Background: Patient flow and throughput are challenges that hospitals throughout the country face daily. Delays in throughput lead to prolonged ER times, delays in patient care, increased length of stay, patient dissatisfaction and frustrations for the medical team. Prior studies have shown that discharges before noon does improve hospital throughput. However, hospitals struggle in creating a long standing and a sustainable process. At our institution it has been especially difficulty with the teaching services given the concern that focusing on early discharges compromises the resident teaching experience.
Purpose: Our goal was to create a multidisciplinary initiative that would increase the number of discharges before noon and not compromise resident teaching. This not only involved the residents and interns, but required a collaborative effort with the families, care management, social work, and nursing.
Description: On October 1, 2018 our discharge before noon (DBN) pilot was launched on one of the primarily housestaff units. At interdisciplinary rounds every weekday morning, the two resident teams as well as the physician assistant teams led by the hospitalists would each identify one to two patients that were felt to be potential discharges before noon for the following day. Those particular patients were reconfirmed during afternoon rounds at 2:30 pm with medical team, care management, and the charge nurse. Any potential barriers to discharge were identified at that time and were addressed. The patients and families were notified by the medical teams as well as social work and care management on the day prior to discharge. Care coordination worked with our ambulance services to have specific ambulances designated for pre-noon discharges. Labs were also given priority and arranged with phlebotomy to be drawn earlier to ensure results were available during morning rounds. The charge nurse facilitated the discharges to allow the staff nurses to attend to other acute patient care needs.
We reviewed the data from the nine months prior to the start of the DBN initiative and compared it to the 4 weeks post intervention. In the first nine months of this year, 68 of 1422 (4.8%) patients on the unit were discharged before noon. With the implementation of the DBN pilot, 24 of 185 (13%) patients were pre-noon discharges. Furthermore, an additional 16 patients (9%) were discharged before 1 pm, making the percentage of patients discharged before 1 pm at 22%. Barriers to early discharges were identified and included delays in transportation, patients requesting lunch prior to discharge, timely completion of discharge paper work by medical teams and nursing. Despite these barriers, the number of discharges before noon, as well as before 1pm in the afternoon, had drastically increased with the multidisciplinary approach. The housestaff teams and attending physicians also did not feel any compromise of education with implementation of this initiative.
Conclusions: Although our Discharge Before Noon Initiative is in its early stages, the impact has been profound. In a one month period, the percentage of discharges before noon and 1 pm has increased by 22%. This initiative remains ongoing as we continually adjust our approach and identify new barriers. Future goals for our study includes analyzing the change in ER to floor admission times and expanding our initiative to other medical and surgical units in the hospital.