Care Redesign I

How We Created a Pediatric Surgical Extended Care Unit

Case Study · January 4, 2016

At All Children’s Hospital Johns Hopkins Medicine, we designed a surgical extended care unit (SECU) for children who undergo low-complexity surgery and cannot be discharged soon after awaking from anesthesia, but who do not warrant inpatient admission. The SECU has safely shortened hospital stays and lowered care-related costs for these children while maintaining a high level of family satisfaction.

Key Takeaways

  1. Involve all possible stakeholders in planning discussions, and repeatedly educate the entire staff (not just SECU caregivers) about the SECU’s purpose and goals.

  2. Have face-to-face discussions, in advance, with staff who are likely to be high utilizers of the SECU.

  3. Conduct mock training that simulates how the SECU will work after patients start being admitted.

  4. Evaluate the physical space at multiple times of the day and night, to anticipate how well it will serve patients and their families.

The Challenge

Children who undergo low-complexity surgeries, such as tonsillectomy or uncomplicated appendectomy, are often discharged home soon after awaking from anesthesia, subject to the discretion of the physician team and the child’s parents. In some cases, though, children initially identified as candidates for discharge from the post-anesthesia care unit (PACU) require a stay beyond 4 hours, which most PACUs cannot handle for lack of staffing or other limitations. Children who need to stay somewhat longer (up to 12 hours) are often admitted to the regular inpatient unit and mixed into the general population of pediatric patients, which can lengthen their hospital stays beyond what is warranted.

Take, for example, a child who cannot tolerate oral liquids after a tonsillectomy and is admitted as an inpatient. Nurses on the inpatient unit may have to focus on children with more acute needs. The post-tonsillectomy patient, lacking the nursing attention to facilitate a timely discharge, may then stay several hours or even a whole day beyond what is necessary.

In July 2015, All Children’s Hospital Johns Hopkins Medicine (ACHJHM) created a surgical extended care unit (SECU) for such children. We applied the concept of strategic bed placement, which involves segmenting a patient population into clinical-care units designed specifically to meet each segment’s needs. Our challenge: Give pediatric surgical patients “the right bed, for the right time span, at the right cost.”

The Goal

Design and evaluate an SECU specifically for children undergoing low-complexity surgery who require post-anesthesia recovery of 4 to 12 hours, as recommended by the physician care team or requested by the family. The SECU’s purposes are to monitor patients for surgery-specific complications, provide adequate pain control and oral intake, and facilitate a safe, timely discharge.

The Execution

We identified unused space in our existing PACU for the planned SECU. The SECU now handles up to 12 postoperative patients at a time and typically serves about 25 patients per week. It is open Monday morning through Saturday afternoon, precisely when our operating rooms are in use.

Most SECU candidates are identified preoperatively, based on the type of surgery and the patient’s age (typically, 1 to 5 years), or are admitted after hours via the emergency department. Occasionally, a patient’s PACU course will prompt admission to the SECU.

Surgeons, nursing, and ancillary staff — redeployed from the emergency department observation unit and the surgical floors — were trained for two weeks in how to care specifically for SECU patients. The training involved mock admissions (using mock codes), and all relevant technology systems were tested. Potential high utilizers of the SECU (from otolaryngology, orthopedics, and general surgery) were educated about the SECU in face-to-face meetings and informed about order sets for SECU patients.

Before the SECU was established, input was sought from multiple stakeholders, including physicians, nurses, and staff from information technology, dietary services, environmental services, case management, and patient placement. The entire hospital staff was informed about the SECU at staff meetings, in electronic newsletters, and at an open-house forum where all questions were answered.

Consistent with ACHJHM’s mission of providing family-centered care, all services for SECU patients (registration, surgery, recovery, and discharge) are integrated on one floor, and educational material about the experience was developed for families.

The Design Team

The SECU design team comprised the Medical Director of Care Coordination and the Quality Advisor, who are co-chairs of the Patient Placement Re-Invent Team; the Clinical Manager of Patient Placement and Supervision; the Director of Perioperative Services; the Clinical Manager of Perioperative Services; and the Clinical Nursing Director.

The Metrics

For patients who fit the SECU clinical and surgical profile, the mean length of stay has been shortened from at least 24 hours (before we had an SECU) to 13 hours. We now have six patients, rather than four, for every SECU nurse (thereby lowering nursing costs). Overall, the average direct cost of care per patient has dropped from $2,015 to $1,506. Family satisfaction remains high (97%). Since inception, only one of the 511 SECU patients has required escalation of care and hospital admission. There have been no adverse safety reports. In a qualitative survey of families, 73% reported discomfort and lack of privacy in the SECU, such as sounds of crying babies and lack of sleeping accommodations for parents.

Lessons Learned

Our greatest challenge in launching the SECU was getting buy-in from surgeons, who worried that patients might be deprived of high-quality inpatient care and get “pushed out” of the hospital. Our leadership team had one-on-one discussions with all concerned physicians, who were assured that patients would continue to receive optimal care from highly qualified nursing staff who had been transferred from the ED or the surgical floor. It was made clear that patients would be discharged only when they and their families were ready. However, given the inherent challenges in changing any culture, many surgeons did not become entirely comfortable until they witnessed high-quality care being provided after the SECU opened.

We have also learned that families in the SECU need more comfort and privacy than a PACU typically offers. Therefore, we are exploring the option of replacing curtains with glass doors and adding sleeper chairs to the SECU rooms.

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign I

Poor Care Is the Root of Physician Disengagement

When physicians and health care executives disagree over the purpose of medicine, disengagement is the inevitable result.

Population Health: The Ghost Aim

We are finally at a moment in the history of health care when we know what to do to achieve better health, who should do it, and how to get it done.

Rethinking the Primary Care Workforce — An Expanded Role for Nurses

In the primary care practice of the future, the physician’s role will increasingly be played by nurse practitioners.

Survey Snapshot: How to Achieve Post-Acute Care Coordination

Commentary from NEJM Catalyst Insights Council members on preferred post-acute networks and the importance of communication.

Care Redesign Survey: Strengthening the Post-Acute Care Connection

Ties between health systems and post-acute care facilities are on the rise, but much work remains to truly coordinate care.

The Hard Work of Health Care Transformation

Experience shows that although a changed market may be a helpful precondition to local performance improvement, it hardly guarantees effective operational change.

Creating the Optimized Surgical Journey

Results from the implementation of an enhanced recovery pathway (an “Optimized Surgical Journey”) for patients undergoing cystectomy at MD Anderson Cancer Center.

An Operational Standard for Transitioning Pediatric Patients to Adult Medicine

Transitioning young adults from pediatrics to adult medicine can be cumbersome, patchy, and confusing. A standard operational framework that leverages the right organizational resources could be just the solution primary care needs to reduce frustration, gaps in care, and loss of patients.

My Favorite Slide: What Is the Right Size for Your Team?

Bigger is not always better for effective teamwork and communication.

The Value of ICU Care at the End of Life

How do physicians decide the right care as patients approach death? The answer must come from the patient.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Triggering the Tipping Point in Payment…

The Co-chairs of the Guiding Committee of the Health Care Payment Learning & Action Network…

Coordinated Care

95 Articles

How to Have a High-Performing Employed…

It’s a generally accepted view that all hospital-employed physician groups are constitutionally incapable of operating…

Primary Care

127 Articles

How to Have a High-Performing Employed…

It’s a generally accepted view that all hospital-employed physician groups are constitutionally incapable of operating…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now