The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients

Many hospitals and emergency departments (EDs) face challenges posed by overcrowding and hospital throughput. Slow ED throughput has been associated with worse patient outcomes.¹ One strategy increasingly employed to improve hospital throughput is to increase the rate of inpatient discharges earlier in the day, which is often defined as discharges before noon (DCBNs). The hypothesis behind DCBN is that earlier hospital discharges will allow for earlier ED admissions and thus mitigate ED overcrowding while optimizing inpatient hospital flow. Previous quality improvement efforts to increase the percentage of DCBNs have been successfully implemented. For example, Wertheimer et al. implemented a process for earlier discharges and reported a 27-percentage point (11% to 38%) increase in DCBN on general medicine units.² In a recent survey among leaders in hospital medicine programs, a majority reported early discharge as an important institutional goal.³

Studies of the effectiveness of DCBN initiatives on improving throughput and shortening length of stay (LOS) in adult patients have had mixed results. Computer modeling has supported the idea that earlier inpatient discharges would shorten ED patient boarding time.⁴Wertheimer et al. performed a retrospective analysis of a DCBN intervention on two inpatient medicine units and reported an association between slightly shorter observed versus expected inpatient LOS² and earlier arrival time of inpatient admissions from the ED.⁵ In contrast, Rajkomar et al. conducted a retrospective analysis of the association of DCBN and LOS in a predominantly surgical services population and reported a longer LOS for DCBN patients when controlling for patient characteristics and comorbidities.⁶ These mixed findings have led some authors to question the value of DCBN initiatives and created concern for the potential of prolonged patient hospitalizations as a result of institutional DCBN goals.⁷ The impact of DCBN in pediatric patients is much less studied.

A question of interest for hospitals is if DCBN is a good indicator of shorter LOS, or is DCBN an arbitrary indicator, as morning discharges might just be the result of a delayed discharge of a patient ready for discharge the prior afternoon/evening. Our study objectives were: (1) to determine whether DCBN is associated with a shorter LOS in a pediatric population at an academic medical center, and (2) to examine separately this association in medical and surgical patients given the different provider workflow and patient clinical characteristics in those groups.

Patients and Settings

This retrospective cohort analysis included pediatric medical and surgical inpatient admissions from a single academic medical center from May 2014 to April 2017. The University of North Carolina (UNC) Children’s Hospital is a 175-bed tertiary care ‘hospital within a hospital’ in an academic setting with multiple residencies. UNC Children’s Hospital contains three units providing inpatient pediatric care. Each unit occupies a floor of the Children’s hospital and are loosely regionalized, as follows: (1) Unit 7 is focused on surgical patients; (2) Unit 6 is focused on general, neurologic, and renal patients; and (3) Unit 5 is focused on hematology/oncology and pulmonary patients. Extending the entire study period, Unit 6 initiated a quality improvement effort to discharge patients earlier in the day, specifically before 1 pm; however, the initiative did not extend beyond this one unit.