Background: Prioritizing hospital discharges to improve throughput and safety is a common theme in hospital systems. More recently, there has been an increasing importance placed on early discharges. Earlier discharges help to improve flow for admitted patients through the emergency department. In addition, by expediting patient care, patients are able to have their questions answered by their provider in a timely manner and pick up their medications from their pharmacy during open hours. Expediting hospital discharges improves patient satisfaction scores. Data collected from the HCAHPS survey from 2018 through 2020 at our institution shows that patients discharged before 2 PM recommended the hospital and rated the hospital at higher numbers as compared to those discharged after 2 PM. Previously, when the objective was placed on increasing early discharges, an unfortunate consequence had been an increase in the length of stay.
Purpose: The purpose of this intervention was to create a new interdisciplinary process to increase the number of early hospital discharges without adversely affecting overall length of stay.
Description: Our institution has developed a unit-based model of care delivery involving a multidisciplinary team, focused on throughput and patient safety on the medicine and telemetry floors. This team includes a physician lead (hospitalist), a nurse manager, advanced care practitioners, case managers, social worker, physical therapist, pharmacist, and unit clerk. In addition to morning interdisciplinary rounds on these floors, we standardized brief afternoon rounds to focus on the projected discharges for the following day. The goal of afternoon “huddles” allows for a more educated decision about the likelihood of discharge and informs the key players involved in the discharge process of the pending items needed prior to discharge. Additionally, a “prepare for discharge” order is placed into the EMR to notify everyone involved about the planned discharge. A discharge hotline is called to alert hospital administration of pending testing needed to prioritize the discharge and ensure timely completion of the test. The medical team begins the discharge paperwork, and family is notified in order to prepare for pickup or transportation arrangements. Pharmacy completes any necessary prior-authorization and medication reconciliation. The collaboration with the multidisciplinary team ensures the timely and efficient use of resources. Preliminary data from our institution shows improvement in decreasing excess days with earlier discharges. Excess days per case from June through October 2020 compared to 2019 decreased on average between 0.1 to 0.7 days per case per unit. Five out of the seven units showed an increased percentage of patients discharged before 2 PM as compared to the prior year (absolute increase in rate of 3-6% on average).
Conclusions: Our preliminary data shows an overall improvement in early discharges compared to data from the previous year and in fact and an improvement in length of stay per case. The addition of the brief afternoon huddle, “prepare for discharge” order, and discharge hotline have helped facilitate this process. Our next steps would be to take best practices from the highest performing care model floors to further standardize afternoon rounds and review readmissions data.