The Earlier, the Better

The Hospitalist. 2011 October;2011(10):

October 1, 2011 | The Hospitalist

Dr. Wilson

“One of the biggest factors for readmissions are things like pharmacy errors, and lack of follow-up, and other loose ends that, if you’re in too much of a hurry to get people out and you don’t have the whole team approach and make sure all your I’s are dotted and T’s are crossed, then they have an increased chance of coming back,” Dr. O’Boyle says. “So we focus on patient satisfaction, and we focus on the discharge day and the discharge time to prevent readmissions and to maximize patient satisfaction. That’s the bottom line for the hospital…It’s interesting how the bottom line seems to follow quality.”

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Helpful Hints

1. Hold discharge conferences. Hospitalists can’t determine a patient’s readiness for discharge in a vacuum. Pre-discharge meetings with nurses, case managers, pharmacists, and other health professionals can make sure every stakeholder is working toward the same goal. Consider scheduling conferences the day before discharge to reduce time pressures.

2. Start at admission. The axiom that discharge begins at admission is true for a reason. Dr. Nelson suggests making a habit of forecasting a discharge day in a chart’s order section, not just in the progress report section, to ensure the planned-for date is seen by all parties.

3. Do it today. Putting together discharge notes the night before certainly makes for a longer shift, but it can save valuable time the next morning. Consider cases in which compiling the discharge notes the day before can highlight a final test or procedure that should be ordered. In those instances, waiting until the morning to begin that process would undoubtedly delay the eventual discharge until later in the day.

4. Early birds get the worm. The first shift for HM groups often starts between 8 a.m. and 10 a.m., so consider having a physician start their shift earlier to focus on discharges before rounding and other clinical responsibilities.

Inherent Conflicts?

Early-day discharge actually can be a bad thing in some cases, Dr. Nelson says. Think of a case in which a patient might be ready for discharge in the late evening or during an overnight. To wait until the morning to send that patient home might not be the best approach.

The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.

—Louis O’Boyle, DO, FACP, FHM, medical director, Advanced Inpatient Medicine, Honesdale, Pa.

“The place that manages length of stay most efficiently probably has plenty of late-day discharge,” he says.

Another potential conflict getting in the way of early-day discharge is what Dr. Wilson calls “admission competition.” For example, a hospitalist is working on discharge papers early in the morning but is then called away for a consult on an acute-care case in the ED or elsewhere. Each of the duties is important, but conflicting duties leave the hospitalist having to make choices.

“It’s not all straightforward,” Dr. Nelson says.

Emergency Nurses Association President AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, says that collaboration between nurses and physicians is an answer to such competition. Calling the problem a “wrinkle across the system,” Papa says that without hospital administrators taking point and declaring the issue of discharge a priority, little wholesale improvement will be made. Even then, physicians and nurses—as the two main groups interacting with the patient—have to work together, she adds.

“Hospitalists have to partner with nurses,” Papa says, imploring physicians and nurses to work together on discharge decisions. “If the physicians and nurses collaborate on the decision and plans of care for the patients and the care they’re giving them and the discharge instructions, then it’s a win-win for everybody.”