Care Redesign

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
How Adequate Are Your Organization's Mental and Behavioral Health Services to Meet the Needs of the Patient Population?

Care Redesign Survey: It’s Time to Treat Physical and Mental Health with Equal Intent

By neglecting mental and behavioral health, our society has made it virtually impossible to succeed in holistic health, and thus to improve health outcomes.

2015 and 2016 Gallup Sharecare Well-Being 5 Key Metrics Data for NCH Healthcare System Blue Zones Project Life Expectancy

Decreasing the Cost of Care by Avoiding Illness

NCH Healthcare System’s success in lengthening life expectancy and improving health and happiness for its community while lowering health care costs for large employers is an example worth emulating.

Optimizing Diversity and Inclusivity Real People Providing Feedback on Precision Medicine Study Design Precision Medicine Initiative for All Community Medicine

Precision Medicine for Everyone

Until we create an environment where diverse patients are considered participants as partners, the goals of individualized research, prevention, and treatment will be unrealized.

Preventable Contributions to Death in USA Public Health Social Determinants of Health Mental and Behavioral Health

Up-Streamism: Health in the 21st Century

With a concerted effort that incorporates principles of understanding, engaging, and connecting with diverse communities, health care leaders can impact patients’ lives early on, preventing adverse conditions and improving outcomes.

Findings from NYC Health + Hospitals ED Care Management Program

Learnings from a Large-Scale Emergency Department Care Management Program in New York City

A CMMI-supported interdisciplinary care team effort helped a safety-net system strengthen primary care engagement and identify unmet needs.

Chronic Treatment Is Not “One and Done”

Clinicians need to adopt a holistic approach to care, particularly for older patients with chronic and comorbid conditions.

virtual visits nonvisit health care

In-Person Health Care as Option B

What if health care were designed so that in-person visits were the second, third, or even last option for meeting routine patient needs, rather than the first?

Innovative Health Care Organizations - Organizational Designs for Innovation

Small Improvements versus Care Redesign: Can Your Organization Juggle Both?

What are the best ways to introduce innovation capacity into your organization?

Key Recommendations from the National Academy of Medicine Applicable to Health and Social Services Professionals

Creating Healthy Communities after Disasters

Recommendations for health and social service professionals to translate the compassion generated by aftereffects of natural disasters into tangible actions applicable to their own communities.

Family Physicians EHR Use by Time of Day

Infographic: Date Night with the EHR

Studies have found that physicians spend nearly 30 hours per month working on the EHR in their homes — including morning and evening hours over the weekend.

Connect

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

Learn More »

Topics

Care Integration

54 Articles

The “Stranger Effect” — A Look…

Why do miscommunications between teams and consultants occur, and what can we do about it?

Care Redesign Survey: It’s Time to…

By neglecting mental and behavioral health, our society has made it virtually impossible to succeed…

Primary Care

135 Articles

Care Redesign Survey: It’s Time to…

By neglecting mental and behavioral health, our society has made it virtually impossible to succeed…

Insights Council

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

Apply Now