Out by noon—a win­ning strat­egy to re­duce crowd­ing, shorten stays

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

In early 2011, NYU Lan­gone Med­i­cal Cen­ter aimed to get 30% of its dis­charged pa­tients out the door be­fore noon in an ef­fort to re­duce bot­tle­necks and ease pa­tient flow.

One year later, dis­charge-be­fore-noon rates for the New York hospi­tal’s medicine ser­vice lagged far be­hind that tar­get. Dis­charges were de­layed be­cause test re­sults weren’t ready or trans­porta­tion hadn’t been ar­ranged. Res­i­dents were be­hind fill­ing out dis­charge or­ders or pa­tients and their fam­i­lies hadn’t re­ceived post-dis­charge ed­u­ca­tion. Some pa­tients just wanted to stay for lunch.

“It seemed like the moons had to be aligned to get pa­tients out by noon,” said Dr. Kather­ine Hochman, di­rec­tor of the hos­pi­tal­ist pro­gram and as­so­ciate chair for qual­ity at NYU Lan­gone. “To me, it was a marker that ev­ery­one was not on the same page.”

Dis­charg­ing pa­tients late in the day is linked to emer­gency-depart­ment over­crowd­ing, longer lengths of stay and lower pa­tient-sat­is­fac­tion scores. Like 791-bed NYU Lan­gone, many hos­pi­tals are look­ing at set­ting early dis­charge tar­gets as a way to avoid grid­lock and make it eas­ier for dis­charged pa­tients to ac­cess same-day ser­vices such as pri­mary-care ap­point­ments and home health.

“Pa­tients get home early enough so that if there are chal­lenges, they can ad­dress them right away,” said Scott Croon­quist, as­so­ciate chief nurs­ing of­fi­cer of the Univer­sity of Vir­ginia Health Sys­tem, Char­lottesville, which un­der­took an early dis­charge ini­tia­tive sev­eral years ago. “It’s much bet­ter for them.”

Be­cause dis­charge-be­fore-noon rates on NYU Lan­gone’s medicine units were at or near 7%, the low­est in the hospi­tal, Hochman and her col­leagues started there. Un­like surgery, where ad­mis­sions and dis­charges tend to fol­low typ­i­cal sched­ules, medicine dis­charges are harder to pre­dict. “If the medicine ser­vice could suc­ceed at a dis­charge-be­fore-noon ini­tia­tive, any­one could,” she said.

Hochman and Martha Bai­ley, NYU Lan­gone’s man­ager of op­er­a­tional ini­tia­tives, fo­cused their ef­forts on the 17th floor of Tisch Hospi­tal, which con­sists of two 35-bed in­pa­tient med­i­cal units, each led by a hos­pi­tal­ist. A four-week as­sess­ment found no one fac­tor ac­counted for most de­layed dis­charges.

Be­gin­ning in March 2012, Hochman and her col­leagues in­sti­tuted af­ter­noon mul­ti­dis­ci­plinary rounds, used to iden­tify pa­tients likely to be dis­charged the next day. They made a check­list of all dis­charge-re­lated tasks and the staff mem­ber re­spon­si­ble for each one. Nurses, for ex­am­ple, do pa­tient ed­u­ca­tion and so­cial work­ers or care man­agers ar­range at-home ser­vices.

The team also cre­ated a web­site with the names of pa­tients ex­pected to be dis­charged the next morn­ing. At 4:30 p.m. each day, the site gen­er­ates au­to­mated emails to more than 200 key staffers list­ing the next day’s dis­charges and in­di­cat­ing bar­ri­ers that need to be ad­dressed. Up­dates of the list go out to the list­serv at 7 p.m. and again at 7 the next morn­ing.

“If we knew a pa­tient was go­ing home to­mor­row and was go­ing to need oxy­gen, we placed or­ders the day be­fore with the DME com­pany,” said Dr. Ra­mon Ja­cobs, the hos­pi­tal­ist in charge of one of the med­i­cal units.

Fi­nally, the units in­sti­tuted daily lead­er­ship meet­ings at 11 a.m. to iden­tify missed op­por­tu­ni­ties in the pre­vi­ous day’s dis­charges. “If there was a prob­lem with trans­porta­tion, why did it hap­pen?” said Dr. Ben­jamin Wertheimer, leader of the other unit.

Within a month dis­charge-be­fore-noon rates in the two units rose sharply and av­er­aged 38% over the 13-month ini­tia­tive. The aver­age dis­charge time moved one hour and 31 min­utes ear­lier in the day, from 3:43 p.m. to 2:13 p.m. Aver­age ob­served/ex­pected length of stay also fell 10% to 0.96 from 1.06.

To dis­pel con­cerns that ear­lier dis­charges would lead to more re-hos­pi­tal­iza­tions or har­ried pa­tients, Hochman and Bai­ley mea­sured 30-day read­mis­sion rates and pa­tient-sat­is­fac­tion scores at the be­gin­ning and end of the ini­tia­tive. Read­mis­sion rates fell from 14.3% to 13.1% and scores im­proved on sev­eral HCAHPS mea­sures, in­clud­ing dis­charge in­struc­tions and com­mu­ni­ca­tion with nurses.

“I think they’ve done well,” said Croon­quist, whose own ap­proach to early dis­charges at the Univer­sity of Vir­ginia Health Sys­tem served as a model for NYU Lan­gone lead­ers. “Suc­cess de­pends so much on the cul­ture of the hospi­tal.”

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