Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge

It is difficult to compare our EDC improvements to those of previous studies, as we are unaware of published data on pediatric EDC efforts across an entire hospital. In addition, studies have reported discharges prior to different times in the day (noon, 1 pm, etc).^{12, 13} Our interventions were similar to those of Wertheimer et al.,¹¹ including the use of interdisciplinary rounds, identification of potential EDCs the afternoon before discharge, and “reward and recognition.” Wertheimer also sent an e-mail about EDCs to a multidisciplinary group, which was then updated as conditions changed. Unlike Wertheimer, we did not include physicians in our e-mail due to the large number and frequently changing physician teams. Our EDC rate prior to 11 am was lower than their achieved rate of 35% prior to 12 pm. When we assessed our discharges using 12 pm, our rate was still lower (22%-28%), but a direct comparison was complicated by different patient populations. Still, our study adds to the evidence that interdisciplinary rounds and reward and recognition lead to earlier discharge. In addition, this study builds upon Wertheimer’s results as although they later assessed the timing of ED admissions as a result of their EDC improvements, they did not directly assess inpatient bed wait times as we did in our study.¹⁴

As providers of all types were aware of the constant push for beds due to canceled surgeries, delayed admissions and intensive care transfers, and the inability to accept admission, it is difficult to compare the subgroups directly. Furthermore, although physician teams and units are distinct, individuals (nurses, case managers, trainees) may rotate through different units and teams and we cannot account for individual influences on EDCs depending on exposure to interventions over time. Although all groups improved, the improvement in slope in group 4 (exposed to interventions 1 and 3) was the only significant change. As group 4 contained a large number of surgical patients who often have more predictable hospital stays, perhaps this group was more responsive to the interventions.

Our EDC improvements were associated with a decrease in ED and PACU bed wait times. Importantly, we did not address potential confounding factors impacting these times such as total hospital admission volumes, ED and PACU patient complexity, and distribution of ED and PACU admission requests throughout the day. Modeling has suggested that EDCs could also improve ED flow,⁷ but studies implementing EDC have not necessarily assessed this outcome.^10-15 One study retrospectively evaluated ED boarding times in the context of an EDC improvement effort and found a decrease in boarding times.²¹ This decrease is important as ED boarders may be at a higher risk for adverse events, a longer LOS, and more readmissions.^3,7 Less is known about prolonged PACU wait times; however, studies have reported delays in receiving patients from the operating room (OR), which could presumably impact timeliness of other scheduled procedures and patient satisfaction.^22-24 It is worth noting that OR holds as a result of PACU backups happened more frequently at our institution before our EDC work.

Our limitations include that individual providers in the various groups were not completely blind to the interventions and groups often comprised distinct patient populations. Second, LPCHS has a high CMI and LOS relative to most other children’s hospitals, complicating comparison with patient populations at other children’s hospitals. In addition, our work was done at this single institution. However, since a higher CMI was associated with a lower probability of EDC, hospitals with a lower CMI may have a greater opportunity for EDC improvements. Third, hospital systems are more impacted by low EDCs when operating at high occupancy (as we were at LPCHS); thus, improvements in ED and PACU wait times for inpatient beds might not be noted for hospitals operating with a >10% inventory of beds.²⁵ Importantly, our hospital had multiple daily management structures in place, which we harnessed for our interventions, and better patient flow was a key hospital initiative garnering improvement of resources. Hospitals without these resources may have more difficulty implementing similar interventions. Finally, other work to improve patient flow was concurrently implemented, including matching numbers of scheduled OR admissions with anticipated capacity, which probably also contributed to the decrease in ED and PACU wait times.