From the 2022 HVPA National Conference
Rey Marrero Alamo MD (University of Central Florida HCA Healthcare GME, Greater Orlando, Florida), Melissa Khalil MD, Victoria Odeleye MD, Heather McGovern DO, Musab Shouman MD, Zeeshan Zafar MD, George Alvarez DO, Joshua Shultz MD, Ashwini Komarla MD
Discharging patients, before 11AM is increasingly being recognized as a key dimension of quality of care. Late hospital discharges (LHD) have become a major topic of discussion in the last decade. They have implications on many components of hospital workflow. Many hospitals across the nation have shown interest in this because early discharges affect throughput and patient flow. Consequences of LHD include increased emergency room boarding and unit transfer times, increased hospital length of stay and implications for patient satisfaction and hospital cost.
We aimed to increase the number of early discharges before 11 AM (from 18%) to 25% on the resident teaching team by May 2022.
We constructed a process map of the discharge procedure and found that some of the delays to discharge occurred from late staffing with the attending, delayed labs or imaging and follow up from consultants. We also developed a pre-intervention survey for residents on the inpatient service about each recent discharge and asked them to identify delays to the discharge. The most commonly mentioned delay was “unable to staff before 11am” (Figure 1). Once we identified these root causes, we aimed to change workflow to have residents preround with their attending before 9 am and identify the possible discharges the day before to expedite staffing and pending labs, imaging, and communication with consultants. We discussed this expectation with faculty in the faculty meeting and with residents at morning report. We displayed flyers in our work areas and had the medical admitting resident give reminders to the resident teams. We also sent out weekly text reminders to attendings. We tracked the discharges through information provided by the hospital and shared this information with inpatient teams. We also created a contest with incentives for the team with the most discharges before 11am. Finally, the data from the resident service of early discharge orders was analyzed utilizing a run chart (Figure 2).
See Figure 2. We were able to sustain an early discharge rate (EDR) above our median line with an average rate over 25%, our goal. Implementation of incentives to the team with the earliest discharges and the text reminder to all attending in the services was able to generate the biggest jump in the EDR.
Our interventions were able to increase the EDR. Root cause analysis identified the most common barriers to early discharge. A developed process map helped us to understand the existing discharge process and allowed for QI initiatives to develop a consistent and sustainable discharge process. Patient discharge percentages before 11 AM increased by 16%. We will have to track this to make sure the change is sustainable over time and with new residents.
Residents can work with the hospital and attendings to change workflow. Reminders from staff on site to attendings and senior residents are effective. Contests can also provide incentive to really change behavior.