Background: The discharge process has been identified as a choke point for efficient patient flow through the hospital1,2. Delayed discharges have been associated with ER overcrowding, increased length of stay, and increased risk for patient harm1-4. Early discharge initiatives such as discharge by noon have been adopted by hospital systems as a way to improve patient flow5,6. One barrier to early discharge often encountered in academic medical centers is final discharge recommendations from consultant physicians. While prior studies have sought to understand early discharge barriers from a primary team or hospitalist perspective, none to our knowledge have evaluated early discharge initiatives from the consultant perspective6. The aim of this study was to survey internal medicine (IM) subspecialty fellows at one large academic medical center to elicit their perspectives on discharge timing.

Methods: This is a survey study in which an 11-question online survey was developed by adopting questions from prior studies evaluating discharge timing6-8. General IM clinical experience, barriers to early rounding, and prioritization of early discharge were analyzed. Email addresses for all IM subspecialty fellows at one large academic medical center were obtained from fellowship program directors and program coordinators. The anonymous surveys were sent to participants via email. Data was analyzed using descriptive statistics.

Results: We received 55 responses from 107 IM subspecialty fellows (51% response rate). 13 respondents (24%) reported working as an IM hospitalist attending prior to fellowship training. 28 respondents (54%) “strongly agree” or “agree” that their fellowship program orientation emphasized the importance of early discharges as a financial metric for the hospital/healthcare system. 39 respondents (71%) “strongly agree” or “agree” that they prioritize seeing potential discharges first when rounding. 29 respondents (56%) “strongly agree” or “agree” that their attendings prioritize early availability/rounding to discuss patients pending discharge. 36 respondents (65%) “strongly agree” or “agree” that insufficient labs/imaging, unexpected findings, and/or changes in clinical status requiring longer length of stay often arise leading to discharge delays. Less than half of the respondents (n = 21; 40%) “strongly agree” or “agree” that their specialty has a clear process for expediting discharge recommendations and formalizing clearance for discharge in order to expedite early discharges. 14 respondents (26%) “strongly agree” or “agree” that patient discharges are often delayed because the process to arrange follow up for their specialty is not clear/complete. Morning clinic (n=19; 35%) and didactics (n=18; 33%) were noted as the two main barriers preventing fellows from completing inpatient rounds prior to noon.

Conclusions: IM subspecialty fellows have awareness of early discharge prioritization but opportunity exists for further education and improved processes for early discharge. Creating a formalized system to finalize consultant discharge recommendations and outpatient follow up could lead to increases in early discharge and subsequently improve patient flow through the hospital. Efforts to modify morning clinic and academic obligations for IM subspecialty fellows should also be considered, as these are identified barriers to the early discharge process.

IMAGE 1: Specialty Training

IMAGE 2: Survey Results