Background: Earlier discharge time is an important satisfaction metric for patients, maximizes the utilization of hospital beds, and reduces waste and capacity issues in EDs /PACUs. Overall, early discharge represents high-value care and responsible stewardship of a scarce resource. Our healthcare system assessed the discrepancy between bed demand and bed needs, finding 25% of Tuesday through Friday discharges were needed by 11AM to maintain sufficient operations. Our hospitalist program was asked to participate in this project.
Methods: Our institution created a generic workflow wherein providers enter discharge orders prior to 9:30AM and nursing units then discharge patients prior to 11AM. Ideally, patients targeted for an early discharge are flagged by case managers as a “priority” in our EMR the day before discharge. Ancillary services such as physical therapy, specialty pharmacies and phlebotomy prioritize the delivery of care to patients flagged for priority. Our hospitalist service implemented the priority discharge project in several PDCA cycles (Table 1). Each phase had several interventions; each intervention was continued once started.
We used chi-squared analysis to determine the effect of each phase of interventions on the percent of discharges prior to 11AM (DC11%) with comparison to baseline data from the year prior. Only patients being discharged on Tuesday through Friday were included in the analysis. Length of stay (LOS) was also assessed to determine if patients were being held longer to achieve this goal.
Results: We compared a total of 4367 patients pre-intervention and 3718 patients post-intervention, with a significant increase in DC11% from 3.7% to 8.9% (P < 0.001). When broken down by phase, we noted an initial increase in DC11% with subsequent fall. Phase 3 and 4 interventions were successful in improving performance to a peak of 16.3% (see Figure 1). By the last phase of the project, the odds ratio of a discharge by 11AM was OR 5.1 compared to baseline (P < 0.001). Baseline LOS was 5.1 days with no significant change over the project.
Conclusions: Iterative interventions can generate a successful, self-sustained early discharge process without leading to an increased LOS. Daily use of a highly visible tracking tool and a consolidating afternoon phone call with case management on the day prior to discharge are specific interventions with potentially high value in an early discharge project.