From the 2021 HVPAA National Conference
Fiorella Castillo (Brookdale Hospital Medical Center), Ishmael Opare, Marvic Taborda, Salome Wiredu, Yanki Kaan Okuducu, Shatha Kayed, Utsav Timalsina, Nastassia Burak, Rosemarie St. Vincent, Fernanda Kupferman, Kusum Viswanathan, Ratna Basak
Prolonged discharge boarding time (DBT) is recognized worldwide as a major concern in hospitals and has negative ramifications for patients, clinical staff, and health care institutions. With a national DBT benchmark of 2 hours, studies have shown estimated cost savings of $5.9 million that directly apply to families and hospitals, as well as improvement in patient satisfaction scores.
This Quality Improvement (QI) project focuses on improving the DBT at Brookdale Hospital’s pediatric inpatient unit by increasing the percentage of patients being discharged within 2 hours of being medically ready for discharge by 25% (goal of 47.2%) from baseline in 6 months using facility-tailored interventions. The balancing measure is 30-day readmission rate for the same or related cause.
A needs assessment was completed in July 2020 in which DBTs were collected along with perceived barriers faced to discharge patients in a timely way (Figure 1). Meetings were held with key stakeholders (nurses, social workers, transportation managers) to discuss the project and assess barriers (figure 2). Plan-Do-Study-Act methodology was implemented, data collection began in December 2020. Cycle 1 focused on obtaining social clearances 24 hours prior to discharge or by Friday (if weekend discharges were anticipated), Cycle 2 focused on the preparation of discharge summaries at least 12 hours prior to discharge, and Cycle 3 focused on parental notification of discharge at least 12 hours prior to discharge.
Baseline DBT average was 5.1 hours, and only 22.2% of patients were discharged within 2 hours. Main barriers encountered were obtaining social worker clearance (average 10.5 hours), parental readiness (average 1.5 hours), transportation arrangements (average 3.5 hours), discharge summary (average 1.4 hours), pending consults (average 2 hours), medication reconciliation (average 1.1 hours), nursing delays (average 1 hour), and appointment scheduling (average 6.25 hours). Cycle 1 showed an average DBT of 3.5 hours (reduction of 1.5 hours from baseline), and 25% of patients were discharged within 2 hours (increase of 2.8%). Cycle 2 showed an average DBT of 3.5 hours (reduction of 1.5 hours) and 27.3% of patients were discharged within 2 hours (an increase of 5.58% from baseline). Cycle 3 showed an average DBT of 2.7 hours and 47.6% of patients were discharged within 2 hours (an increase of 25.42% from baseline) (Figure 3). In cycle 2 the readmission rate was 1.8% (1 out of 54), while in cycle 3 it was 3.6% (3 out of 84).
Facility-tailored DBT interventions based on needs assessment and early involvement of key stakeholders were crucial to the proper implementation of this project. Interventions have been successful in decreasing DBT and we were able to reach our goal by the 3rd cycle. Future cycles will target appointment scheduling, early identification of potential discharges, improving communication with parents and staff, and introduction of a discharge checklist.
Reducing DBT is associated with reduction in length of stay, improvement of quality of care, reduction in cost of care, increases in access to available hospital resources and improvement of overall patient satisfaction.