Background: In November 2021, we initiated a project to improve our length of stay (LOS) and plan of care for patients with a LOS of ≥6 days. We created the Complex Cases Rounds (CCRs) for all patients hospitalized under the hospital medicine service in our community hospital, Emory Johns Creek Hospital.
Purpose: CCRs provide a multidisciplinary format to review patients’ needs and identify the barriers for discharge in our hospital. Such barriers may occur when the patient is not medically ready; when placement is difficult (this can include discharge to acute rehabilitation facilities, subacute rehabilitation, home health, or home); when the patient or their family has difficult or challenging behaviors; when the patient is uninsured; or when delays occur in laboratories, procedures, and/or imaging.
Description: The CCR team is led by the medical director of care coordination and includes the social worker and the patient’s hospitalist. The CCRs take place every Tuesday and Friday. The hospitalists and the social workers are notified which patients will be included in CCRs 1 day in advance. This gives them enough time to review the possible barriers, if any, for discharge.The social worker and the hospitalist are expected to attend the scheduled CCR, to identify potential discharge needs, and to intervene proactively to assure that patients are discharged to the appropriate level of care in a timely manner. The discussion is led by the medical director of care coordination and is based on discharge needs, the plan of care, anticipated discharge date, anticipated level of care at the time of discharge, any barriers to discharge identified, and actions needed.Interestingly, once we began conducting CCRs, we found that there were frequent delays in sub-specialist plan of care, including poor communication with the hospitalist. Delays in IV orders, especially IV antibiotics and total parenteral nutrition, were especially common. We also observed that it can be difficult for patients in our catchment area to get special care needs met, including home nursing and wound care.
Conclusions: When we started the CCRs, we had around 55 patients with LOS >6 days on average. Currently, we are proud to say that we have a generally have a census of ≤30 patients with LOS more than 6 days. The CCRs provide us with early identification of potential barriers, giving us the opportunity to create strategies to mitigate them. Though we still have a relatively high number of patients with LOS >6 days in our hospital, our goal with the CCRs is to decrease the number of patients who remain to just those patients who are not medically ready to be discharged; the average number of such patients is approximately 10 per day.