‘discharge by Appointment’ Improves Patient Flow, by Increasing Number of Discharges Before Noon

Background:  Most patient discharges(DC) from hospitals occur in the afternoons, thus creating patient flow and potentially patient safety issues. This creates increased ER boarding hours and delays interunit patient transfers between ICU, stepdown and medical units. Sick patients may not be getting the appropriate level of care due to lack of higher level of care beds.

Purpose:  To increase discharges before noon on general medical floors by giving DC appointments.

Description:  Multiple efforts including incentivising hospitalist physician groups to increase DC orders before 11 am, only helped to increase the number of DC orders but not actual early discharges. Some barriers in early DC orders not translating into early discharges, were lack of transportation, and lack of standardized DC process.

Utilizing the PDCA methodology and tools, a multidisciplinary team consisting of the Unit Based Medical Director, Nurse Manager, Patient Care Facilitators (PCF), Case Manager(CM), Social Worker(SW) and Bedside Registered Nurse (RN) developed a process map to better understand and communicate each step of the new work flow methodology. Team roles were defined and tasks mapped out which included identifying potential early discharges and necessary needs for DC to ensure meeting the DC appointment time. We developed a Predicted DC Tool to capture the necessary facets of managing a patient’s DC by appointment.

Key aspects of the Process Improvement included:

• Physician identification of patients with 80-90% confidence of being DC the next day
• 3:00 pm team huddle: the PCF updates the Predicted DC Tool with identified patients and DC appointment time based on discussion with attending physician and confirmation by patient
• PCF to address with CM and SW: post hospital care, referral status and insurance
• 7:00 am RN reviewed if assigned an early DC patient, review / escalate to PCF any DC issues
• PCF or Charge RN review Predicted DC Tool and confirm with RN if on-time for DC

We also developed a streamlined DC workflow methodology (Process Map) and established role expectations throughout the process(RACI). Giving patients that have a high predictability of being discharged next day, an appointment, and set off a series of steps to be completed the day before discharge including, notifying the transport team/family members of the appointment, helped improve the number of discharges before noon significantly. The new process was started on one general medical unit(5C), resulting in increased discharges before noon from 15% in January 2015 to 29% in June 2015. In the same time period, other general medical units in the hospital increased from 9% to 16% as there was enough awareness of ongoing efforts on the pilot unit. On an annualized basis, 244 additional patients were discharged from the pilot unit, thus increasing throughput on the unit significantly.

Then the ‘Discharge by appointment’ process was implemented across all general medical units at Christiana hospital by the Department of Medicine, and the overall number of discharges before noon has increased to 20% for the last 3 months. The pilot unit is still sustaining at 25% over the last 3 months.

Conclusions:  A concerted, standardized effort from patient care teams by treating discharges as a priority and giving discharge appointments will significantly increase early discharges and may help in patient flow and potentially patient safety.