As construction continues on the Pavilion — Penn Medicine’s new $1.5 billion inpatient facility — transformative changes at the Hospital of the University of Pennsylvania (HUP) are in the works, too.
When the Pavilion project was first announced, people began to speculate about HUP’s future. Some thought all services would move to the Pavilion and HUP would close. Others said it would become a University building. Regina Cunningham, PhD, RN, HUP’s chief executive officer, has consistently been quick to address — and squash — these and other myths. “The Pavilion is part of HUP,” she said. Along with the Perelman Center, “it is all one campus. One mission, one team, one HUP.”
With more than half of HUP’s clinical services moving to the new facility across the street, however, a re-imagining of the Health System’s flagship hospital will give services remaining on the “west side” of the HUP campus the breathing room they need to expand and bring patient care to new levels. “We are transforming how we organize and deliver care,” she said. “That’s what’s so exciting about the future of HUP. It’s a once-in-a-lifetime opportunity.”
A Brief History
When plans were made to relocate the University to West Philadelphia, an additional 6.9 acres were purchased (at a cost of $500) to ensure that the hospital, which opened in 1874, had plenty of room to expand. And grow it did, with new buildings added along both 34th and Spruce Streets. But because HUP is landlocked — surrounded on each of its sides by, respectively, the University, Children’s Hospital, and the two streets — it could only expand so far.
As established services grew and new ones came on board, changes were made. Outpatient practices were moved out of the hospital but, still, available space remained limited. As a result, changes were not always made in a strategic way, Cunningham said. “Services that logically should fit together clinically are offered in different parts of the hospital.”
But that will change as part of the new vision. Care will be organized by specific patient populations and patients with related clinical needs will be located in closer proximity. For example, the cardiac surgery intensive care unit will be located next to the cardiac surgery step down unit, making the flow of patients more efficient and the care of patients seamless. This type of organization is associated with improved outcomes. “When nurses have competencies to address particular patient populations, we know that they provide more proactive care based on anticipated needs; this drives quality and minimizes complications,” she said. “Members of the clinical teams need to communicate with one another. When you work in geographic proximity, it enhances communications and care.”
While many of the clinical services remaining at HUP will be updated to increase efficiency and improve patient care and outcomes, the process will begin with Women’s Health. With OB/GYN chair Deborah Driscoll, MD, at the helm, preliminary discussions for renovating this department are starting, with the development of a vision for the future of Women’s Health at HUP.
A New Look at Women’s Health
When it opened in 1889, HUP’s Obstetrics and Gynecology Department was the first maternity hospital in the city. It included five labor and delivery (L&D) rooms, a nursery, and a sunroom. Because most women gave birth at home at that time, only 30 babies were delivered at the hospital that first year.
Fast forward 130 years. HUP’s obstetrical service delivers thousands of babies each year; over 4,300 last year alone! And as patient needs have changed over the decades, care has evolved and advanced. Today, HUP is one of the top centers for high-risk obstetrical care in the region.
Although very much in the early stage of planning (no renovations can even begin until the move into the Pavilion in 2021), a task force is examining many potential changes to Women’s Health, all focused on creating a space that will be “functional and flexible to adapt as care needs change, as well as a comfortable, cared for, inviting place for patients,” Driscoll said.
Right now most of HUP’s OB/GYN inpatient services are “stacked” on two floors of adjacent buildings. Labor and Delivery and the intensive care nursery (ICN) are on Ravdin 7 and 8 while Silverstein 7 and 8 are home to the postpartum “mother and baby” unit as well as gynecology inpatients. The proximity of these units helps clinical staff provide better care across the continuum, but the lack of “breathing room” presents challenges.
For example, pregnant patients requiring in-hospital monitoring, such as those with congenital heart disease, often stay on the gynecology unit. And postpartum moms who need a higher level of care than may be available on the postpartum unit stay on L&D, filling beds needed for women in labor. Driscoll’s vision of a new Women’s Health service includes separate units for each of these patient populations. And she would also like to include a unit for gynecologic oncology patients who are often very ill, with private patient rooms that offer “enough space for family support, which is so important,” she said.
Results from current OB/GYN pilot projects with the Center for Health Care Innovation will also play a role in the redesign. For example, the “Healing at Home” pilot showed that the majority of participants who had an uncomplicated vaginal delivery preferred to go home a day early. By accelerating newborn processes that take place prior to discharge by a full day and then supporting postpartum moms with two-way text messaging 24/7 and lactation consultation visits at home, the length of stay in the pilot was reduced one full day.
A randomized control trial will start this fall but, “if we were to offer this option to our patients, it would essentially generate 1,000 additional bed days, based on the number of deliveries we do and the number of uncomplicated vaginal births. This trial will inform just how many postpartum beds we should have in addition to providing the support that new mothers need.”
The Helen O. Dickens Center for Women, which primarily cares for those from underserved communities, is “one of the busiest practices at HUP, with over 58,000 visits a year and contributing to over 50 percent of our delivery volume,” Driscoll said. However, a lack of space is holding them back from expanding services. For example, Driscoll would like to use a pre-natal care group model at the Center, in which moms-to-be share experiences and learn about nutrition, relationships, labor and delivery, and newborn care. “This model has been shown to improve maternal and infant outcomes and reduce pre-term birth rates,” she said. “We implemented the program on a small scale last year. If we had more space, this model could be more widely used.”
Emergencies and Preemies
Because seconds count in an obstetrical emergency, the shifting of emergency care from HUP to the Pavilion is very much on the minds of OB/GYN leaders. “We’re concerned about the time it will take for patients to get through the tunnel to L&D,” Driscoll said. For the past 18 months, a task force has been examining possible redesigns for HUP’s Perinatal Evaluation Center and ED triage. Currently, women more than 16 weeks pregnant who come to HUP’s ED are sent directly to the evaluation center, a quick elevator trip up to Ravdin 7. Women in earlier stages of pregnancy are first triaged in the ED. “Potentially I’d like to have a triage unit at HUP West for all pregnant women, regardless of gestational age,” she said. “We need to think about alternatives and, in partnership with the ED, have a more efficient care model.”
Expanding and updating the intensive care nursery (ICN) is also essential. Its current four “open bay” models with 38 bassinettes is “overcrowded,” said Michael Posencheg, MD, medical director of the ICN. Private rooms would provide a quieter environment for the preemies, but this model may eliminate “the line of sight for nurses, which allows them to respond quickly and to get help quickly,” Posencheg said. He’d also like to include nearby “communal spaces” where families can eat and talk together as well as additional overnight rooms for families, “away from the stress of the ICN environment.” To help make decisions, leaders from OB/GYN and neonatology are traveling to see new ICNs in other hospitals. “We’re drawing upon both their successes and their failures to design the best for our babies.”
In redesigning both Women’s Health and HUP itself, staff engagement is critical. “I want to hear from those on the ground who are providing the day-to-day care for our patients and watch how staff across disciplines work as a team,” Driscoll said. “They understand patient needs but I also want to meet their needs as well, to create a work space that is efficient, welcoming and supportive.”
Cunningham agreed. Transforming HUP “is something that’s bigger than any one of us but it’s something all of us can do together.”