"CODE HELP!" is a frequent page that travels through the Lahey Hospital and Medical Center beeper system and lights up the devices of many of the health care professionals working at this busy 340-bed tertiary care facility in Burlington, Mass. It is a directive to prioritize patient discharges, while admitted patients wait in the crowded emergency department for beds to become available.
This is a common problem faced by many medical centers with unrelenting patient traffic, limited acute care beds and complex patient morbidity requiring inpatient-level care. Lahey is the hub of a recently formed multihospital system and is experiencing continued growth in patient volume. Efforts to decrease length of stay and increase bed availability, safely and efficiently, is of utmost importance. Messy and unpredictable discharge planning, however, can lead to delays in check-out times.
In addition, extended ED boarding times not only affect patient satisfaction but also safety. Multiple studies have shown increased rates of hospital mortality and longer lengths of stay associated with ED patients not receiving timely inpatient-level care. According to the Joint Commission, 50 percent of sentinel events occur in the ED, and approximately one-third of these are related to overcrowding. Reducing ED boarding time can have positive financial implications as well, research says.
Looking for answers
To address issues like these, the Lahey administration created a multidisciplinary task force to develop an early morning discharge program in order to decompress the ED and create greater bed availability for the influx of patients in the afternoon, when gridlock is most palpable. The goal: discharge 20 patients by 10 a.m. hospitalwide. The target was decided on to address the situation of 15-20 patients frequently boarding in the ED each morning — a number that represents 30 percent of average daily discharges. Thus, the initiative is named “20 by 10.” The purpose is simple enough, but, from the start, the initiative faced multiple hurdles:
- A commonly accepted culture of late-afternoon discharges (with an average discharge time of 3:25 p.m. prior to project initiation).
- Providers with little incentive to prioritize discharges during a busy morning that includes patient rounding and who did not have a direct appreciation of adverse events related to ED overcrowding.
- Bridging the communication gap among the multiple role players who participate in successful patient discharge, including family members.
- Promoting the initiative while the hospital acclimates to a new electronic medical system.
- Limited frontline engagement in efforts related to quality improvement perpetuated by an environment of low employee satisfaction.
The 20 by 10 initiative kicked off 1½ years ago, with a steering committee consisting of the hospital's chief medical officer, a service line administrator, the physical therapy director, a senior hospitalist, nursing leadership and staff nurses, case managers, and a medical resident. The group analyzed the patient journey from admission to discharge and identified best practices that would promote early discharges, including:
- Identifying suitable patients prior to admission for elective surgery, as well as emergency admissions who might potentially be good candidates for a 10 a.m. discharge.
- Recognizing early the day before that a patient will be discharged the following day and communicating the discharge time with the patient, family and nursing staff.
- Appropriately ordering tests and workups to prevent delays in the morning.
- Confirming the day before that transportation will be available by 10 a.m. the day of discharge.
- Placing the discharge order by 8 a.m. to allow enough time for the floor nurse to educate the patient about the discharge plan and medication list.
The task force has used a variety of strategies to stimulate and incentivize the improvement effort, including:
- Continually updating frontline staff about project progress, sharing best-practice tactics and factoring in staff feedback for continuous quality improvement.
- Utilizing a staff checklist on the new electronic health record system to methodically guide the process of discharge planning and requirements for patients designated for a 10 a.m. departure.
- Encouraging multidisciplinary rounds to strengthen the communication loop between all personnel involved in the patient’s care and discharge planning.
- Promoting data transparency and sharing results with individual floor units and all department heads, hoping to spur accountability and friendly competition.
- Providing gift cards to medical residents who achieve the most discharges by 10 a.m. and recognizing nursing units for progress made in the form of pizza parties.
- Offering free parking and breakfast vouchers for patient family members who are responsible for providing transport.
- Employing a social marketing approach to demonstrate that the project is focused on improving patient safety and satisfaction rather than just maximizing bed availability.
More work to do
Since the beginning of the 20 by 10 initiative, the goal of 20 discharges by 10 a.m. has yet to be achieved. The program currently lacks adequate recruitment of potential patients to meet the target, and certain system barriers continue to delay discharges — notably, discharge orders placed after 8 a.m. and late arrival of patient rides.
Nearly half of these barriers are staff- and care-team dependent. The marketing campaign to promote earlier discharges, however, has had a positive effect on practices and has led to a significant increase in the percentage of total hospital discharges between 10 a.m. and noon compared with the previous baseline. Partly as a result, the overall median discharge time has improved from 3:33 p.m. to 2:52 p.m. hospitalwide.
Percentage of total morning Lahey Hospital discharges pre- and post-intervention
The preliminary results are encouraging, but the task force realizes that a hospitalwide transformation in practice behavior is difficult and requires patience. Culture change is uncomfortable and demands strong leadership, organizational engagement, resilient teamwork, meaningful performance measures and constant re-evaluation of the improvement process.
Perhaps the goal of 20 patients discharged by 10 a.m. is too ambitious. Could utilizing discharge-efficiency metrics to determine bonus compensation for physicians be effective? Even innovative tactics such as creating “discharge lounges” or boarding patients temporarily on the inpatient floor rather than in the ED may prove to be worthwhile. Lahey is in the midst of building a bigger ED to address overcrowding and accommodate the high volume of patients. Vanderbilt University Medical Center, however, studied the effects of ED expansion and realized that it did little to reduce the “bottleneck effect,” and, surprisingly, was followed by an increase in the length of patient stays in the ED.
If creating capacity is not the solution, then the entire patient journey, from ED to inpatient unit and ultimately to discharge, needs to be evaluated using a “lean" management approach to identify and solve problems. Regardless, success will depend on varying strategies, a collaborative process of evaluating frontline feedback, recognizing barriers and understanding what motivates staff to engage in a sustainable manner.
Anubhav Kaul, M.D., M.P.H. is a hospital administration fellow at Lahey Hospital and Medical Center in Burlington, Mass. David Brabeck, M.D., is a senior hospitalist and assistant program director of internal medicine at Lahey. Michael Rosenblatt, M.D., MBA, M.P.H., is Lahey's chief medical officer.