In many cases, patient discharge procedures hinder a health system’s ability to accept more patients from outside sources, wastes precious resources, and may mean patients stay longer in certain departments, such as the emergency department. An article featured in Nursing Administration Quarterly1 details an advanced practice provider (APP) led initiative to identify strategies to improve patient discharge times. Together, the APPs identified six key areas that ultimately led to improved patient discharge times by enhancing communication among providers using the electronic medical record (EMR) system.
Study design
All patients enrolled in the study received care from the cardiac surgery service at a large, level 1 trauma and quaternary care academic medical center. In the majority of cases, these patients were admitted to the cardiac surgery step-down unit after undergoing one of several cardiac procedures, such as coronary artery bypass grafting, mitral valve replacement or repair, and transcatheter aortic valve replacement.
The APPs identified and enacted design thinking methodology as the foundation of the discharge timeliness project. Design thinking is an iterative process that seeks to understand the user (in this case, the interdisciplinary healthcare team), challenge assumptions, and redefine problems to help identify alternative strategies and solutions that may not be immediately apparent.2
This process took place through a workshop that included many members of the interdisciplinary healthcare team, including APPs, physical and occupational therapy (PT/OT), pharmacy, social work, case management, patient flow nurses (PFNs), and attending doctors.
Six strategies to improve the discharge process
The main target goal for the study was to have 25% of patients discharged by 11:00 am, with a secondary goal of having 30% of discharge orders entered into the EMR by 9:30 am. Improving communication among the team emerged as a common theme, which helped identify new strategies for facilitating the discharge process, including:
- Identification of early discharge patients
- Morning stand-up bed management huddle
- Prioritization of early discharges
- Interdisciplinary transition management huddle
- Patient flow nurse
- Shared discharge plan
Shared discharge plan
A new shared discharge plan was embedded in the facility’s EMR to help enhance communication among all patient care providers. Included in this plan were 15 separate critical discharge elements broken down by profession:
- APPs – estimated date of discharge, PT/OT evaluation, medication reconciliation, postop appointment scheduling, discharge orders
- Nursing – discharge barriers, patient education, “meds to beds” pharmacy requests, after-visit summary, transport
- Case management – planned disposition, predicted score for post-acute care, case management assessment, durable medical equipment needs identified, ride confirmed
Progress on each of these elements was updated daily and visible to all team members involved.
Identifying early discharge patients
As patient care is shared among the interdisciplinary team, improved communication regarding the discharge process can help tremendously in getting patients home faster. APPs worked to identify patients who could potentially be discharged before 11:00 am the day before discharge on morning rounds. This information was shared among the healthcare team using the shared discharge plan in the EMR and on nightly rounds.
Morning bed management huddle
Each morning, a group of healthcare providers met for 10 minutes to discuss the logistics of patient flow for the day, including the operating room schedule, pending patient transfers from outside hospitals, anticipated direct admissions, potential transfers from the CVICU to the step-down unit, and potential discharges.
Prioritizing early discharges
To achieve the goal of discharging 25% of patients by 11:00 am, APPs realized the need to have all discharge orders entered into the EMR by 9:30 am the same day. When a potential early discharge patient was identified, this information was entered into the EMR and shared among staff during the interdisciplinary transition management huddle the day before the anticipated discharge. Each patient was reevaluated on the day of discharge and, if stable overnight, discharge orders were entered before 9:30 am.
Interdisciplinary transition management huddle
An RN case manager moderated this meeting to update other providers on daily patient progress and clinical status within the scope of the shared discharge plan in the EMR. During this meeting, APPs discuss each patient’s anticipated discharge date and any barriers which may prevent discharge from happening.
Patient flow nurses
The PFN role supports patient throughput and provide a single point of contact for providers, primary nurses, and patients. The role also includes providing comprehensive discharge education, and the PFN coordinated with the pharmacy for bedside medication delivery and teaching.
The results
At the end of the study period, 14% of patients were discharged before 11:00 am, an improvement from the baseline measurement of only 9%. Additionally, 26% were discharged before noon, and 16% of patients had discharge orders entered into the EMR before 9:30 am. While the process did not achieve its main goals, it was noted that the average length of stay decreased by a total of 6.48 hours.
Improving discharge times is a complex process requiring input from multiple healthcare providers. The identification of strategies to improve discharge times, as well as the use of modern technology to help facilitate communication, is essential to the success of such efforts.
