BACKGROUND: Optimizing hospital operations is a critical issue facing healthcare systems. Reducing unnecessary variation in patient flow is likely to improve efficiency and optimize capacity for hospital inpatients. The objective of this study was to determine whether changing admissions, from a “bolus” system to a “drip” system, would result in a smoothed daily discharge rate, and reduce the length of stay of patients on a General Internal Medicine clinical teaching unit over a period of 1 year. METHODS: We conducted a retrospective analysis of the General Internal Medicine inpatient service at Toronto General Hospital for the 6‐month periods from March to August during 2 consecutive years. Length of stay distributions and daily discharge rate variations were compared between the 2 study periods. RESULTS: There were a total of 2734 discharges, 1446 occurring in the pre‐change period, and 1288 in the post‐change period. There was overall smoothing of the daily discharge rates, and a reduction of 0.3 days in median length of stay in the post‐change period (P = 0.0065). CONCLUSIONS: Restructuring the admission system to achieve constant daily admissions to each care team resulted in a smoothing of daily discharge rates and improved operational efficiency with shorter lengths of stay. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

BackgroundFraming bias occurs when people make a decision based on the way the information is presented, as opposed to just on the facts themselves. How the diagnostician sees a problem may be strongly influenced by the way it is framed. Does framing bias result in clinically meaningful diagnostic error?MethodsWe created three hypothetical cases and asked consultants and registrars in Emergency Medicine and Internal Medicine to provide their differential diagnoses and investigations list. Two of the presentations were written two ways to frame the case towards or away from a particular diagnosis (Presentation 2 – pulmonary embolus (PE) and Presentation 3 – interstitial lung disease (ILD)) and these were randomly assigned to the participants. Both versions were however entirely identical in terms of the objective facts. Physician impressions and diagnostic plan were compared. A third presentation was identical for all and served as a control for clinician baseline ‘risk-averseness’.ResultsThere were significant differences in the differential diagnoses generated depending on the presentation’s framing. PE and ILD were considered and investigated for the majority of the time when the presentation was framed towards these diagnoses, and the minority of the time when it was not. This finding was most striking in Presentation 2, where 100%versus50% of clinicians considered PE in their diagnosis when the presentation was framed towards PE. This result remained robust when undertaking stratified analysis and logistic regression to account for differences in seniority and baseline risk-averseness— neither of the latter variables had any effect on the result.ConclusionWe demonstrate a clinically meaningful effect of framing bias on diagnostic error. The strength of our study is focus on clinically meaningful outcomes: investigations ordered. This finding has implications for the way we conduct handovers and teach juniors to communicate clinical information.

This project owes its success to the following factors - management support; iterative engagement of a range of staff; provision of timely data analysis; increases in senior medical officer staffing and reorganisation leading to more predictable and fair work practices. One challenge is discontinuity, whether between doctors and patients or within the medical team.