Changes in regulatory and reimbursement factors are making it more likely that children’s hospitals will follow in the footsteps of health systems and focus on improving patient throughput and reducing readmissions.
“Historically, children’s hospitals have not had to have a focus on managing length of stay or managing throughput,” says Lesly Whitlow, DNP, MBA, RN, vice president of access and care coordination at the Ann & Robert H. Lurie Children’s Hospital of Chicago.
“We weren’t impacted by DRGs [diagnosis-related groups] and all contracts were per diem, so there never was an emphasis on length of stay or managing throughput,” Whitlow says.
For children’s hospitals in Illinois, this changed when the state introduced DRGs through Medicaid several years ago, she says.
“When that happened, we had to start looking at our practices and look at our healthcare environment, which was changing, and we had to be proactive in managing that,” Whitlow explains. “That’s when it started to shift.”
The shift meant children’s hospitals would need to look at discharge milestones, DRGs, and length of stay (LOS).
“It wasn’t until this fiscal year when we were looking at length of stay and a few DRGs to get best practices in place,” Whitlow says. “For the last fiscal year, we started to look at how we could improve or move up the time of day when patients are being discharged.”
For example, there are patients whose parents do not arrive until the late afternoon or evening, so their discharges mostly occur between 3 p.m. and 7 p.m. or 4 p.m. and 7 p.m., she notes.
“We wanted to move that up to have beds available for patients earlier in the day,” Whitlow says. “So we started looking at discharge milestones.”
The hospital’s baseline percentage of discharges by 2 p.m. is under one-third. One goal is to increase that to 40% discharges by 2 p.m., she says.
When the hospital underwent an electronic health record upgrade, they defined discharge milestones, describing discharge tasks that would be the focus in improving throughput and increasing the proportion of earlier discharges, Whitlow says.
“Discharge planning starts at admission and involves understanding the patient and family and their normal daily activities,” she explains. “How can we ensure they have transportation to pick up the child at 2 in the afternoon instead of 5 in the evening?”
A key step in creating a more efficient discharge is knowing patients’ and families’ schedules. Healthcare staff and case managers also should understand clinical criteria for discharge. And they need to help patients and families set expectations about discharge so they can work together toward the same goals, she says.
“Our goal was to increase the discharge time from an average of 4 p.m. and 5 p.m. to 2 p.m.,” Whitlow says. “This change allows people to enter beds in the later afternoon.”
There were some structural changes that the hospital could make, including ensuring the patient transport team was ready for an earlier discharge. And there were cultural changes that proved more challenging, such as facilitating earlier attendee or resident rounding on patients who are to be discharged that day, she explains.
“We need to discuss how we might facilitate attendees and residents rounding on those patients that might be discharged that day,” Whitlow says. “We need to talk with them about rounding on discharge patients first so the resident can follow behind them and get all of the paperwork done.”
The hospital hasn’t made the change yet to prioritize rounding on patients identified for discharge. That is a goal and would be a big change, requiring more staff education, data tracking, and data sharing, she adds.
Cultural change involving physicians also requires physician leadership. “Our case management department has a medical director who does a lot of education for physicians and the medical team,” Whitlow notes.
“We know what the next step is, and it’s really around that culture change with rounding,” she adds. “First, we have to get the chief physicians behind us because that’s where the change will come from.”
The discharge milestones list includes the following:
• 9 a.m.: Documentation to arrange transportation, social work readiness, and case management readiness is completed.
• 10 a.m.: Providers complete medication reconciliation. “We need to make sure medication reconciliation is done earlier in the day,” Whitlow says.
• 11 a.m.: Request facility transport. “Our transport team in the hospital makes sure they have the patient on their docket as being discharged that day. So when the time comes for discharge, they are free to come and get the patient,” she says.
• 12 p.m.: Medications should be at the bedside, along with printed discharge instructions. “The discharge instructions should be printed by noon so that the nursing team can review them with patients’ families prior to the 2 p.m. discharge time,” Whitlow says. “That is our goal.”
• 1 p.m.: Enter discharge order. The physician enters the discharge order; the social worker documents that psychosocial needs are met, and the case manager indicates the plan is in place and the patient is ready to be discharged, Whitlow says.
• 2 p.m.: Discharge patient.
Case managers help facilitate a timely discharge throughout the process.
For example, they round with the medical team and collaboratively come up with the date of discharge, Whitlow says.
“One thing that’s important to understanding an efficient discharge is you need everyone to understand — the medical team, the patient, the family — what the anticipated date of discharge is,” she says.