Call Re-Design: Changing the CTU admission structure from a bolus system to a trickle system
On March 2nd, 2009, the Toronto General Hospital (TGH) General Internal Medicine (GIM) Clinical Teaching Unit (CTU) implemented a major structural change to its admission process. Prior to the change, the four physician-led care teams rotated between designations of ‘on-call’, ‘post-call’ and ‘pre-call’ over the course of the week, and only the team designated ‘on-call’ accepted new admissions. This ‘bolus’ call structure created large variations in admissions and workload for each team. Previous work in this area tells us that daily variation in patient care processes, particularly relating to admissions and discharges, creates inefficiencies and decreases hospital inpatient capacity.
The new structure, through a reorganization of the ‘on-call’ personnel, ensures that all four care teams admit approximately the same small number of patients daily, the trickle system. Other advantages of the new admission system include (1) decreased cross-coverage of patients, (2) improved continuity of care for patients, and (3) shorter work-hours for residents and attending staff.
The goal of this change was to improve operational efficiency, improve the quality of patient care, and improve resident and staff satisfaction at work.
To date, we have carried out two research projects exploring the impact of this structural change. The first is a qualitative focus group study exploring the attitudes and perceptions of attending staff, residents, and students comparing the two systems. The second is an analysis of the operational efficiency of the CTU in both structures, measuring Length of Stay (LOS) and smoothing of daily discharges. Of particular note, the new structure was associated with a decrease in the median LOS of 0.3 days.
Our sister hospital, TWH, has already adopted the same structural change in an attempt to resolve similar issues of resident work-hour restrictions, and patient cross-coverage. CTU’s in other centers that provide team-based care for their inpatients can use the organizational principles guiding this structural change to achieve improved operational efficiency and patient care.
For more information please contact:
Nicolas Szecket MD, MPH, FRCPC
General Internal Medicine
Toronto General Hospital
University of Toronto
(416) 340-3724 (office)
(416) 595-5826 (fax)
nicolas.szecket@utoronto.ca
Publications
Szecket N, Wong H, Berman HD, Wu, R, Morra D. Implementation of a continuous admission model reduces the length of stay of patients on an internal medicine clinical teaching unit. Journal of Hospital Medicine (Submitted)
Stroud L, Szecket N, Ginsberg S. Effects of a Re-structured Schedule on Internal Medicine Clinical Teaching Units (CTU): A Study of Attending Physicians, Residents, and Medical Students. (Manuscript)