From the 2022 HVPA National Conference
Saida Kent, Doctor of Medicine (St. Louis University Hospital), Zafar Jamkhana, Doctor of Medicine
Optimization of patient throughput can improve the quality of care patients receive. One key area of throughput is discharge. Poor discharge planning can lead to premature and unsafe discharge or delayed discharge which prolongs the length of stay and can lead to adverse patient outcomes. Effective discharge planning is usually seen as a complex issue requiring interdisciplinary collaboration for effective coordination. Our safety-net hospital formed a multidisciplinary committee to improve discharge planning.
Focus on promoting effective communication among multidisciplinary teams by implementing structured daily rounds with the goal of early identification of discharge barriers.
Root cause analysis of barriers to good discharge planning found four main categories: communication, transportation, placement, and socio-economical barriers. We focused on communication by forming a unit-based interdisciplinary team for daily rounding (Monday to Friday) to discuss discharge planning for each patient. Members included the charge nurse for each unit who was the lead, care coordinators (Social worker and case manager), Physical Medicine and Rehabilitation representative (physical or occupational therapy), and clinician (Hospitalist, advanced care practitioner, or senior resident). Utilized Interdisciplinary Rounding (IDR) toolkit from the Veterans Affairs which factors in an academic setting with rotating residents unfamiliar with people and processes involved in discharge planning. Step-wise implementation with 3 phases adding teams and units as more structure was formed. Had biweekly meetings pre and post-intervention for 6 months by multidisciplinary committee members to identify barriers to effective rounding. Project limited to general Internal medicine hospitalist teams (3), teaching teams (4), and subspeciality primary teams of liver, cardiology, hematology, and geriatrics services.
Through an informal survey given to various multidisciplinary teams conducted 6 months after IDR intervention, three main themes prevailed. There was a feeling of improved staff satisfaction, improved workflow, and improved communication. With data collection, recurring discharge barriers were identified and targeted. For example delays due to lack of transportation to facilities prompted the hospital to buy 2 medically equipped vans to transport patients. Continued challenges included lack of geographical rounding for physicians, lack of attendance of all members, especially during COVID surges, and disruption of morning rounds for teaching teams for residents to attend IDR.
Having discussed and agreed upon patient-centered daily planning helped prioritize and personalize patients’ needs which helped improve the overall patient experience. For example consistent communication of treatment plan, united presentation, and effective discharge planning. Senior residents became more involved in inter-professional teams, improved interpersonal and prognostication skills, and are learning to identify barriers involved in transitioning patients across various health delivery systems, especially for undeserved patients.
IDR rounding helps develop interdisciplinary and multidisciplinary relationships and connections that enhance patient care and breeds work satisfaction, especially for non-physician members. The next focus is to facilitate early and safe discharge for patients by moving IDR rounds to the afternoon to give teams time to formalize plans for the next day and minimize morning workflow disruptions.