Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge
BACKGROUND: Discharge delays adversely affect hospital bed availability and thus patient flow.
OBJECTIVE: We aimed to increase the percentage of early discharges (EDCs; before 11 am). We hypothesized that obtaining at least 25% EDCs would decrease emergency department (ED) and postanesthesia care unit (PACU) hospital bed wait times.
DESIGN: This study used a pre/postintervention retrospective analysis.
SETTING: All acute care units in a quaternary care academic children’s hospital were included in this study.
PATIENTS: The patient sample included all discharges from the acute care units and all hospital admissions from the ED and PACU from January 1, 2014, to December 31, 2016.
INTERVENTION: A multidisciplinary team identified EDC barriers, including poor identification of EDC candidates, accountability issues, and lack of team incentives. A total of three successive interventions were implemented using Plan–Do-Check-Act (PDCA) cycles over 10 months between 2015 and 2016 addressing these barriers. Interventions included EDC identification and communication, early rounding on EDCs, and modest incentives.
MEASUREMENTS: Calendar month EDC percentage, ED (from time bed requested to the time patient left ED) and PACU (from time patient ready to leave to time patient left PACU) wait times were measured.
RESULTS: EDCs increased from an average 8.8% before the start of interventions (May 2015) to 15.8% after interventions (February 2016). Using an interrupted time series, both the jump and the slope increase were significant (3.9%, P = .02 and 0.48%, P < .01, respectively). Wait times decreased from a median of 221 to 133 minutes (P < .001) for ED and from 56 to 36 minutes per patient (P = .002) for PACU.
CONCLUSION: A multimodal intervention was associated with more EDCs and decreased PACU and ED bed wait times.
© 2019 Society of Hospital Medicine
Patient flow throughout the hospital has been shown to be adversely affected by discharge delays.1 When hospitals are operating at peak capacity, these delays impact throughput, length of stay (LOS), and cost of care and block patients from the emergency department (ED), postanesthesia recovery unit (PACU), or home awaiting inpatient beds.2-5 As patients wait in locations not ideal for inpatient care, they may suffer from adverse events and poor satisfaction.3,6 Several studies have analyzed discharge timing as it relates to ED boarding of admitted patients and demonstrated that early discharges (EDCs) can impact boarding times.7-9 A number of recent improvement efforts directed at moving discharges earlier in the day have been published.10-15 However, these improvements are often targeted at specific units or teams within a larger hospital setting and only one is in the pediatric setting.
Lucile Packard Children’s Hospital Stanford (LPCHS) is a 311-bed quaternary care academic women and children’s hospital in Northern California. As our organization expanded, the demand for hospital beds often exceeded capacity. The challenge of overall demand was regularly compounded by a mismatch in bed availability timing – bed demand is early in the day and bed availability is later. This mismatch results in delays for admitted patients waiting in the ED and PACU. Organization leaders identified increasing early discharges (EDCs) as one initiative to contribute to improved patient flow.
Our organization aimed to increase the number of discharges before 11
METHODS
Setting
We focused our EDC interventions on the 87 acute care beds at LPCHS. All patients discharged from these beds were included in the study. We excluded patients discharged from intensive care, maternity, and nursery. Acute care includes five units, one focused on hematology/oncology (Unit A), one focused on cardiology (Unit B), and the others with a surgical and medical pediatric patient mix (Units C, D, and E). Although physician teams have primary units, due to unit size, patients on teams other than cardiology and hematology/oncology are often spread across multiple units wherever there is a bed (including Units A and B). Most of the frontline care physicians are residents supervised by attendings; however, a minority of patients are cared for by nurse practitioners (NPs) or physician assistants (PAs).
