Optimization of Patient Progression in a New Era: A Comprehensive Framework.

PURPOSE/OBJECTIVES: The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments. PRIMARY PRACTICE SETTINGS: Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign. FINDINGS: Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days). CONCLUSIONS: Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

Prone Positioning of Patients With Acute Respiratory Distress Syndrome Related to COVID-19: A Rehabilitation-Based Prone Team.

OBJECTIVE: Prone positioning is an effective intervention for acute respiratory distress syndrome (ARDS). An increasing number of patients with ARDS related to coronavirus disease 2019 require prone positioning, which poses a challenge to the intensive care unit staff at Brigham and Women's Hospital. METHODS: A prone team service of physical therapists and occupational therapists with critical care experience was established to assist with increasing demands for prone positioning of patients who were mechanically ventilated. The goals of the rehabilitation-based prone team were to provide support to nursing and respiratory therapy; create a consistent, efficient process; and ensure patient and staff safety. RESULTS: The service evolved over 7 weeks, expanding to 24-hour coverage and adding responsibilities to support the staff as patient volume grew. The volume of requests to the rehabilitation-based prone team generally increased to week 4 and has, since then, declined. Key points for successful implementation included identification of rehabilitation therapists with intensive care unit experience and leadership qualities, multidisciplinary collaboration, availability of needed positioning devices and supplies to protect the integument, and well-defined roles of all disciplines participating in position change process. CONCLUSION: The description of the development, operations, evolution, and utilization of a rehabilitation therapist prone team acts as a guide for future development and implementation. IMPACT: This case report is one of the first reports of a rehabilitation-based prone team established to assist with positioning patients in prone as an intervention for ARDS related to coronavirus disease 2019 and will help guide other institutions.