Background: Early morning patient discharge is increasingly being recognized as a key dimension of quality care. Late discharges are associated with hospital overcrowding, delayed inter-unit patient transfers, lower patient satisfaction and longer emergency room length of stay (1). At our institution there is a significantly lower early discharge rate on teaching hospitalist teams in comparison to non-teaching services, which can be contributed to different barriers on respective services (2). We studied the effect of a resident-driven intervention in the teaching medical services to increase overall discharge order rate before 11 AM (DOB-11) and assess the effect of this intervention on hospital length of stay (LOS), 30-day readmission rates (RR) and resident perception.
Methods: Our discharge protocol consisted of an educational didactic in conjunction with resident-attending walking rounds followed by resident-led multidisciplinary discharge huddle to identify next day discharges. The educational workshop emphasized the importance of early discharges and the impact on quality of patient care. Resident-attending rounds identified early next day discharges, and the multidisciplinary discharge huddle alerted all ancillary staff so any potential barriers could be identified and solved. The study was conducted using interrupted time series as well as controlled before-after designs with a primary outcome of DOB-11 rates 18 months pre- and 12 months post-intervention. Secondary outcomes included LOS and RR. In addition, resident perception of the early discharge protocol was assessed.
Results: The DOB-11 rate increased from 12% to 29% (p<0.001), LOS increased by 1.471 days (P<0.001), and RR increased by 0.318% (P=0.8377), respectively on the teaching teams. Compared to the non-teaching (control) teams, the teaching teams registered a greater increase in DOB-11 rate (17.05% more increase, p<0.001; ratio of adjusted ORs: 2.164; 95% CI, 1.646, 2.845; p-value<0.001) and small increase in LOS (0.742 day more increase, p=0.3925; ratio of adjusted post-/pre intervention ratio (teaching) and post-/pre intervention ratio (non-teaching) =1.048, 95% CI, 0.967, 1.137, p=0.2246). Approximately 55% (16/29) of the residents agreed that the early discharge initiative helped in understanding the importance of prioritizing patients for early discharge. Additionally, 55% (20/36) of the residents ‘agreed’ that the early discharge initiative compromised their learning during teaching rounds.
Conclusions: Our study demonstrates that DOB-11 is an achievable goal, not only for non-teaching teams but also for resident-run teaching teams. However, this may be to the detriment of resident education.