By Melinda Young, Author


For some hospitals — especially during the flu season — ED overcrowding and inpatient bed waits are common. The key to improving bed flow and efficiency is to implement a program that increases morning discharges, freeing up space earlier for additional patients.

  • Targeting early-day discharges is one solution to admitting and discharging patients more efficiently.
  • Increasing early-day discharges requires a culture change led by project team managers and case management teams.
  • One health system went from 3% of discharges before 11 a.m. to 11% of discharges before 11 a.m.

Hospital and ED overcrowding can be especially problematic during flu seasons — like the especially deadly season experienced last winter.

The 2017-2018 flu season resulted in more hospital crowding than the previous record during the 2014-2015 season when more than 700,000 Americans sought medical care for the flu (

Some hospitals had so many ED patients waiting for inpatient beds that people would sleep on beds in hallways for days (

Seasonal and infectious disease trends like this can strain hospitals’ resources, particularly if they already are operating at nearly full capacity. This highlights the need for strategies that improve bed flow and help to admit and discharge patients more efficiently. Targeting early-day discharges could be one solution.

Hospitals can improve morning inpatient bed access through a program that involves hospital case managers, social workers, physicians, and others working together, says Teresa Jacobs, MD, medical director of care management and professor of neurosurgery and neurology at Michigan Medicine at the University of Michigan in Ann Arbor.

“We had a culture of discharges happening much later in the day, throughout the system,” Jacobs says. “Before noon, less than 4% of patients were discharged.”

After rolling out a process to increase morning discharges, the health system’s morning inpatient bed access improved. Among its highest performers, more than 24% of patients were discharged before 11 a.m.

Overall, the percentage of morning discharges has nearly quadrupled from 3% before the program to 11% now, says Josh Thielker, MPH, senior project manager, care management, at Michigan Medicine.

“This certainly has improved our patient throughput and wait times for patients to get beds,” Thielker says. “And we know it’s also enabled us to grow our discharge volume within pretty tight capacity constraints, and this has all been during a period of pretty rapid change for the health system.”

The gap between available beds and patients being admitted has improved significantly. This is important because the hospital often has patients waiting in the ED for an inpatient bed, Jacobs says.

“There is increased demand on our hospital system,” she notes. “When the hospital is this full, you don’t know if you have a bed to put someone into, so having bed availability in the morning hours is better.”

The goal is to achieve an overall 20% of discharges occurring by 11 a.m., Thielker says.

“We’re still striving toward that, although the goal is something we continue to monitor and update as part of the dynamic of health system and flow changes,” he adds.

“It’s hard to get a 1,000-bed hospital and all of its employees to move in a different direction,” Jacobs says. “You have to have a plan that gives reasonable change, so you can accomplish the goal incrementally.”

Everyone has to be involved in the process. But three groups are the ones that should be focused on first: physicians, care management, and nurses.

Physicians give orders for earlier discharges. Care managers facilitate communication between providers and make sure everything is in place, and nurses plan patient discharges.

The program involved nine steps to educate staff, clinicians, and patients, and changed standard processes and culture to shift toward a priority list of patients in need of a morning discharge. (See story on the nine steps in this issue.)

Project team managers help facilitate staff education and culture change.

“These are people like me,” Thielker says. “When we were rolling out the program in new areas, project team managers were on hand and on the units to follow through with the process and reinforce the project by helping to solve any new or unforeseen issues that might come up.”

The mere presence of project team managers helped reinforce the importance of the change.

“Before rolling out the change in each new area, we sat with bedside nurses on the unit and provided them with the resources they needed,” Thielker says.

The education included strategies for shifting discharge tasks earlier. For example, nurses were told to start discharge education the day before, including the following:

  • Explain that the goal was to have the patient discharged by 11 a.m. the next day.
  • Tell patients to arrange for a ride the next morning.
  • Coordinate with security to have the patient’s personal belongings brought from storage to the patient’s room first thing in the morning.
  • Work with nutrition services to get the breakfast brought up early and prepare a packed lunch.
  • Work on order reconciliation in the health record.
  • Discuss the patient’s status changes that might affect the early discharge at handoffs or shift changes.
  • Tell nurses at handoffs what tasks the incoming nurse would need to complete to keep the patient on track.

These kinds of changes take time, continual focus, and patience.

When the health system first rolled out the program to improve morning inpatient bed access, only three units were high performers, Jacobs says.

“That’s out of 21 top discharging services. So we sat down with all 21 different services and talked about what was working out for those groups of high performers,” she says. “We shared ideas and showed an action plan.”

The next data showed that eight were high performers, a definite improvement.

“We had one more cycle where we brought in a chief clinical officer and chief nursing officer and had a meeting, broke into groups, and went over practices that worked,” she adds.

This resulted in 12 high performers, and the health system has been able to sustain these results over time, Jacobs adds.

“Every time we did one of these action plans for performance, we made an improvement,” she says.

The change pleases patients and providers when it works correctly, Thielker says.

“In general, operationally, it has also helped us to flatten our discharge curve a little more and shift discharges from the afternoon to early in the day.”

This redistribution of work volume improves efficiency, reducing the spike of activity in the late afternoon, he says.

“It’s been a great experience to work on this and see changes occurring and moving in the right direction,” Thielker says.