Maryland facility begins discharge by appointment

Plan 'truly' begins at admission

This month, St. Joseph's Medical Center in Towson, MD, begins discharging patients by appointment, in the latest phase of a three-year effort toward capacity maximization, says Jackie Connor, RN, MS, CCS, director of case management.

When Connor was hired in April 2005, she was asked to take over the part of the project that included improving the discharge process, "the back end of patient flow," she adds. "Other teams were working on the emergency department [ED], the front end.

"We had an issue with 'boarders' in the ED and as we started collecting data, what came to the surface was that if we could just fix transportation and discharge, 80% of the problem should be fixed."

Connor says her sense of the situation, however, was that a more comprehensive solution was needed. "We put together a multidisciplinary team last June, started working on the problem and, as we moved forward, put together subgroups as issues arose."

When the discharge task force was established in June 2005, one of the main goals was to increase the percentage of patients discharged by noon, Connor adds. But even with that specific intent, several months of data collecting revealed little change.

"What we found was that it was causing what we called 'bolus' discharges," she says. "It was a rapid, concentrated effort, a massive amount of patients, trying to get it all to happen before noon.

"Later in the day we would have 'bolus' admissions as the ED and the catheterization lab would empty out," Connor adds, "so there was not an even workload throughout the day."

That's when the decision was made to move to discharge by appointment, she says. "What we're attempting to do — and I haven't seen this in any of the literature on the subject — is to try to schedule discharge for all patients, not just surgical patients."

The idea has been piloted on the surgical unit with some success, and then with interventional cardiology patients, and is now being expanded to all patients, Connor notes. One group that will not be included is the maternal/child patient population, she adds, because there are no throughput issues there.

The process works as follows, Connor explains.

1. Planning begins on admission for the anticipated discharge.

"I know everybody says they do that, but we truly are going to begin — meaning we will assess the patient, discuss the plan, and then set the anticipated date."

2. Nursing, case management, and physicians work daily on evaluating the plan and the anticipated date.

3. Ancillary departments will be notified of the anticipated discharge date and time and their turnaround of tests and procedures, and their goal is to meet the deadline — to prioritize based on the date given.

4. The patient is informed all along the way of what the plan is.

"We're trying to plan from day one to get everybody moving in the same direction," Connor adds.

The team will monitor:

  • The percentage of patients who have a discharge appointment.
  • The percentage of patients who have an appointment who are discharged within 30 minutes of the appointment.
  • The percentage of patients who are identified as potential discharges at least 22 hours prior to the actual discharge.

(Editor's note: Jackie Connor can be reached at jackieconnor@chi-east.org. Look for a follow-up on the 'discharge by appointment' initiative in a future issue of Hospital Access Management.)