Impact of Admission Nursing Team on Timely Inpatient Discharge in Acute Hospital Care Setting

Background:

Emergency Department (ED) overcrowding and delays in ED throughput have several important consequences , such as boarding of admitted patients in the ED, longer hospital stays and delay in effective inpatient discharge planning (1).

Longer ED boarding time and delay in inpatient discharge process are parts of a vicious cycle of internal bottleneck contributing to hospital overcrowding and jeopardizing patient safety. (1)

 As this is a constant focus of “ process improvement projects” among most hospitals in USA, a common consensus is that the work towards an effective and early discharge  should begin upon admission.(2)

In this study, we aim to show if an intervention of  “admission cohorting team ” comprised of 2-3 registered inpatient floor nurses (assigned to report to ED and start admission process form the ED ), a triage physician (who coordinates with the ED and lets the admission nursing team know about an admitted patient located in ED), can potentiate early patient discharges from the hospital floor.

Methods:

At the Johns Hopkins Bayview Medical Center, we have launched a pilot project by incorporating “admission cohorting team” dedicated to one hospital floor, and collected prospective data for all patient discharges for the consecutive 8 months after launching this program on the floor.

We have also collected data for all patient discharges from other floors, where there was no “admission cohorting team” activated and patients were received through usual ED to floor transport system.

Results:

We have applied the statistical software R version 3.2.2 to calculate the frequency of the fraction of patients discharged before 2 pm from the intervention and control floors.

The table below shows the total number of patients admitted under observation on floors X (intervention floor), Med  A and B (Control Floors) and the number of patients discharged before 2 pm from these 3 inpatient units over the period of 8 months.

The attached Days_vs_fracBefore2PM* plots show the frequency of the fraction of patients discharged before 2 PM, separately for Floor X (the intervention floor), Med A and Med B. Clearly, the Floor X plot peaks at a larger value of the fraction than the other two. Here is some quantification of the differences:

 Defined average fractions f = (discharged before 2 PM)/total for the 8-month period between September 2013 and April 2014.

 f:

  FloorX: (40.3 +/- 2.4)%

  MedA: (20.8 +/- 2.3)%

  MedB: (20.9 +/- 2.4)%

 p-values for the difference in f:

  MedA, MedB: 0.97 (as expected, there is no difference between the two control samples)

  FloorX, MedA: < 2.2e-16

  FloorX, MedB: < 2.2e-16

 The <2.2e-16 value is the smallest float the R system reports, which can also be reported as

 p < 0.001, meaning that the improvement in f is statistically very significant.

Conclusions:

The analysis clearly shows significant improvement in early discharges of observation patients after initiating the pilot project of “Admission Cohorting Team” in Floor X.