Background: Hospital throughput and length of stay (LOS) are important drivers of success in an increasingly competitive healthcare landscape where revenues are down and demand can exceed hospital capacity. More specifically, longer LOS and hospital throughput bottlenecks impact access to timely care, the quality and safety of care delivery, patient and family satisfaction, and provider experience. Although there are several reasons for delays in hospital discharges, asynchronous coordination of care amongst the inter-professional team and challenges in quickly determining accurate care coordination status and discharge readiness from multiple sources of information has been shown to contribute to extended processing time and increased LOS.

Purpose: Develop and implement a novel, automated discharge checklist called discharge milestones in an electronic health record (EHR) that enables real-time inter-professional team communication about discharge planning at an academic tertiary care hospital.

Description: Our aim was to promote safer, smoother, and more efficiently coordinated discharges by enhancing inter-professional team communication around progress towards discharge readiness in the EHR that leverages existing documentation and workflow on five pilot inpatient units consisting of hospital medicine and orthopedic surgery services. Of 22 discharge milestones created, 17 milestones are automatically updated and completed. Thus, our goal was to not build a traditional checklist which team members would be tasked with keeping updated and potentially add to the unreliability of the checklist, but instead build a tool that could be easily accessed and automatically updated based on logic created from existing documentation workflows in the EHR. Partnering closely with an inter-professional team of stakeholders, we significantly modified the existing Discharge Milestones functionality in Epic Systems Corporation (Epic). An iterative, continuous improvement process was deployed to identify and prioritize key facilitators and barriers in discharge planning, automate milestones, and ensure that milestones could be easily located by all members of the care team, including the ability to view milestones from patient lists without opening patient charts. In addition, we added estimated discharge dates to discharge milestones to assist with hospital-wide bed capacity planning and to prioritize therapy, radiology, and consulting services for patients anticipated to be discharged within 12-24 hours. Lastly, we partnered with trainees in creating a more robust inpatient discharge report that included details beyond what could be conveyed in discharge milestones, such as specifics of follow-up appointments, post-acute care placement, and discharge orders placed.

Conclusions: EHR discharge planning tools can be leveraged and automated in novel ways to improve the accuracy and reliability of discharge planning information presented to all members of the patient care team with the aim of improving efficiencies and reducing length of stay. Estimated discharge date accuracy within 12 hours of a patient’s actual discharge increased from 45% to greater than 65% and LOS index decreased from 1.04 to 1.02 on our pilot units within 3 months of the pilot launching, meeting the goal of a 1% reduction in LOS. Further study is needed to study longer-term gains and sustainability of the intervention.

IMAGE 1: Figure 1. Conceptual design of Discharge Milestones to improve inter-professional discharge planning communication in the EHR

IMAGE 2: Figure 2. Example of Discharge Milestones use case demonstrating automated functionality based on provider documentation workflow in the EHR