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Struggling with Early Patient Discharges

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Source: Today’s Hospitalist

FOR SEVERAL YEARS, hospitalists at the University of Virginia Medical Center in Charlottesville worked to meet an early-discharge target: Physicians were expected to place 50% of their discharge orders by 9 a.m., and patients were supposed to be out of their beds by noon.

But the hospital ran into the same problems that many groups struggle with when it comes to early discharges. Length of stay went up, and “there was clear evidence of gaming in some instances,” with doctors keeping patients who could have been discharged the day before overnight to meet the incentive, says hospitalist director, George Hoke, MD. The UVA initiative was abandoned by 2015 and never resurrected.

“It defeated the whole purpose of improving throughput,” Dr. Hoke points out. “The concept of discharge by noon as a means to improve bed availability and capacity problems is flawed.” Why? “Because most hospitals are operating at too high a capacity for optimal patient flow. The right answer is to either reduce length of stay by improving efficiency or add more beds.”“You have to know your hospital, your hospitalists and your patient population, then set the right target.”~ Jose Fernandez-Duarte, MD Memorial Healthcare System

Not so, says hospitalist Katherine Hochman, MD, the former hospitalist director and now associate chair of quality at New York’s NYU Langone Medical Center. For years, NYU Langone has sustained a better-than-40% discharge-before-noon rate—with patients out of their beds by noon—as described in separate studies published in the April 2014 and October 2015 issues of the Journal of Hospital Medicine.

The center’s observed-to-expected length of stay has decreased, even though patient acuity and surgery volume have risen. “The discharge-before-noon metric,” Dr. Hochman contends, “is a measure of teamwork and coordination on your service.”

So who’s right? The conflicting opinions underscore the fact that hospitalist groups implementing early-discharge initiatives report a wide range of experiences, from train wreck to high-functioning discharge machine.

The 2016 Society of Hospital Medicine survey notes that just over half— 54%—of nonacademic hospitalist groups that treat adults have an incentive tied to early-morning discharge orders or times, meaning that just under half don’t. It’s a controversial topic that generates a lot of debate.

The right answer is that it depends, says Jose Fernandez-Duarte, MD, the system medical director for five TeamHealth hospitalist programs within Memorial Healthcare System in southern Florida. He and his colleagues launched an early-discharge initiative in one hospital last year.

“You have to know your hospital, your hospitalists and your patient population, then set the right target,” Dr. Fernandez-Duarte says. “It’s certainly not right for every hospital.”

The need for comprehensive coordination

The 227-bed Hamilton Medical Center in Dalton, Ga., launched an early-discharge initiative earlier this year. But as Laura Conger, MD, the hospitalist director, explains, it’s already crashed and burned.

The hospitalists did meet their target, filing at least 40% of discharge orders by 11 a.m. But “doctors got very creative at finding ways to file orders tagged as dependent on something else, like a certain specialist clearing the patient first,” Dr. Conger notes. “The order was on time, but the patient didn’t actually leave the building.”

But what really killed the initiative, she explains, was the fact that all the other hospital services involved in discharges weren’t retooled to follow the hospitalists’ lead. Housekeeping was particularly hard-hit by the early orders and ended up being over-staffed at some times, under-staffed at others. As a result, patients ended up spending many more hours in the hospital after discharge orders were placed than they had before.

“It totally screwed up throughput because the services involved weren’t coordinated,” Dr. Conger points out. “There was such a domino effect that our CEO said, ‘Don’t do this any more.’ ”

At the other end of the spectrum, NYU Langone’s Dr. Hochman credits comprehensive coordination for her center’s discharge-before-noon (DBN) success. Far from being just a hospitalist project, the initiative became “a really big part of hospital culture. We’re very metric-driven,” an approach that includes ancillary and administrative services.

The original 2012 initiative involved only one general medicine floor but plenty of preparation and fanfare: a kickoff event and unit champions, an interdisciplinary checklist and twice-daily DBN automated e-mails, real-time progress posters, and a late-morning meeting with medical directors and nurse managers to review that day’s “failed” DBNs.

Many “fails” were due to transportation and communication problems, Dr. Hochman says. As one fix, case management began targeting patient transportation the day before discharge.

And “dialysis patients weren’t leaving by noon because their four-hour dialysis session began at 8 a.m,” she notes. “One dialysis nurse stepped up and started working at 7 a.m. instead.” That speaks, she adds, to the “innovation, creativity and grit this takes to get it done.”

Should it be incentivized?

After five years, says Dr. Hochman, the DBN metric is so well-established that it’s now part of physician incentives.

But initially, it wasn’t incentivized. Instead, Dr. Hochman made the case for patient safety as to why patients should be discharged as soon as appropriate, and success with the metric was celebrated with pizza parties and cupcakes, not bonuses.

At St. Peter’s Hospital in Albany, N.Y., an early-discharge initiative likewise isn’t incentivized. Instead, “it’s all about the pride,” says Thea Dalfino, MD, hospitalist department chief. Launched in 2015, the initiative’s goal is to have the group’s 13 rounding physicians and five advanced practitioners submit discharge orders for seven patients before 10 a.m.

“We were at 15% when we began, and we’re up to 29% without any increase in length of stay,” says Dr. Dalfino. To motivate doctors, she posts “everyone’s names, how many orders they did that day and that week” in the hospitalist office every day. While doctors have been meeting (or beating) their target for more than a year, that daily list is still posted.

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