A Quality Improvement Project to Improve Discharge Before Noon at a Children’s Hospital

From the 2022 HVPA National Conference

Logen Breehl DO (Akron Children’s Hospital), Marshall Leland DO, Allison Schule MD, Brittany Potts MD, Karen Willis MD, Samantha Gunkelman MD, Karan Johnson MSN RN, Angela Contant MSN RN, Prabi Rajbhandari MD

Background

The discharge process of hospitalized children may be delayed due to various non-medical reasons, which creates overcrowding in the hospital. Even though patients may be medically ready discharges typically happen in the afternoon, given the need for rounding in the morning. This creates a mismatch between demands and supply and hence overcrowding in hospitals. Providers should discharge patients when they are medically ready. Timely discharge is known to improve patient throughput and improve patient satisfaction.

Objective

To increase the “early discharge” rate of patients on the pediatric hospitalist medicine (PHM) service by 5%, (from 27% to 32%) by December of 2022.

Methods

A Quality Improvement (QI) team of residents, hospitalists, bedside nurses, nursing supervisors, case managers, and clinical care coordinators convened together in January 2021. The model for improvement was chosen as the methodology for the project. Our primary outcome was increasing the “early discharges” within the PHM service. “Early discharge” was defined as the percentage of discharge orders written in our electronic medical record(EMR) before noon. We also tracked our readmission rates and length of stay(LOS) as balancing measures. We collected monthly data for these measures using our electronic medical record (EMR).

We identified key barriers to early discharge using a multidisciplinary survey and the Failure-Mode-Effect-Analysis (FMEA) tool. A key driver diagram ( Figure 1) was created, and interventions were concentrated to improve the identified barriers. Multiple Plan-Do-Study-Act cycles were completed including obtaining buy-in from various stakeholders ( nursing, residents, hospitalists, bed control, case management ), spreading knowledge and education, improving communication using a multidisciplinary afternoon huddle, and integrating a resident assistant as a facilitator for early discharges. The afternoon huddle was specifically utilized to discuss goals of care, anticipated discharge date, barriers to discharge, and assess each patient’s social work and case management needs. Similarly, the resident assistant was responsible for various non-clinical duties, including information gathering, scheduling follow-up appointments, and completing paperwork before discharge.

Results

Our institution’s baseline rate for “early discharge” was 27%. The response rate for a multidisciplinary survey assessing the barriers was 59% ( 98/166). The survey showed that our most significant barriers to early discharge were poor communication between team members (66%) and discharges not prepared in EMR (52%). After focusing our interventions on these barriers, we successfully achieved a 5% increase in the “early discharge” rate. The statistical process control (SPS) charts showed a special cause variation (Figure 2) in August 2021. We did not notice a change to our balancing measures, and our 7-day readmission rate and LOS remained the same.

Conclusions

Understanding the barriers and improving communication among various team members was crucial in achieving a sustainable and consistent early discharge process. These improvements will serve as a stepping-stone as we continue to improve the timeliness of discharges.

Clinical Implications

Timely discharge improves hospital throughput, allowing for less ED overcrowding, reducing patients’ LOS, and improving bed availability in hospitals. It may also possibly improve healthcare costs and improve patient satisfaction.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog