Discharge Planning Advisor

Set discharge time that works for you

Don’t obsess on that number’

Consider patient volumes and staff constraints and set a discharge time that makes sense for your facility, suggests Jonathan Morris, RN, bed management coordinator at Wake Forest University (WFU) Baptist Medical Center in Winston-Salem, NC.

"Look at those processes within patient flow and within the discharge process itself," he adds, "and ask, What are those that will make or break the goal?’ If you’re setting an unreasonable goal, why even set it?"

"Don’t obsess on that number, just optimize what you have. Your [appropriate time] might be noon, 1 p.m. or 2 p.m. At a smaller facility, you might be able to do 11."

At academic medical centers like WFU Baptist, where residents do teaching rounds before handling discharges, "that in itself will prevent you from getting [patients] out" at 11 a.m.," Morris points out.

Waiting on ancillary departments to finish tests and lab work further complicates the effort, he adds.

"In my opinion, [consistent 11 a.m. discharge] is unobtainable because there are so many other factors in a complicated medical environment," Morris says. "In order for a patient to be discharged before 11, they should have been ready the day before. If they’re ready the day before, then in order to do that, you’ve increased your length of stay."

If everything has been finalized and a patient is ready to be discharged the day before — at say, 5 p.m. or 6 p.m. — go ahead and let the patient go, he advises. "Don’t get into the mindset of, You can’t get out by 11, so just stay another day.’ If they’re ready to go, why hold them?"

"You have to look at it from the quality perspective, as well," Morris adds. "Research shows that the longer you’re in a hospital, the higher the risk of catching other things. Immune systems get accustomed to being at home."

While improvements at Wake Forest have enabled staff to move some discharges to earlier in the day, more than half of the medical center’s patients still leave after 2 p.m., he notes. "We’ve looked at how many are discharged after 2 p.m., as opposed to 11 a.m. Don’t set yourself up for failure."

When there is an occasional backup in the flow to patient beds, hospital staff do other things to ease the situation, Morris says. "We work with patients to make sure they are comfortable, are getting the things they need."

If people are waiting in the lobby, he adds, "we check on them, and if it’s lunchtime, send them for a meal in the cafeteria." The most important thing, Morris notes, is to explain why the wait is occurring. "Most patients are much happier if they know you recognize that they’re waiting."

Discharge unit tried

For about six months, the hospital experimented with a special discharge holding unit aimed at enhancing patient flow, Morris says. The unit was designed for patients whose discharge orders are written but who are waiting for medication, for example, or a ride home, he adds.

That unit has been closed for the time being because not enough patients were using it to make it worthwhile, Morris says. "Obviously, we weren’t using it for the nursing home population, and those waiting for rides were leaving early enough that it wouldn’t justify coming down [to the unit] for an hour or two. There were all sorts of different factors and variables. It helped, but not enough to justify keeping it open with two nurses."

In place of that unit, he says, the hospital wants to establish an express admission unit, which is expected to have a bigger payoff in terms of increasing patient throughput.