Background: At our institution, late discharge times and low rates of discharge before noon (DBN) have historically been associated with bottlenecks and delays in patient care. During the COVID-19 pandemic, changes in hospital census and staffing further increased the need for efficient and safe patient discharges. To address these barriers, we formed a multidisciplinary quality improvement (QI) team during the COVID-19 pandemic to improve DBN and early hospital discharges.
Methods: The QI team was comprised of Hospital Internal Medicine (HIM), nursing leaders, pharmacists, social workers, and case managers. We performed process mapping, stakeholder interviews, and observed the discharge process to identify barriers to DBN. This effort identified crucial steps in early discharge planning: notifying patient of discharge time, arranging transportation, and advanced preparation of paperwork and prescriptions. Baseline analysis showed patients discharging home (self-care or with services; grouped as “home discharges”) had a lower DBN rate compared to that of all discharges, representing a key group for targeted interventions. We created a pilot Discharge Coordinator (DisCo) position to facilitate early discharges from HIM services. The DisCo was a HIM nurse practitioner or physician assistant who assisted with the following tasks: visits with patients to review the discharge plan (Figure 1), preparation of discharge paperwork or prescriptions, and ad hoc tasks requested by the primary team. The DisCo tracked their level of assistance with discharge preparation, divided into categories of “direct” (face-to-face visit) and “indirect” assistance. Outcomes from the intervention period (June 1, 2020 through July 31, 2020) were compared with the pre-intervention period (January 1, 2020 through March 31, 2020). The primary outcome was the percentage DBN; the secondary outcome was the average time of discharge.
Results: There were 1029 home discharges in the pre-intervention period and 743 in the intervention period (Table 1). The DBN percentage of all home discharges did not change significantly between the two periods (14% vs 15%). However, the 173 patients who received DisCo assistance did have a significantly higher percentage DBN than those without DisCo help (21% vs 14%, p=0.012). Subgroup analysis of DisCo patients also showed a statistically significant difference in DBN between those who had a direct visit with the DisCo and those who received indirect discharge assistance (28% vs 15%, p=0.045). Similar patterns were seen in average discharge times. Average discharge time in all patients going home improved by just 3 minutes in the intervention period compared with pre-intervention baseline. However, there was a 39-minute improvement in the intervention period when assessing discharges assisted by the DisCo. This effect increased to a 73-minute improvement when narrowed to only patients who received direct assistance from the DisCo.
Conclusions: The DisCo role did not result in large scale improvements in global discharge metrics; however, the role was successful when working directly with patients and families. Informal patient feedback showed a high level of satisfaction with DisCo visits. DisCo effectiveness was limited by patient selection and complexity of certain indirect discharge-related tasks, but primary teams appreciated the assistance.
