Why Won't They Leave? Discharge Timing Doesn't Speed Departures

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.

SAN DIEGO – Moving the timing of discharge orders from afternoon to morning did not get patients out the door earlier in the day in a study at Mount Sinai Medical Center, New York.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times," Dr. Ramiro Jervis said at the annual meeting of the Society of Hospital Medicine.

After 6 months of employing multiple strategies to get discharge orders written before 11 a.m., the mean time of discharge orders for patients on medical wards improved by 78 minutes, from 1 p.m. to before noon, but patients left the hospital only 12 minutes earlier on average, closer to 4 p.m., said Dr. Jervis, director of the quality hospitalist division at the medical center.

Results were similar for teaching and nonteaching services at the 1,171-bed tertiary-care urban teaching facility.

To determine why patients didn’t leave earlier, Dr. Jervis reviewed 51 charts for patients discharged after 3 p.m. from a teaching medicine unit during a 30-day period, with those discharges happening more than 4 hours after the actual discharge order.

In about 63% of those cases, the hospital had to arrange transportation for the patient, which may have delayed discharge. Sixteen percent of patients were awaiting family, and approximately 16% had tests pending. Some 4% were awaiting a physician or consultant.

"An intervention to improve discharge order times is not sufficient to impact actual discharge times."

The hospital will continue to offer incentives to physicians for discharge orders to be completed before 11 a.m. and will prospectively investigate why patients don’t leave soon after the orders are given, Dr. Jervis said. The investigators also plan to add incentives for nurses, social workers, and patients for early discharges.

Dr. Jervis and his associates received an honorable mention from judges picking the best research presentation at the meeting.

The medicine service at the hospital handles 1,000 discharges per month, excluding interventional cardiology. To shift the timing of discharge orders, the study organized discussions and recording of discharge order times at resident reports each morning. House staff and hospitalists received weekly feedback. Each month, the two top-performing teaching teams received awards – such as $30 gift cards for house staff members – for completing earlier discharge orders.

In addition, organization of medical teams shifted to geographic localization. Providers participated in daily interdisciplinary rounds. Teaching rounds were moved to afternoons so that the morning focus would be on work rounds, Dr. Jervis said.

Other potential reasons why discharge times didn’t shift as much as discharge order times could be that nurses were holding off on discharges or perhaps patients were staying for meals, he speculated.

Another possibility, albeit doubtful, he said, is that the residents were gaming the system which he explains this way: "If you discharge all your patients in the morning, and then cancel discharges, you’ll have lots of discharge orders in the morning and win the prize, even though patients don’t leave earlier."

As the project continues, unit directors will now assess and prioritize potential discharges with staff after interdisciplinary rounds, he said.

Mount Sinai Medical Center had 57,913 discharges in 2011, approximately one-fifth of which were from medical services. The hospital typically operates at approximately 80% capacity.

Improving "throughput" can help maintain a high volume in the face of limited inpatient capacity, Dr. Jervis said. Earlier discharges may free up inpatient beds, decrease strain on crowded emergency departments, and provide timely inpatient care to patients admitted from the emergency room.

The timing of discharge orders often has been considered to be the main factor in the timing of patient discharge, but this assumption had not been tested until the current study, he said.

Dr. Jervis did not report his financial disclosures.