A green day is a good day: Building new habits to get patients home from hospital faster

Photo of Sarah Wagner, Registered Nurse

By Norma Lee MacLeod

Sarah Wagner has seen a lot of changes come and go in her 14 years as a registered nurse. So she was skeptical when her unit at Cape Breton Regional Hospital agreed to test a new daily routine that would set daily priorities for patients on Unit 3B. It’s called the SAFER-f Patient Flow Medicine Bundle. Each letter represents a series of actions and steps that ultimately determine when a patient can go home.

“To be completely honest, I was not overly optimistic and was terribly negative at first. I honestly thought the whole thing was going to add too much work to an already busy day,” said Wagner.

That’s not what happened.

“If there is one thing I could tell other hospitals and health care staff about SAFER-f is that it works,” said Wagner. Here’s how it is working on 3B. Each morning, the health care team gathers for “bullet” rounds. This includes not just physicians and nurses, but all disciplines ranging from occupational therapists and physical therapists to continuing care and pharmacy. They spend no more than two minutes per patient discussing each patient’s care so the patient and family will know the answer to these four key questions:

• Why am I in hospital?
• Will I have any tests and treatments today?
• When will I see my doctor today?
• When will I go home?

The goal of asking these questions is to reduce unnecessary waiting. If the patient is undergoing a test or a treatment, the day is marked green. The day is flagged red if nothing is happening that will move the patient toward recovery or discharge from hospital. A green day is a good day. This information is displayed on a monitor in the unit so the whole health care team can measure progress and figure out how to turn a red day into a green day.

“It’s focusing on the importance of patients’ time,” said Lynn Edwards, Senior Director of Clinical Services Networks, Access and Flow and Frailty for Nova Scotia Health. “Every minute that the patient is in the hospital, every day, needs to be an active day in their care plan,” said Edwards.

“There is no time well wasted in healthcare and the patient’s time is a most precious commodity,” said Dr. Tanya Munroe, co-lead and Senior Medical Director of the Access and Flow Network. “Every day spent in a hospital needs to bring value to the patient, whether the focus is on recovery and return home for those who can, or dignity and symptom control for those who cannot.”

The daily bullet rounds and checklist change the way teams work together. “It is about the teams getting together and our systems aren’t necessarily set up for that to happen organically,” said Lorianne MacLean, Network Leader for Integrated Access and Flow with Nova Scotia Health.

The SAFER-f model means collaboration on a unit is efficient and baked in. Some of that was lost when COVID-19 restrictions limited how teams could meet, but it is always a challenge coordinating the many different health care workers who care for a single patient.

“With all of these different professionals with different backgrounds and ways of doing things coming together…if you don’t pause to talk about it, it makes it really hard to develop that team approach,” said MacLean. “We need to strengthen the unit team to become more comfortable challenging each other, working with each other, learning from each other versus just coming in and doing your own little part. It’s the bigger picture that we need to pull together - building trust among team members and engaging patients and families as part of the team is key to supporting our patients. “

SAFER-f is one of the initiatives to improve access to health care under Nova Scotia’s Action for Health plan. When the bundle of steps is built into the workday, the health care team can see the big picture on the unit at a glance, set the priorities of the day together and bump up tests or treatments. It should mean more time in hospital is spent getting care rather than waiting for care. Ultimately, it means the patient gets home sooner, opening a bed for someone else in need.

“As you are waiting there is someone waiting in the emergency department, there is someone waiting in community. By trying to find efficiencies, even carving two hours off discharge makes a significant difference in access to the person that needs that care,” said MacLean.

SAFER-f is being tested at eight hospital units across the province. Teams from each of the units meet regularly to share their wins and take home examples of best practices to fine tune how the SAFER-f steps are working on their unit. Eventually the approach will be adopted across all inpatient care within Nova Scotia Health.

Wagner is a convert after her initial fears about how SAFER-f might affect workload. “Instead of meeting with each discipline individually and repeating the same information over and over, everyone is now in the same room, and we only have to go over it once. That alone has saved me over an hour in the morning,” said Wagner.

Her advice to other units is to keep an open mind. “It will take some trial and error, but once it’s up and running you will see the benefit of it and wonder how you ever worked without it.”