Hospitalist Perceptions of Barriers to Discharge

Background:

Our employed Hospitalist practice in a large academic medical center has been asked to assist with Emergency Department throughput by increasing the number of discharges by noon. Retrospective data analysis of our group showed that less than 20% of our physician discharges are before noon. To further analyze, we looked at discharge data from our primary geographic unit where we staff over 75% of unit patients. The unit is staffed by a new hospitalist each week. New patients are largely received from the Emergency Department, Intensive care unit and step down units. Patient transitions occur from admitting to unit rounding provider and at physician weekly shift transitions. Unit data revealed that approximately 22% of the practice’s patients on that unit are discharged at the physician’s first visit and 7% at the second visit. If this data is extrapolated to the entire practice and physician shifts transitions are accounted for, this number will be much higher.

Purpose:

Before we put forth solutions, we set out to understand provider perception of barriers to efficiently discharging patients new to them: new encounter inertia¹. Specifically, we wanted to understand providers’ satisfaction of discharge related communication and discharge preparation prior to patient handoffs.

Description:

A survey was sent to 33 physicians. The survey assessed the percentage of time physicians perceived that specific vital steps in discharge were performed at the time of service change in addition to overall satisfaction, barriers to discharge, and ways to overcome new encounter inertia.

Response rate was 51% (17/33). 47% of respondents were dissatisfied or very dissatisfied with discharge-related handoffs. Communication regarding upcoming discharge was reported at a median of 50% (range 15-80%) for patient/family and 75% (range 25-90%) for oncoming providers.

Making appointments and initiating discharge paper work were perceived to occur less frequently at 20% and 30% respectively. When provided with potential barriers, lack of adequate communication to patient/family (35%) and patient being new to the discharging team (35%) were identified as the most frequent barriers to efficient discharge. When questioned about what would have the most impact on overcoming new encounter inertia, 53% responded increased discharge preparation and 12% increased communication.

Conclusions:

Almost half of the respondents are dissatisfied or very dissatisfied with discharge-related handoffs. Although communication (to oncoming providers and patient/family) regarding impending discharges seems to happen the majority of times, it was identified as a significant barrier to timely discharges. This could mean that discharge related communication is extremely important for discharge efficiency. In addition, discharge preparation prior to patient transition seems to be key for efficient discharges. We believe that suitable solutions can be developed by obtaining feedback from providers when concerning provider workflow. As a result, our practice is developing standard expectations for communication and preparation for discharge at the time of any service change.

References:

1.  H.J. Cho, MD, N. Desai M, A. F. Florendo, MSN, FNP-C, C. Marshall, MSN, ANP-BC, J. J. Cutson, PA-C, N. J. Lee, A. S. Dunn, MD, FACP S. E-Dip: Early Discharge Initiation Project. an Innovative Model for 1-Day Admissions and Throughput – SHM Abstracts. SHM Annual Meeting 2014.