Initiative aids discharge planning, throughput

Families alerted to discharge day early in the stay

Before Mease (FL) Dunedin Hospital began a Six Sigma project to improve patient discharge, only 45% of patients whose discharge orders were issued by noon were being discharged by 1 p.m.

Since the discharge process was tweaked, 90.2% of patients with discharge orders issued by noon are leaving the hospital by 1 p.m.

Before the project started, the hospital was experiencing increasing hours of emergency department (ED) diversion.

"When we examined the problem, we found that it wasn't necessarily because of the size of the emergency department but was due to the throughput of patients," says Carol Przybycin, BSN, MS, director of Six Sigma deployment for BayCare Health System, with headquarters in Clearwater, FL.

At the time the project began, 54% of patients were leaving after 1 p.m. and 66% of the hospital's emergency department diversion hours were occurring after 1 p.m.

"In our data collecting, we found out that there were a lot of times when we were not discharging patients in a timely manner. There was a huge standard deviation between when we got the order and when the patient was actually discharged," says Przybycin.

The purpose of the project was to improve patient throughput and free up inpatient beds for patients coming into the hospital. They worked to increase inpatient capacity by removing the roadblocks to discharging patients in a timely manner, she adds. "If we have the order by noon and the patient is discharged by 1 p.m., it opens up beds for incoming patients and allows a more predictable work flow for the hospital team."

Since 82% of the 173-bed hospital's patients are discharged to home, the project focused on patients going home, rather than those being placed in post-acute care.

Members of the interdisciplinary team included the director of nursing, the director of case management, nurse managers, the case management manager, and the clinical resource coordinator, an RN case manager who manages the course of treatment for the patient. The champion of the team was the vice president of patient services, who assisted the team in removing any barriers it encountered.

The team gathered data on patient discharges and used brainstorming and other techniques to identify variables to discharge and to come up with ways to overcome the barriers.

The team found that three factors were involved in most of the discharge delays: transportation home, consults for post-discharge care, and communications between the staff members and between the staff and the patient and family.

Lack of transportation home was the cause of a delay in discharge in the majority of the patients.

"Most of the time, the family members who take the patient home work during the day. If they don't know in advance that the patient isn't going to be discharged, they can't make arrangements ahead of time," Przybycin says.

The second biggest cause of delays was a delay in orders being written for hospice or home health consultations. Often, the orders were being written the day of discharge.

"With good discharge planning throughout the stay, the case managers can anticipate the needs before discharge. We worked to insure that the consults were ordered in a more timely manner," she says.

The team found that sometimes the patient load of the nurse caring for a particular patient interferes with discharge being a priority.

"We looked for other staff who could be available to help with what the patient needs to be ready for discharge," Przybycin says.

For instance, the charge nurse, the discharge nurse, or a peer on the unit should be able to pick up the responsibility of insuring the patient's discharge needs are met, she says. The hospital's admissions nurse is available as a resource to help with the discharge when the primary nurse is busy with other things.

Lack of communication often was the biggest factor in discharge delays, regardless of the actual cause.

"Often the problem was a lack of awareness on the part of the nurse, the patient, or the family that the patient was going to be discharged that day. Our communication circle was not sophisticated enough to have ongoing discussions about discharge from the time the patient was admitted. We made improvements to that process as well," Przybycin says.

The team came up with ways to emphasize the importance of making discharge planning a priority, including getting medications, tests, and therapy ordered.

To make sure that everyone focuses on discharge efforts, the team added a space for discharge planning information at the top of the daily written report sheet that the nursing staff uses to document information that should be passed along from shift to shift.

"We put anticipating discharge planning right there on the main trigger list with information about risk for falls and special monitoring needs, so that the staff will be focused on it at all times," she says.

The hospital now requires nurses to write the anticipated date of discharge on the report and document that they have talked to the patient and family members about discharge plans and transportation home.

The team developed a pink sticker for the progress notes that physicians use to alert the staff of any discharge needs the patient may have and the anticipated time frame for discharge.

"The doctor often writes the discharge plan in the progress notes, but the nurses were not attuned to reading that and passing the information along. This allows the staff to interact with the physicians sooner, rather than waiting for the discharge order," Przybycin says.

The team scripted an interaction about discharge for the nurses to use as they talk with the patient and family.

The interaction is to take place at five designated times: admission, the day following admission, when the doctor indicates a discharge plan, the day before the planned discharge occurs, and the day of discharge.

In addition, team members created a poster, which hangs in each patient room, alerting the family to their role in discharge planning.

"We wanted to create awareness for the patient and family that we are focusing on a timely discharge," she says.

The poster includes information on the Four Cs of Discharge Planning: communication with the family and caregiver; coordination of care after discharge; collaboration between the patient, family, and hospital; and collaboration between the family and hospital.

"To serve you better and to accommodate other patients, our goal is to complete discharge within one hour of the time the physician writes the order," the poster reads.

The hospital has standardized the discharge process and discharge planning from floor to floor.

The patient care nurse, social worker, charge nurse, clinical resource coordinator, and physicians, if available, attend a daily discharge meeting with the discharge nurse.

On occasion, with orthopedic patients, the physical therapist also will attend to give an update.

"The key piece is that whoever is in that meeting needs to make sure that they communicate with the other nurses, the patient, and the family," she says.

All of the patients are discussed on a daily basis, to differing degrees depending on their readiness for discharge, and the information is communicated to the bedside nurses, who take any action necessary.

"By doing this, we are able to identify if the doctor hasn't written the order for the consultation, and we can request on the patient's behalf to get the orders in place. This way, we don't have five sets of orders for consults coming in at once on the day of discharge," she says.

The nurse on the day shift now knows that the discharge order is a priority and no longer waits for the change of shift for the discharge to take place.

"No matter what time that order comes in, we want everything in place so that the discharge can take place within the hour. We have improved from discharging patients within the hour 22% of the time to discharging them within an hour 45% of the time," she says.