How to unjam your discharge bottlenecks

Failing to do so means lost revenue

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Are admitted patients being held for a long time in the emergency department while they wait for an inpatient bed to become available? Do patients in specialty care units stay longer than necessary because there is no general unit bed for them to be transferred to?

When ambulatory surgery patients need to stay overnight, are they kept in a hallway or a special holding area until an inpatient bed is freed up? If you answered yes to any of these questions, your organization has a serious patient flow traffic jam. Inability to bring in new admissions or transfer inpatients to the appropriate level of care means lost revenue for your organization.

In addition, patient satisfaction is adversely affected by long waits for inpatient beds. Often, this problem is blamed on a lack of bed capacity when in fact the source of the problem is inefficient patient flow. The beds are there; the hospital just doesn’t turn them over effectively.

An old idea that is regaining popularity is the discharge lounge. Once considered merely a convenience for patients who don’t have a ride home immediately upon discharge, the discharge lounge has become an important bed control mechanism.

The basic idea is to free up hospital beds for patients needing acute care or active clinical observation. Patients who are ready to leave the hospital can go to the discharge lounge while waiting for their ride home. These can be discharged inpatients, ambulatory care patients, or people who have been discharged to home from the emergency department.

A clinician, often a registered nurse or licensed practical nurse, and support staff or volunteers staff the lounge. These people can assist discharged patients by telephoning family members, arranging for physician follow-up appointments, helping patients plan for basic home care needs, and obtaining prescribed medications from the outpatient pharmacy. If there still are some unresolved financial issues, counselors can discuss paperwork or insurance information with patients in the discharge lounge. And of course, light meals or snacks are provided.

If your hospital does not enforce a defined discharge time, this issue must be revisited before creating a discharge lounge. If patients are discharged at any time throughout the day, the hospital’s ability to manage patient flow is greatly hampered. Are patients often allowed to stay for lunch or dinner, even though they no longer require acute care services?

This may improve patient and family satisfaction with the discharge process; however, those patients in holding areas waiting for inpatient beds likely will be very dissatisfied if admission is not timely. Physicians must be encouraged to discharge patients in the a.m. so hospital beds can be freed up for new admissions. Show physicians the big picture and let them see how they contribute to success or failure. Key statistics on discharges and admissions will let doctors understand how missing an 11 a.m. discharge can impact overall patient flow.

It should not be acceptable for physicians to discharge patients during evening rounds when a discharge order would have been just as appropriate in the a.m. Physicians should receive regular feedback about their discharge practices and the effect of these practices on patient flow, e.g., number of patients discharged after 5 p.m. vs. number of patients in holding areas waiting for admission to those beds. Physicians who are repeat offenders should be referred to the department chair for action.

Patients and families should be notified of the hospital’s discharge time and encouraged by the physicians, nurses, and case managers to leave by this time when they have been discharged. Case managers should reinforce the discharge time by inquiring about rides home, etc., early in the hospitalization so special arrangements can be made if necessary.

If the hospital has a defined discharge time, the environment may be right to create a discharge lounge. Patients who are ready for discharge but for some reason cannot leave the hospital right away can wait comfortably in the lounge until their departure. If possible, locate the lounge in close proximity to admitting, the emergency department, or an appropriate exit area.

Ideally, patients can look out the window and watch for their rides. The discharge lounge should feature reclining chairs, televisions, private bathrooms, and other amenities.

The aim should be to develop a "home from home" atmosphere on the unit. It should be open during the day and close sometime in the evening. Staff the area with appropriate clinicians (e.g., RNs or LPNs) in addition to support staff. Otherwise, emergency department staff or inpatient bedside nurses may resist the lounge idea — afraid that patients are being moved to an unsafe, unmonitored area.

Waiting for physicians and nurses to use the discharge lounge can lead to no use. Have the clinician assigned to the discharge lounge, as well as case managers, make rounds to identify patients ready for discharge who are candidates for the lounge. Staffing the lounge with volunteers who simply wait for discharged patients to be escorted in will result in minimal usage. Case managers should reinforce the purpose of the discharge lounge and encourage patients to take advantage of this service if it appears that departure may be delayed.

Nursing staff also must be involved in voicing this encouragement. New unit admissions can mean additional work for the nursing staff, so it is understandable why they may be reluctant to persuade patients to vacate beds as soon as possible. The inpatient units often are full, so moving out healthy patients who require relatively little work frees up beds that are immediately going to be filled with still-sick, high-maintenance patients.

So in the current environment, there actually is an incentive for caregivers to slow the discharge process. That’s why support of the discharge lounge by senior leaders as well as charge nurses and supervisors is very important.

At first, there may be some reluctance by physicians or staff to release patients to the lounge in case an untoward incident occurs. To overcome this resistance, undertake an awareness-raising program of education to gain support of the medical staff and other caregivers.

Once the discharge lounge is equipped and staffed, make it available as a pilot project. Gather patient satisfaction data from all patients who used the lounge to determine success from the patients’ perspective. Also gather information on how many inpatient and emergency beds were freed up by having discharged patients use the lounge. Success of the initiative can be measured by evaluating issues such as:

  • length of stay in holding beds for patients awaiting admission;
  • frequency of the hospital being on divert status;
  • percent of emergency patients waiting more than four hours from decision to admit to being transferred into an inpatient bed;
  • percent of ICU/CCU patient transfers to general unit beds that occur within four hours of transfer order.

The measurement data, if they support the value of the discharge lounge, can help build momentum for increased use of the lounge. Eventually, the discharge lounge nurses will be able to free up even more valuable resources by providing a safe and patient-friendly atmosphere for people waiting to leave the hospital.