Background: Hospital overcrowding and extended Emergency Department (ED) wait times are challenges facing most urban hospitals today. There is growing evidence to show that overcrowding in the ED is associated with increased morbidity, mortality and patient dissatisfaction. To improve overcrowding, hospitals have focused on discharge before noon (DBN) as an impactful and sustainable remedy. While some studies have shown that moving up discharge time by an hour can impact ED boarding time, the effect of DBN on length of stay (LOS) in hospitalized medicine patients has often been questioned. Studies have even shown increased LOS in medical patients who were discharged before noon.
Purpose: The purpose of our initiative was to increase DBN rate to 15% from a baseline of 12.8% in 2021 for hospital medicine patients and to measure its impact on LOS.
Description: After obtaining approval from the hospital Quality Improvement Council, a standardized interdisciplinary DBN planning process was initiated in July 2022. After identifying potential before noon discharges for the following day, case management was tasked with listing patient initials and location on the unit daily management board. An Electronic Medical Record (EMR) chat including the medical team, bedside nurse, social worker, and physical therapist was initiated at 2 PM to confirm the discharges discussed earlier in the day and identify any potential barriers. Delays in testing, bedside delivery of meds and transportation challenges were escalated through appropriate channels by the unit leadership. Physicians or Advanced Practice Providers were asked to place a check mark on the daily management board when discharge was confirmed. Following this confirmation, the bedside nurse provided twenty-four-hour discharge notice to the patient. The following morning teams were encouraged to place discharge orders before 10 AM.
Conclusions: With our standardized interdisciplinary process, we were able to increase the average DBN rate on the hospital medicine service from 12.8% in 2021 and 14.1% in the first six months of 2022 to 21.4% from July through November 2022. Average LOS for 2021 was 7.32 days (Observed/expected (O/E) 1.85) and for January – June 2022 was 7.46 (O/E 1.97). Adjusted LOS is currently available through September 2022, and the average since July is 7.11 days (O/E 1.87). The monthly DBN rate after initiation of a standardized interdisciplinary process has been consistently above 20% with no notable change in the LOS.
