SIRBs: Lessons Learned for Physician Advisors

Many hospitals have found that putting SIBRs into place is incredibly challenging.

The Case Management Society of America’s (CMSA’s) 28^th Annual Conference and Expo recently took place in Chicago, and I was fortunate enough to be a part of it. Attracting professionals represented within CMSA’s strategic mission – collaborators across the healthcare continuum who advocate for patients’ well-being and improved health outcomes – over 1,000 participants shared ideas, exchanged best practices, and encouraged continued success.

As a physician advisor, two sessions in particular piqued my interest. One was presented by Colleen Royer and Karen Smith from Cleveland Clinic about developing case management (CM) in the emergency department (ED), and the other was presented by Nicole Berman, Mary McClaughlin-Davis, Karen Hooven, and Vitrea Singleton, also from Cleveland Clinic, about structured interdisciplinary bedside rounding (SIBR.)

CM in the ED is something one of my health system’s hospitals initiated in the last couple of years. We have found success in situating a case manager within the ED who works closely with its staff and admitting physicians to determine appropriate status right from the start of the hospitalization. Also, in working with a social worker staffed in the ED, the ED case manager has been able to assist in identifying patients who are appropriate for placement into a Skilled Nursing Facility (SNF) directly instead of placing them into the hospital while searching for a facility. However, one snag has been the amount of time it can take to accomplish this. EDs are often measured by throughput, or, how long it takes to move a patient from triage to discharge. Holding a patient in the ED for multiple hours while the case manager and social worker make arrangements for transfer to a SNF, or for assistance at home when the patient is not safe for discharge but does not medically require hospitalization, skews the metric in the wrong direction.

The team at Cleveland Clinic has solved this problem and eliminated the hesitancy of ED staff to hold these patients by removing them from the metric entirely. This way, the six hours a patient remains in the ED is not “held against” the ED as a prolonged length of stay when ultimately the patient is transferred to a SNF instead of being placed onto an inpatient unit in outpatient status. Additionally, “saved days” are tracked and reported regularly. These represent the one or two days patients would have been hospitalized while arrangements were being made for care outside of the hospital setting. Categories include the following:

• Direct placement to post-acute
• Obtained DME (durable medical equipment)
• Referred to community resource
• Referred to social work/psych
• Transferred to outpatient service

Structured interdisciplinary bedside rounds (SIBRs) is another topic near and dear to many physician advisors’ hearts. Not only does it actively allow us to collaborate with the care team on a daily basis, but it bring us closer to the care of the patient than simply reviewing charts can.

However, many hospitals have found that putting SIBRs into place is incredibly challenging. Multiple interruptions, no consistent start time, and lack of structure about what needs to be addressed and who will follow up on items identified can lead to a quick death of any bedside rounding initiative. At CMSA 2018, the speakers targeted the following points as imperatives:

• Ensure the program is nurse-led at the patient bedside.
• Follow a specific structure to discuss plan of care, determine medical and patient priorities, and coordinate transition from one level of care to the next.
• Ensure brevity, with sessions held at the same time daily even in the absence of any one discipline.

At the core of SIBR is increased understanding about patient progression during hospitalization and efficient planning to address patient needs in preparation for discharge. This leads not only to improved outcomes for the patient, but also for the hospital. When patients and their caregivers understand the medical reasons for hospitalization and the goals of care, both in and out of the hospital setting, they become more active participants in the recovery process. Likewise, proper management of patient care through team collaboration and communication decreases avoidable day delays and length of stay, both of which lead to cost savings for the hospital.

Clearly, the success of a health system depends greatly on the various facets of case management, which touch patients at every point in the continuum of care. Physician advisors are intimately involved in case management and utilization efforts, which was why one exciting announcement made at the opening session of the conference made perfect sense. Official collaboration between CMSA and the American College of Physician Advisors (ACPA) is now underway, and plans are in the works regarding how the two institutions will work together to educate members in a well-rounded, organized fashion.