay area last year resulted in a 30 per cent reduction in patients’ average length of stay, including many children who were safely discharged the same day they had their procedure. Patient satisfaction rates increased, and families expressed that they felt better prepared for discharge.

Additional projects to reduce average length of stay include:

• Medicine Alternate Care Environment, known around SickKids as “ACE Space”: a new care model designed for patients who require inpatient services but do not need overnight nursing care and monitoring.  Patients are assessed to determine whether an overnight stay is necessary; if not, they can receive care by an inpatient team during extended daytime hours (8 a.m. to 8 p.m.), and go home with their family overnight. If needed, they can return to the ACE Space the following day – for example, to receive IV treatment. The implementation of the ACE Space resulted in a reduction of 385 patient days over the course of nine months within the Paediatric Medicine inpatient units, allowing these units to accept more children requiring a higher level of care.
• Clinical practice guidelines: reducing variability through the development of standard approaches for diagnosis, treatment and/or follow-up for select patient populations.  These efforts focused on the development of improved family education material and establishment of discharge-readiness criteria for six high-volume patient populations, including appendectomy and scoliosis-correction surgeries. Engaging patients and their parents in discharge planning early on enables care teams and families to work together with discharge in mind throughout the child’s hospitalization.
• Care coordination practices: a consistent bundle of activities used on all clinical units across SickKids to better prepare patients for a timely discharge, through standardized family-centred rounds, regular discussion of estimated discharge dates, and use of a discharge-readiness checklist.

Building on the success of these initial pilot projects, SickKids continues to work toward reducing the average length of stay – part of the organization’s commitment to ensuring that children receive the right care, at the right time, in the right place. 

“The changes we have made reflect the growing trend toward patient-centred care,” says Travis Beamish, Program Manager of Strategic Initiatives at SickKids. “We are ensuring that our inpatient services are properly configured around the needs of our patients when they are here, but also providing care in a way that allows children to go home with their families sooner.”