Wednesday, May 14, 2008

Advance by day, maintain by night

If hospitals finally designed truly rational production processes and became 24 hour enterprises, care might work better and be safer--but where would the romance of the night shift be?

I'm quoted today in White Coat Notes, a brief quote in which I say that in the hospital "We maintain by night and advance by day", which might be worth explaining a bit more.

The hospital is a constant production process. But it's in transition: it inherits many of the features of its pre-industrial roots. A truly efficient production process never stops, but the hospital slows down considerably at night. I think there would be a lot to be said for a truly 24-hour hospital. But that would require more health care workers, more money to pay people extra to work overnight, and a completely different way of arranging care.

Hospital care moves in fits and starts. We try to help people with the hospital's resources and then move them out of the hospital before they begin accumulating too many of the hospital's risks, like hospital infections, or unnecessary procedures stemming from results of unnecessary tests.

The five-day-a-week, 10-hours-a-day schedule of much of the healthcare system means that the discharge that could happen on Saturday waits until Monday because there's no skilled nursing facility screener who can come on a weekend to accept the patient. A CT scan that could take place overnight waits until the next day because there are only enough radiology technicians and radiologists to staff emergencies at night.

Meanwhile, there are things we do to advance care at night. For instance, we might start an infusion of medicine overnight. But most of what we do is planned and started in the daytime. We make our plans by day, do most of our testing and procedures and imaging by day, and make most of our clinical assessments by day.

A hospital would be more efficient, and care would happen more quickly and probably yield more clinical benefit if we operated hospitals on a 24 hour schedule. Care would probably be better if it took place at a constant pace rather than a stop-and-start pace.

The argument against the 24 hour hospital is obvious: it's nice that for a while, we can just let our patients sleep. On the other hand, most people don't sleep well in the hospital. If we could get them out 50% faster, they'd get more sleep where they're going than the hospital where they're staying. And at least from the house staff point of view, it's frightening to cover patients on a hospital floor where nurses and other staff don't regularly come in to rooms to take vitals and check on how they're doing.

On the other hand, maybe this is all self-justifying fantasizing from a pre-call intern, the root idea of which is: We're awake. Maybe the rest of the hospital should be too.


Moondance said...


As a patient and provider, I couldn't agree with your statements more.

Anonymous said...

You are on to a big issue - the medical "plant" is in fact open 24/7, it is the ancillary, and most importantly, the administrative plant that is an 8-5, M-F plant, with minimal flexibility. In "The Old Days" [TM] the VA was by far the most limited nights and weekends, friends tell me it has improved in part.

And Rep. Stark and others wonder why surgeons want to move out of general hospital practices and into autonomous specialty hospitals that might actually "work" - geeesh.

David said...

I think it is interesting that you think industry as a whole has solved this problem. I don't think they have. Many industries shut down overnight. Their employees must sleep and it works out better that way. Of course taxicab drivers, world-market watchers, news companies, and many other industries DO continue around-the-clock. I think it is always an economic question. It would be worth speaking to your hospital administrators to see if the extra cost is worth it. I suspect though that they have already answered that question - so far, it isn't.

Joe Wright said...

Thanks Moondance. Anonymous: the VA still definitely has a marked difference in this respect. On night float, if I wanted someone to get a radiology study I needed to wheel them down to the scanner myself, and if I wanted a blood test I needed to do the phlebotomy. Hard to know how much this is an issue of hospital size, but at least part of it still might be just a feature of VA culture.

David, I agree: there has got to be a reason that the economics work out to sustain this system. For all of the talk about turnaround time, the economic incentive for speed of diagnosis and discharge must not be enough to counterbalance the extra cost of night-time services.

It's true that lots of industrial processes shut down at night--but lots of them have realized what can be added if they think on a 24 hour clock. Retail too (since a hospital is some combination of a retail and an an industrial process). For instance, the 24 hour supermarket is a relatively recent invention--it used to be only small convenience stores that were open all night. But I think someone realized at some point that if a supermarket is big enough, it's got people stocking shelves all night anyway--so they might as well keep a couple of checkers working to keep the store open and bringing in revenue during that time.

In other words, if there's already a production process taking place at night, what can you add to it to take advantage of that already-existing process? I think the larger tertiary care hospitals probably have enough people sitting and waiting for radiology studies overnight that it would be worth it to pay radiology techs to keep all of the CT and MRI scanners going at a constant pace. I wonder if one challenge is that decisions like this are made department by department: what specifically does the radiology department gain financially by increasing speed? That benefit only accrues to the hospital as a whole. And from the MD point of view, it's hard to see how radiologists in particular gain by spreading out their schedules, when many chose radiology partly because they had more control over their schedule than other medical specialties. So, the radiology department is always going to push back against a truly 24 hour schedule, and MDs (who are often not hospital employees) will always have some power to simply refuse to do something, unless the benefits of speeding up come back to them specifically.

So, it seems like one challenge from an administrative point of view might be to figure out how to quantify the benefit of 24 hour scheduling and kick some of the benefit back down to the specific departments that would pick up the extra load.

But most of this remains mysterious to me: I definitely can not claim to understand the complexities of hospital administration, nor of industrial production in general.

Joe Wright said...

PS: One specific way of changing this might be to build in incentives for departments which do diagnostic studies and procedures to reduce the time from order to completion. lf we recognized that waiting for studies and procedures was a major rate-limiting step for hospital work, then we should give specific incentives to increasing the rate of that step so that it no longer limits the speed of the rest of the process.