How one hospital made its DP more efficient
Add p.m. rounds and physician extenders
Hospitals can improve their discharge process by taking a close look at the units where discharges tend to create bottlenecks and marketing process changes to physicians and staff.
Discharge planners can assist with process changes by educating themselves about ways other organizations have improved their discharge process and collecting data about the times that pose the most discharge challenges within their own hospitals.
Two experts offer these suggestions for how to improve your hospital's discharge process:
1. Collect comprehensive data on discharge times.
During a pilot phase of changing the discharge process, Children's National Medical Center in Washington, DC, used a tracking tool to collect information about discharge times, says Kathleen Rigney-Radford, RN, MSN, CCM, manager of case management.
"The charge nurse or bedside orderly would write down who the patient was, what time they were supposed to leave, and then indicate if they left within 30 minutes of the set time," Rigney-Radford says. "Then, if the patient did not leave within 30 minutes of when they were supposed to, they'd indicate why."
Rigney-Radford found that staff often would not answer the question about why a patient was not discharged on time, although they supported efforts to streamline the discharge process.
"It'd get hectic and they'd forget, and collecting the information was labor intensive," Rigney-Radford says. "The transparency of being able to plan when patients were close to going home and to organize their care was seen as valuable by the staff and also by the administrative directors who would come around and say, 'So at 11 o'clock, you think you'll have four beds available?'"
2. Add afternoon rounds to discuss patient discharges.
One of the obstacles to discharging patients earlier in the day was that patients often needed lab work, medication observation, and other things done before discharge, so the discharge would be pushed back to the next day.
One way to avoid this obstacle is by having afternoon rounds where physicians would start patients on their transition diet or order lab work for that night instead of waiting until the next day, Rigney-Radford says.
"This shifted things around, and they were doing the discharges in a more timely fashion," she adds.
Physicians had thought the rounding would take too much time, but that proved not to be the case with the surgical afternoon rounds, she notes.
"Their afternoon rounds take five to 10 minutes tops," Rigney-Radford says. "They give a highlight on the status of the patient and what can be done to move the patient."
During the afternoon rounds, physicians discuss with case managers and nurses which patients might be ready to return home the next day and what needs to be done to expedite the process, she adds.
Since the hospital has a priority discharge process, a physician has the option of discharging a patient first thing in the morning, Rigney-Radford says.
"The physician could get the paperwork done the night before, and that's a way to fast-track the whole process," she explains. "A limited number of patients qualify for priority discharge, but when they do, it can be wonderful for the family and staff, and the medical team doesn't have to include that patient in the rounds in the morning."
The hospital's staff liked the afternoon rounds because they improved patient flow and continued discharges through the evening when there was more access to patients' family members, says Mary Daymont, RN, MSN, CCM, CPUR, director of clinical resource management at Children's National Medical Center.
"Since we rolled this out hospital-wide, we've already seen a 14% improvement in discharges before 3 p.m., so we're happy about that," Daymont says.
The average length of stay also has dropped slightly, and these changes occurred hospital-wide within a couple of months, she adds.
3. Add physician extenders to assist with discharge process.
"We supported a budget process to add physician extenders to every unit in service except endocrinology, hematology, and neurology, which didn't think they needed it because their services were so small," Daymont says.
Physicians and physician trainees focus on the acute patient who is admitted to the hospital and who needs immediate attention, Daymont says.
So, they spend less time anticipating patients' discharge and thinking about the discharge process.
While beginning afternoon rounds was one way to focus attention on the discharge process, another way is to hire a trained professional specifically for working on discharge planning. The Children's National Medical Center chose to hire physician extenders, including nurse practitioners and physician assistants, to work in the afternoon on discharges.
"Having physician extenders available in the afternoon keeps the discharge process flowing while physicians and physician trainees are involved in academic activities," Daymont says.
"The residents have a lot of competing priorities," Rigney-Radford says. "It's really nice when physician extenders have their sole focus on doing patient care."
4. Communicate discharge times to patients and staff.
One of the initial and successful process changes the hospital developed was a dry-erase white board to place in each patient's room for the purpose of communicating discharge criteria and time.
Written, the board might be: "I can go home when I don't have a fever," for instance, Daymont says. "At the bottom, we put the discharge date and time."
The white boards in the rooms gave families a clearer idea of expectations, such as how the child wouldn't be discharged until the third dose of antibiotics had been administered.
"These boards were very helpful in not only putting family members in the loop, but also as a helpful daily reminder for everyone on the team to think about the discharge time," she adds.
The discharge times were scheduled with input from the families about their own schedules. For instance, parents might ask for a 4 p.m. discharge so they have time to pick up another child from school, Daymont says.
5. Adjust discharge changes as hospitals' needs, circumstances change.
When the children's hospital opened a new tower in 2007, the discharge planning changes needed to be adjusted to accommodate a new reality.
For example, the new tower did not permit white boards to be placed in patient rooms, and the new tower was more decentralized, with nurses working independently in stations, Daymont says.
Rather than have scheduled discharge times, the hospital moved to discharge predictions, a labor-intensive and manual process that involves use of a tracking sheet by case managers, Rigney-Radford says.
"Case managers use the tracking sheet to identify the discharges planned for that day," she explains. "They're supposed to indicate whether they think the patient will leave before 3 p.m. or after 3 p.m."
At the afternoon rounds, the case manager can validate whether the patient left, and each case manager will submit by e-mail to nursing managers and executive leaders the planned and possible discharges for the day, she adds.
Hospitals can improve their discharge process by taking a close look at the units where discharges tend to create bottlenecks and marketing process changes to physicians and staff.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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