Background: The timing of discharges of admitted patients has a significant impact on hospital efficiency and throughput. Earlier discharges are associated with improved boarding times, admissions arriving to inpatient units earlier in the day, and decreased length of stay. Discharges that occur later in the day creates a bottleneck effect, causing emergency room congestion, overcrowding, and higher inpatient mortality.
Purpose: This project was developed to address a high volume hospitalist service challenged with meeting early discharge goals. This study implemented a targeted initiative developed to improve throughput by increasing the rate of early discharges before 9 am and 11 am.
Description: Our model implemented an Advanced Practice Clinician (APC) and Physician team to standardize the discharge process of patients on the inpatient hospitalist service in an acute community-based academic medical center. Goals of this innovative staffing plan were to improve the percentage of discharges before 9am and 11am while allowing physicians to be freed up to see critical patients in the morning and APCs to feel engaged and valued. A sign-out method was established to notify a designated APC of potential discharges the day prior to expected discharge, including potential barriers to discharge. On the day of discharge, the APC reviewed the chart and examined the patient. If the APC determined the patient was clinically appropriate for discharge, the APC would notify the physician, discuss the discharge treatment plan, and complete the discharge paperwork. The patient was then evaluated by the APC-Physician team for final instruction and plan of care review prior to discharge. A retrospective analysis was performed to evaluate the percent of patients discharged prior to 9 am and 11 am. The data was obtained over a 6 month period before and after the intervention. Discharge goals of 25% for discharges prior to 9am and 40% for discharges prior to 11am were established.
Conclusions: Prior to the staffing model change, the hospitalist group averaged 28.83% of discharge orders placed before 11am. After the change, the discharge orders before 11am rose to above goal at 43.2% and continues to be successful. This study continues to be at an early stage and represents preliminary data that was gathered to ensure that our intervention is yielding positive improvement to discharge rates. Data analysis is ongoing to obtain the rate of discharges prior to 9am, which are expected to also be above goal for this time period. Preliminary data has shown significant improvement to discharge rates by implementation of our discharge initiative. Future goals will analyze length of stay to ensure that our early discharge intervention does not compromise length of stay.The collaboration of APC and Physician initiative has resulted in profound improvements in the percent of early discharge rates. This was accomplished by shifting the role of an APC to develop a team-based approach to discharge planning. Although still in early stages, this study has demonstrated a successful plan, which improves hospital throughput by overcoming challenges with efficient and successful early discharge of patients.”This project was undertaken as a Quality Improvement Initiative at Grand Strand Medical Center, and as such was not formally supervised by the IRB per their policies.”