KH: Discharge planning should be started on the day of arrival. You absolutely lose the efficiencies that you have with the team if a patient is in the emergency department and they don’t have that team surrounding them. We started this discharge-before-noon initiative, and it absolutely was a multidisciplinary team effort. We knew that we were only as strong as the weakest link. If housekeeping didn’t come up and clean the room, you could have a whole floor of rooms almost ready to go. We had a major kickoff event in which anybody who touched a patient or had anything to do with patient care was included. We jam-packed everybody into one of the conference rooms and discussed this before-noon initiative. We wanted to really hammer home the point that it’s better patient care if the patient is able to safely leave the hospital—the earlier, the better. We don’t want patients acquiring hospital-acquired illnesses, infections, or complications because they are hanging around waiting for lunch or for dinner. If a patient left before noon, the patient could get their medications from the pharmacy. If there was trouble with a pharmacy, someone would be around to field the phone call, and patients would be able to make their follow-up visits in the light of day. Not only was it important for the patient to be discharged, but never sacrificing safety meant that the patient in the emergency department could come up to the floor, the patients in the ICUs could come down to the floor, and also the post-anesthesia care units could become decompressed.
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ACEP Now: Vol 35 – No 12 – December 2016PV: Was this something that you started on medicine?
KH: There had been a goal set by the administration for a 30 percent discharge-before-noon rate. It hadn’t been achieved for several quarters. I would say it was definitely a combined effort of administration and frontline staff and key medicine and nursing leadership.
PV: Usually when you get such a group together, there’s a cacophony of voices explaining why you can’t. How did you deal with all that?
KH: It certainly was an issue. Right before we did the kickoff, I had one of our administrative fellows at the time, Martha Bailey, come around with me while I was on the wards, and I asked Martha to write down the reasons why patients were not being discharged before noon. For 30 patients that we discharged, there might have been 40 different reasons why the patients did not go before noon. They included, “I wanted to stay for lunch,” “I didn’t know that I was being discharged,” “I don’t have a ride,” “I don’t have any clothing,” “My family doesn’t know.” We realized very quickly that there wasn’t a single answer that was going to fix this problem. That’s why we involved every member of the interdisciplinary team, so that everyone knew the plan for the patient. We even had a way of prioritizing patients who needed a specific study or specific lab tests. Those patients would get prioritized first to get their study done so that we could make a decision on the day of discharge.
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One Response to “Early Hospital Discharge Can Improve Capacity, Patient Flow”
December 1, 2022
Mark BThis is ridiculous. The inpatient/hospitalist team controls discharges, and they are trying to get patients out. I am a cardiologist but worked as a hospitalist during and for months past COVID. Everybody wants to discharge. Administration is looking at everyone of your patients and saying about your patient who had two rapid responses overnight “Well these haven’t had one this morning, can they be discharged.” The patients want to leave. They can have two chest tubes in and as your rounding on them they say”can’t you pull these out and I can go home”. Hospitalists make more on discharges than progress notes, so they are trying to discharge their service. But the hospitalists are generally short term employees and so are the dumping ground for the whole hospital. Let hospitalists actually do their job and not be the answer for everything the hospital doesn’t want to deal with. The ER contributes to this issue. If a patient is a true ICU patient and the ICU initially denies, sending them to the floor is not the answer. Spending three hours straight with one patient, you are not going to be able to discharge your other 19 patients. You don’t call to admit a severe nose bleed, then the hospitalist gets down their and the patient is on anticoagulants, has a SBP of 255, and a severe headache. So you are in the ER getting down the BP and ordering a head CT to make sure their is no bleed. The patients need to be reasonably stable. But the hospitalists are quoting. I would estimate over 75% of my shifts we were down at least one hospitalist, which means you are carrying too many patients to just discharge. And the hospitalists are getting worked dumped on them that should not be theirs from all directions. I will never do the job again and most of the hospitalists I worked with are looking for different careers. As their is a hospitalist shortage and I have just gotten two calls in the last hour about opening because their is a shortage, plan on boarding to get worse. We need to discharge more. Thanks for the rocket science.