Throughput drive lowers discharge time, LOS
ED time drops, patient satisfaction soars
When Henrico Doctor's Hospital in Richmond, VA, launched a hospitalwide initiative to improve patient throughput, the team was able to shave 2.5 hours off the average discharge time and decrease the average length of stay on the medical unit from almost 10 days to five days in the first six months of the project.
Before the project was initiated, the hospital's emergency department was frequently on diversion, says Patrick McGrady, RN, MBA, director of med-surg services at the 767-bed hospital with three campuses.
At that time, Henrico's average emergency department length of stay was 270 minutes. Patients who were admitted to the hospital stayed in the emergency department for more than 470 minutes. Bed-hold hours for patients waiting for transfer to an inpatient bed were about 1,500 a month. The percentage of patients who left without being treated was at 4%, twice the national average.
"We knew we had to change the way we were doing things and improve emergency department throughput. The hospital administration enlisted the help of a consulting firm to develop a plan to deal with the issue," McGrady says.
At the end of the improvement process, arrival to treatment time in the emergency department dropped from 77 to 21 minutes and patient satisfaction increased 563%.
When beginning the project, the hospital assembled a process improvement team of more than 90 people including hospital administration, physicians, case managers, bedside nurses, ancillary unit directors, and housekeeping staff.
When the team drilled down to look for the cause of emergency department delays, it determined that one of the biggest issues affecting throughput and bed availability was length of stay on the medical-surgical units, McGrady says.
The team began its initiative to decrease length of stay by investigating the discharge process from various points of view and outlining the roles that physicians, nurses, case managers, patients, and their family members play in the discharge process, looking for barriers to a timely discharge and ways to overcome them, McGrady says.
The team examined physicians' role, including what time of day they make rounds and what kind of communication they need to support the discharge process.
They looked at what kind of rounding the case managers were doing with the staff nurses or charge nurses on each unit or if they were making rounds at all.
"We considered what would be the best time to make rounds, the charge nurse role and how it impacts the length of stay, and the link between the physician and the case manager," he says.
The team also scrutinized what kind of communication various members of the treatment team had with patients and family members about discharge plans from the day of admission to the time of discharge.
One of the goals was to improve communication between the case managers and the charge nurses so both were on the same page about patients being discharged.
Now the case managers meet with the charge nurses in the morning and update them about potential discharges. They look for barriers that might slow down the discharge, such as home health referrals or durable medical equipment, and collaborate to ensure that services are in place and that the barriers are overcome.
The charge nurse team makes regular rounds to keep family and friends of the patient informed about the patient's condition.
The hospital's average discharge time was 5 p.m. when the initiative started. The team set a discharge goal of 11 a.m. for all patients on the medical and surgical units and almost immediately moved the average discharge time up to 2:16 p.m.
"We're still moving toward the 11 a.m. goal, but it's not set in concrete. If patients have extenuating circumstances, we're not going to push them out on the street," he says.
The team put up signs in the patient rooms informing patients and family members about the target discharge time.
"This helped facilitate the conversation about discharge with patients early in the stay. It alerts the patient and family members that they need to start planning their transportation and other discharge needs," he says.
The team also created a flier to educate patients about what they can expect during their stay, including that the discharge target time is 11 a.m.
The nurses give patients the flier and talk with them about what they may need when they go home and what discharge services are available. They can determine from the conversation whether patients need a case manager or social worker to help them prepare to go home.
"The flier helps open up the discussion about discharge planning and helps us plan for the patient's post-discharge needs early in the admission process instead of waiting until the day of discharge to set it up," McGrady says.
The case managers review the charts of patients who exceed the geometric mean length of stay on a case-by-case basis and drill down to find out why patients stayed longer than the expected length of stay.
"Some patients stay longer than expected because of complications or change of DRG. But sometimes patients stay because it's convenient for the family or because the post-acute services are not in place in a timely manner. We looked at all the reasons for the delays and ways we could speed up the process. We did a lot of communicating with physicians and a lot of work instituting culture change," he says.
The case management department tracks patients who have longer stays than expected and follows up with the physicians to address the issue. If the patient is ready to be discharged, they try to make sure the patient is discharged within two hours after the physician writes the discharge order.
"We have been looking at physician-specific data and having a conversation with physicians who might have been keeping patients in the hospital longer than necessary to find out why," McGrady says.
For instance, in the past, lab work for med-surg patients typically was the last drawn and the last to be completed.
"The physicians knew this so they came in late to check on the results and determine if the patients were ready for discharge," McGrady says.
The team created a process that notifies the labs in advance if the patient's discharge or transfer is pending.
"Now physicians get the labs in a timely manner, and patients are not waiting to go home because the lab results aren't in the chart," he says.
When the process began, case managers were seeing the patients only if the physician wrote orders for a consultation. Now, the nurses can call the case manager or social worker in when needed.
(For more information, contact: Patrick McGrady, RN, MBA, director of med-surg services, Henrico Doctors' Hospital, e-mail: Patrick.firstname.lastname@example.org.)