Background: Improvement of discharge times on house staff run medical floors is particularly complicated. Amato-Vealey et al. describe a domino effect of delayed discharges resulting in inability to transfer patients from intensive care units, advancement towards maximum capacity, and failure to move patients from the ER. This leads to delayed procedures, poor patient satisfaction, and increased handoffs. Additionally, resident run floors have frequent handoffs, mandatory educational conferences, and duty hour limitations. These obstacles result in delayed discharges on house staff run floors and we recognized an opportunity to address this problem.
Purpose: Early discharges on the house staff floor averaged 11% prior to our intervention. Similar non-telemetry medicine floors run by nurse practitioners had an average early discharge rate of about 20%. We suspected that mandatory academic conferences and longer rounding times for teaching purposes contributed to the difference in discharges prior to 2 pm. We hoped that with improvement of the discharge process we could improve the early discharge rate without preventing residents from attending academic conferences. An increase in the number of early discharges could improve the time it takes to move admitted patients from the ER to the floor, downgrade patients from the ICU, and discharge patients home. Additionally, patients that leave the hospital earlier could have the opportunity to pick up medications or obtain medical equipment during regular work hours and this may reduce need for ER visits or calls to the hospital after hours.
Description: We met with nursing and physician leadership to devise a plan to improve discharge times without compromising the academic value of work rounds. Each day, chief residents asked teams on the geographic house staff floor to identify two patients for discharge prior to 2 pm the following day. A “prepare for discharge” order was placed in the EMR to facilitate communication between residents, nurses, case managers and attendings to ensure all are aware of the pending discharge. Finally, discharge paperwork and planning were completed the evening prior to discharge and the identified patients were seen first on the morning of discharge.The number of discharges on the house staff run geographic floor at our institution, which is a 33 bed non-telemetry floor run by two teams, averaged 11% from January to July 2019. In comparison, non-telemetry floors covered by NPs had an average 2 pm discharge rate of 20%. Post intervention, the resident run floor achieved a 2 pm discharge rate of 11% in September and 26% in October. Early data from the month of November suggest residents have achieved an early discharge rate of 30%.
Conclusions: We targeted early discharge for several reasons including delayed admission and treatment of patients. Early discharge gives patients the opportunity to fill medications and address post discharge questions during traditional work hours. By identifying two specific patients, we optimized efforts to discharge these patients on time. Although we succeeded in improving the rate of discharges prior to 2 pm, we received feedback that paperwork demands led to increased stress and missed academic conferences. Data collection is ongoing as are efforts to incorporate this process so it does not negatively affect resident education.