Background: Persistently high hospital volumes, increased patient complexity, and lack of skilled nursing bed availability have led to significant bottlenecks in care and decreased inpatient bed availability. A hospital-wide initiative was created to increase the rate of discharge before noon (DBN). To meet discharge targets on hospital medicine units, we formed a multidisciplinary quality improvement (QI) team with hospitalists, nursing leaders, social workers, case managers, and pharmacists.

Purpose: To increase the rate of DBN by using QI methodology to identify barriers to early discharge and implement interventions.

Description: We used Six Sigma methodology to analyze the inpatient discharge process and understand barriers to early discharge. Stakeholder input and process mapping highlighted areas of opportunity for improvement. Multiple interventions were designed, and pilots were conducted in Plan, Do, Study, Act cycles. Two of the most successful interventions were the afternoon E-huddle and discharge “Power Hour”. Afternoon E-huddle Morning multidisciplinary rounds are an essential part of discharge planning. However, there was no standardized method for the multidisciplinary team to touch base again in the afternoon with updates and plan for the next day’s discharges. Several units piloted different versions of afternoon huddles, and the most successful version was an “E-huddle” utilizing a secure chat function in the electronic health record (EHR). The success of this pilot led to rapid adoption across the other units. Every afternoon, the unit coordinator initiated an EHR secure chat with the hospital medicine team, social worker, case manager, and day and night charge nurses. Secure chat was used to identify patients discharging the following day, time of discharge if known, and any discharge-related tasks that could be prepared in advance. The teams considered this an easy medium for communication that did not disrupt workflow, which led to successful adoption across the hospital medicine units. Power Hour The typical hospital medicine workflow was to round on all patients prior to completing discharge tasks, making DBN an infrequent occurrence. The Power Hour intervention flipped the typical workflow so discharging patients were seen first and paperwork completed within the first hour of the day. Feedback from piloting providers was positive, with many noting that the Power Hour allowed more effective prioritization of morning workflow and triage of patient needs. It was subsequently disseminated broadly to additional inpatient medical teams and evolved to encourage discharge preparation well in advance, rather than as a discrete duty to be performed the morning of discharge.

Conclusions: Implementation of the E-huddle and Power Hour interventions into the inpatient hospital medicine practice was associated with an increase in DBN percentage from a baseline of 20.9% in 2019 to a maximum DBN of 28.1% in March 2021 (Figure). There was a slight decline in DBN in the last two months of the intervention (May and June 2021), which may have been related to exceptionally high inpatient volumes. Equally as important as the results, these discharge initiatives restarted the conversation and raised awareness around the importance of discharging patients in a timely fashion.

IMAGE 1: Discharge Before Noon (DBN) rates on hospital medicine units