Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge
BACKGROUND: Discharge delays adversely affect hospital bed availability and thus patient flow.
OBJECTIVE: We aimed to increase the percentage of early discharges (EDCs; before 11 am). We hypothesized that obtaining at least 25% EDCs would decrease emergency department (ED) and postanesthesia care unit (PACU) hospital bed wait times.
DESIGN: This study used a pre/postintervention retrospective analysis.
SETTING: All acute care units in a quaternary care academic children’s hospital were included in this study.
PATIENTS: The patient sample included all discharges from the acute care units and all hospital admissions from the ED and PACU from January 1, 2014, to December 31, 2016.
INTERVENTION: A multidisciplinary team identified EDC barriers, including poor identification of EDC candidates, accountability issues, and lack of team incentives. A total of three successive interventions were implemented using Plan–Do-Check-Act (PDCA) cycles over 10 months between 2015 and 2016 addressing these barriers. Interventions included EDC identification and communication, early rounding on EDCs, and modest incentives.
MEASUREMENTS: Calendar month EDC percentage, ED (from time bed requested to the time patient left ED) and PACU (from time patient ready to leave to time patient left PACU) wait times were measured.
RESULTS: EDCs increased from an average 8.8% before the start of interventions (May 2015) to 15.8% after interventions (February 2016). Using an interrupted time series, both the jump and the slope increase were significant (3.9%, P = .02 and 0.48%, P < .01, respectively). Wait times decreased from a median of 221 to 133 minutes (P < .001) for ED and from 56 to 36 minutes per patient (P = .002) for PACU.
CONCLUSION: A multimodal intervention was associated with more EDCs and decreased PACU and ED bed wait times.
© 2019 Society of Hospital Medicine
Improvement Team
In early 2015, we formed a multidisciplinary group inclusive of a case manager, frontline nurses, nurse management, pediatric residents, and hospitalist physicians with support from performance improvement. We periodically included physician leaders from other specialties to help initiate changes within their own clinical areas. Our group used Lean A3 thinking16 to gather information about the current state, formulate the problem statement, analyze the problem, and consider interventions implemented in three Plan–Do-Check-Act (PDCA) cycles. The A3 is a structured tool to analyze problems before jumping to solutions and communicate with stakeholders. We interviewed leaders, nurses, residents, case managers, etc. and observed work processes around discharge. We met weekly to follow data, assess results of interventions, and problem solve.
Barriers and Interventions
The first barrier we identified and addressed was poor identification and shared team mental model of potential EDC patients and lack of preparation when an EDC was identified. In intervention one starting May 2015, charge nurses on Units C, D, and E were each asked to identify one EDC for the following day. The identified patient was discussed at the previously existing afternoon daily unit huddle17 attended by nurse management, case management, and hospitalist leaders. Following the huddle, the resident, NP, or PA responsible for the patient was paged regarding the EDC plan and tasked with medication reconciliation and discharge paperwork. Others were asked to address their specific area of patient care for discharge (eg, case manager–supplies, nursing–education). The patient was identified on the unit white board with a yellow magnet (use of a visual control18), so that all would be aware of the EDC. An e-mail was sent to case management, nurse leaders, and patient placement coordinators regarding the planned EDCs. Finally, the EDCs were discussed during regularly scheduled huddles throughout the evening and into the next day.17
Despite this first intervention, we noted that progress toward increased EDCs was slow. Thus, we spent approximately seven days (spread over one month) further observing the work processes.19 Over five days, we asked each unit’s charge nurse every hour which patients were waiting to be discharged and the primary reason for waiting. From this information, we created a pareto chart demonstrating that rounds were the highest contributor to waiting (Appendix A). Thus, our second intervention was a daily physician morning huddle that the four nonsurgical physician teams (excluding cardiology, hematology/oncology) implemented one team at a time between November 2015 and February 2016. At the huddle, previously identified EDCs (located on any of the five units) were confirmed and preparatory work was completed (inclusive of the discharge order) before rounds. Further, the attending and resident physicians were to see the patient before or at the start of rounds.
Our working group still observed slow EDC improvement and sought feedback from all providers. EDC was described as “extra” work, apart from routine practices and culture. In addition, our interventions had not addressed most discharges on Units A and B. Consequently, our third intervention in February 2016 aimed to recognize and incentivize teams, units, and individuals for EDC successes. Units and/or physician teams that met 25% of EDCs the previous week were acknowledged through hospital-wide screensavers and certificates of appreciation signed by the Chief Nursing Officer. Units and/or physician teams that met 25% of EDC the previous month were acknowledged with a trophy. Residents received coffee cards for each EDC (though not without controversy among the improvement group as we acknowledged that all providers contributed to EDCs). Finally, weekly, we shared an EDC dashboard displaying unit, team, and organization performance at the hospital-wide leader huddle. We also e-mailed the dashboard regularly to division chiefs, medical directors, and nursing leaders.
