Background: High hospital occupancy can worsen emergency department (ED) boarding times and patient morbidity and mortality1. “Discharge before noon,” or the practice of discharging patients in the morning to make room for admissions in the afternoon, is a possible solution, despite concern that it might lead to higher LOS2. Interventions often incentivize early discharges via a multidisciplinary approach,3-4 but the impact of targeting these interventions toward residents is unclear. Financial incentives have been successful in other areas such as promoting charting timeliness5-6.
Methods: Our study aims to investigate whether financial incentives to residents can improve early discharges without worsening the length of stay (LOS) and 30-day readmission rates.
Results: For a twelve week period, eight resident-led hospitalist teams reported the number of discharge orders placed before 12 PM and after 5 PM every Monday to Friday. Patients discharged after 5 PM were counted to prevent teams from keeping stable patients an extra night. The team with the highest number of discharges by Friday of that week was awarded a $100 gift card. Participants completed surveys to assess attitudes towards hospital overcrowding and barriers to early discharges. The intervention period ran from March 1 to May 31, 2025, and the control periods ran from March 1 to May 31, 2024 and December 1, 2024 to February 28, 2025. Our primary outcome was the percent of discharge orders placed between 12 AM to 12 PM and 5 PM to 12 AM. Our secondary outcomes were LOS and 30-day readmission rates.
Conclusions: During the intervention period, 567 of 1323 discharges (42.85%) occurred from 5 PM to 12 PM the next day. In comparison, 423 of 1,376 discharges (30.74%) from March to May 2024 and 355 of 1,149 discharges (30.89%) from December 2024 to February 2025 occurred in this timeframe. Two-proportion z-tests revealed a significant difference between the intervention and control periods, p< 0.0001. Two-tailed t-tests with a confidence interval of 99% showed no significant difference in LOS between the intervention and control periods. Chi-square testing showed there was also no significant difference in 30-day readmission rates, with 18.4% of patients being readmitted during the intervention period versus 20.3% compared to March to May of 2024. This demonstrates that our intervention resulted in a meaningful change in discharge patterns without significantly increasing LOS or 30-day readmission rates. Surveys showed that 84.4% of residents cited hospital overcrowding as a patient safety issue. This suggests that residents are intrinsically motivated to reduce boarding. Participants also shared that the gift cards promoted team bonding and introduced friendly competition to prioritize early discharges. The survey also identified several barriers to early discharges, including imaging delays, late consultant rounds, and complex social disposition planning. These findings highlight key areas that can be included in future quality improvement initiatives. In conclusion, the improvement in the early discharge rate with monetary incentives shows the extent to which behavioral patterns in resident workflows contribute to this hospital metric.