Opportunities exist to recreate hospital units as effective and reliable microsystems. We used specific structure, process, and management design features to relaunch a hospital medicine unit: 1. Unitbased physician teams, 2. Structured Interdisciplinary Bedside Rounds (SIBR) 3. Unitlevel performance data and 4. Unit comanagement by nurse and physician codirectors. Unitbased physician teams were hospital medicine resident teams whose patients were cohorted almost exclusively to the intervention unit and covered inhospital 24 hours per day. SIBR is a teambased, patientcentered model of care which synthesizes a daily plan of care at the bedside using standardized inputs from the physician, bedside nurse, and patient or family, while also using a qualitysafety checklist.
Using a time series analysis with a concurrent control we examined the effect on mortality in the 12 months before and after the intervention. The intervention unit was a 24bed medical teaching unit within a 579bed tertiary care hospital and the control unit was a 50bed medical unit in a separate 550bed community teaching hospital within the same health system. The number of deaths and discharges to inpatient and home hospice were extracted from administrative databases and was compared using negative binominal regression. The number of hospital admissions was accounted for by using the natural log of hospital admission as an offset variable.
Mortality in the intervention unit fell 73% immediately postintervention, from 1.00 per 100 admissions to 0.27 (p=0.005). In the control unit, a 34% lower mortality rate was observed, from 0.80 per 100 admissions to 0.53, but was not statistically significant (p=0.229). The number of discharges to hospice did not change significantly in either unit. The number of admissions in the intervention unit increased from a mean of 131 to 146 per month (p=0.03), while the number of admissions in the control unit decreased from a mean of 280 to 263 per month (p=0.03).
A large reduction in mortality was temporally associated with a redesign of a hospital medicine unit. The redesign featured structure, process, and management changes all aimed at creating standardized, teambased, patientcentered care, and management accountability. Interpretation of findings is limited by the quasiexperimental design and the possibility of unrecognized confounders. Further research should delineate the precise mechanisms through which the redesign of a hospital medicine unit affects mortality and other quality metrics.
Figure 1Structured Interdisciplinary Bedside Rounds (SIBR) is a teambased, patientcentered model of care that assembles the bedside nurse, attending physician, allied health professionals, and trainees at the bedside every day for a standardized huddle, enabling them to collaboratively cross check information with the patient, family and one another; to hold each other accountable to a qualitysafety checklist; and to synthesize a mutually supported plan of care from standardized inputs.
Figure 2Deaths per month on the intervention unit the run chart graphically depicts the immediate reduction in unit deaths per month following redesign of the hospital medicine unit.
To cite this abstract:Methvin A, Mohan A, Castle B, Payne C, Tong D, Stein J, Vazquez J, Rykowski J, Burleson M. Mortality Reduction Associated with Structure, Process, and Management Redesign of a Hospital Medicine Unit. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97658. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/mortality-reduction-associated-with-structure-process-and-management-redesign-of-a-hospital-medicine-unit/. Accessed September 17, 2019.