Background: Hospitals across the nation are gripped with capacity constraints, and some hospitals have indicated they are operating at “Capacity Disaster” status. It is critical to identify solutions that are beneficial to both hospitals and patients. Destino (2019) indicated that early discharges help decrease emergency department and post-anesthesia care unit hospital bed times. The Reverse Rounding (RR) model is a relatively unknown process that can address capacity and health equity. RR is a process whereby the primary team identifies patients stable for discharge the following day, works with a multidisciplinary team to coordinate all elements of the discharge, and prioritizes rounding on the selected patients early the following day to facilitate early discharge. In this manner, the teams are able to ensure patients are discharged before noon (DCBN) and more importantly, vulnerable patients are set up with resources to thrive on discharge.
Methods: This pilot project is a single center analysis at Penn Medicine involving general medicine patients on a hospitalist team cohorted on a single unit. The study team developed a new workflow for providers, nurses, case managers, social work, physical therapy, and pharmacy. At 2PM the multidisciplinary care team rounds virtually via secure messaging and identifies patients ready for next day discharge. This triggers the team to ensure all follow up appointments are made, prescriptions filled, durable medical equipment (DME) secured, and transportation arranged. The following morning, the provider rounds on the identified patients first, places the discharge order, and is able to discharge the patient before noon. During the first five weeks of the pilot program, data was manually captured including: patient demographic, number of discharge orders before 10AM, DCBN, length of stay, discharge disposition, and barriers to discharge (reasons a discharge was unable to be completed by noon). These data were compared to the weeks prior to intervention.
Results: During the pilot period, 50 discharge opportunities were identified as eligible for reverse rounding. There were 14 (28%) discharge orders placed before 10AM and an additional 12 (24%) placed in the 10AM hour for total of 28 (52%) placed before 11AM. The DCBN rate was 18/50 (36%). Nineteen (38%) were discharged home while the others were discharged to skilled nursing facilities or acute care rehabilitation. 25/50 (50%) of patients had transportation arranged day prior and 47/50 (94%) had all DME needs addressed and completed day prior. When evaluating barriers to discharge, transportation delays (ambulance or family) accounted for 7 discharges not being completed by noon. Comparatively, in the pre-intervention period, discharge orders by 10AM were at 5% and DCBN rate was at approximately 12%. Length of stay (LOS) was improved post-intervention with an average LOS at 7 days compared to approximately 8 days pre-intervention for this specific unit.
Conclusions: The RR intervention led to a marked increase in discharge orders before 10AM, DCBN, durable medical equipment set up by discharge, and overall decreased LOS. This has significant downstream effects on hospital capacity, patient flow, and patient satisfaction. With this collaborative, inter-disciplinary model, all stakeholders were invested in a common goal which led to not only improvements in hospital flow but also ensured patients were set up with medications and equipment. This may be one solution to our nations’ capacity crisis.