Anticipated discharge date improves throughput
St. Joseph's takes three hours off average discharge
By assigning an anticipated date of discharge to every patient within 24 hours of admission, the clinical resources management staff at St. Joseph's Hospital in Tampa, FL, have been able to shave three hours off the hospital's average discharge time, freeing up beds and dramatically decreasing the amount of time patients wait for a bed in the emergency department.
Before the hospital initiated the procedure in January 2008, the average discharge time was about 5 p.m. In just over a year, the average time moved to 2 p.m. and was moving toward 1 p.m. The goal is for discharges to occur by 11 a.m.
The key to the process is assigning an anticipated date of discharge to every patient within 24 hours of admission, says Denita Todd, RNC, MSN, director, clinical resource management.
"The process gets us organized and focused on the discharge. A lot of our success is due to thinking ahead. Instead of being reactive, we're proactive. We no longer are rushing around, tying up loose ends at the last minute," she says.
At St. Joseph's Hospital, case managers, called clinical resource managers, are assigned by unit and have a caseload of about 30 to 35 patients. Social workers carry a caseload of about 40 patients. A case management assistant, previously an admitting representative, works with the team to issue the second Important Message from Medicare notices.
The department has two part-time physician advisors.
CM assigns anticipated date upon admission
When patients are admitted, the clinical resource manager assigns an initial anticipated date of discharge based on the hospital's mean length of stay for the patient's admitting DRG.
The hospital's electronic case management system generates a form in the patient chart for the admitting physician to review within 24 hours.
The physician has the option of signing off on the anticipated discharge date, assigning a new date, or indicating that the anticipated discharge date is unknown. In the latter case, the clinical resource manager periodically reviews the case, depending on the patient's diagnosis and progress, and sends the physician an updated anticipated date of discharge.
If a physician hasn't signed the anticipated day of discharge sheet within 24 hours, the staff nurse touches base with the doctor.
The clinical resource management staff conducted extensive education with the physicians, both at the hospitalists' quarterly meetings and one on one.
"We show them how the process helps them be more organized and get their patients discharged quicker," Todd says.
Three hospitalists groups, one of which is made up of hospital employees, admit about 70% of the patients in the hospital.
"The hospitalists have assisted us in getting the process going," she says.
Social workers, CMs team up
When patients are admitted to St. Joseph's, social workers screen them for discharge needs and collaborate with the clinical resource coordinators to determine if the patient is likely to need home health or extended post-acute care.
Three days before the anticipated discharge date, the team uses that information to develop the patient's final discharge plan.
"We pull out the information on the initial discharge screen, compare it to the patient's progress and condition, and update it if needed," Todd says.
If the patient needs a referral for post-acute care, durable medical equipment, or home health services, the software generates the orders and forwards them to the physician to review and sign.
The goal is to have the physician sign the orders within 24 hours so that all orders for post-discharge needs are in place 48 hours before discharge.
"Once we get the three-day preplanning orders on the chart, the team knows what they need to work on to facilitate the discharge, whether it's to make a referral to a skilled nursing facility or to pull in the home health coordinator," Todd says.
In the past, it wasn't unusual for the social workers to get orders for home health at the last minute and spend a lot of time scrambling to get the service in place with the patient staying in the hospital until 6 p.m., Todd reports.
"Now if all goes well, we have authorization for home health the day before discharge and we can get it set up in a timely fashion," she says.
The clinical resource coordinator, the social worker, and the charge nurse on each unit meet in the morning and afternoon for a discharge huddle.
"These disciplines are the key players on the team. On occasion, other disciplines participate if needed," she says.
In the morning huddle, the team talks about that day's discharges and what barriers they need to overcome for the discharge to take place. During the afternoon huddle, they discuss the next day's discharges and what needs to happen. The charge nurse has the responsibility of seeing that whatever tests, procedures, test results, or consultations necessary for discharge are fulfilled.
The nurses and clinical resource coordinators start telling the family to plan on taking the patient home two days in advance.
"We ask our medical staff what time they plan to be rounding so we can give the family members an idea of when the patient will be ready to go home. Some physicians are predictable and make the rounds at the same time each day. We check with the others to find out a time," Todd says.
The team gives the family an anticipated discharge time and asks them to be at the hospital an hour in advance so the nurses can go over the medications and post-discharge treatment plan.
"We do education all along with the patient and family, but we go through the medication recommendations the hour before discharge so it will be fresh in their minds," she says.
The team calls the family again the day before and reminds them what time they should be at the hospital.
Knowing the time the physician plans to makes rounds also facilitates the discharge process, Todd points out.
"We have all the paperwork ready and all the doctor has to do is check the record, talk to the patient, and sign the discharge orders," she says.
Census activity worksheet also implemented
At the time the hospital rolled out the new discharge planning process, it also implemented a census activity work sheet that allows everyone on the unit to see a list of all current patients and their anticipated date of discharge.
"Everyone can quickly see which patients are scheduled to go home the next day and use the information to set priorities and organize their day," Todd says.
For instance, if the nurse sees that a patient's anticipated day of discharge is approaching, he or she knows to step up the education and start talking to the family about transporting the patient home.
By assigning an anticipated date of discharge to every patient within 24 hours of admission, the clinical resources management staff at St. Joseph's Hospital in Tampa, FL, have been able to shave three hours off the hospital's average discharge time, freeing up beds and dramatically decreasing the amount of time patients wait for a bed in the emergency department.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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