Background: As patient turnover increases, inpatients and providers may feel pressure during discharge preparation. Hospitals emphasize early daily discharge to improve throughput and decrease length of stay. At our academic center, providers often report feeling rushed in the 24 hours before discharge. Increased work intensity may contribute to burnout for the interdisciplinary team. Few studies evaluate frontline provider experience during discharge or the factors contributing to pressure in the discharge process. We conducted an observational study using an interdisciplinary lens to identify the frequency of factors that contribute to perceived rush on the day of discharge (PRD).

Methods: We initiated our study with two full-day focus groups that included physician, resident, nurse practitioner, bedside nurse, case manager, social worker, pharmacist, and unit clerk representatives from one teaching unit and two non-teaching units to better understand current state processes. We made a list of “discharge challenges” (DC) that the interdisciplinary team identified as increasing PRD. We developed a tool to track the frequency of DC and collected data via daily observations of interdisciplinary rounds, nurse huddles, and staff interviews over a total observation time of 28 hours.

Results: During the observation period, 139 discharges occurred, and 240 PRD data points were collected. Delays due to insurance authorization and bed availability at outside facilities accounted for 30.5% of PRD. Delay in placing the discharge order/completing the medication reconciliation accounted for 19.6% of PRD. Waiting for consultant recommendations accounted for 15.4% of PRD. Patient/family factors accounted for 11.3% of PRD. Other discharge challenges were low in frequency and are not reported.
We divided the results into modifiable challenges (those that we control) and non-modifiable challenges (those that we do not control.) Waiting for insurance authorization/bed availability was the primary challenge identified as contributing to PRD, but was non-modifiable. Providers reported that they experience a lull prior to authorization/bed availability, and then an intense rush to make discharge arrangements once clearance is obtained. Coordination of orders for discharge/medication reconciliation was the highest frequency modifiable challenge that increased PRD for the interdisciplinary team.

Conclusions: These results will be used to design a provider experience and process improvement project that will target empowering frontline providers to complete medication reconciliation/discharge planning closer to 24 hours prior to discharge to decrease PRD. Optimizing this process will allow for safer transitions of care as providers will have more time to review the discharge plan and medications with patients and improve provider experience by decreasing PRD.

IMAGE 1: Figure 1. Provider Experience: Frequency of Discharge Challenges Contributing to PRD