A Patient-Centered Approach on Discharge before Noon: A Paradigm Shift

By Nelson Tuazon, DNP, DBA, RN, NEA-BC, CENP, CPHQ, FACHE
Vice president and associate chief nursing officer, University Health System
President, South Central Texas Organization of Nurse Executives

Hospitals continue to search for ways to improve efficiency while promoting patient safety and enhance the experience of patients and their families. Healthcare leaders and administrators feel compelled to adopt strategies to reduce cost by decreasing length of stay and by promoting patient throughput (El-Eid, Kaddoum, Tamim, & Hitti, 2015). The pressure to improve throughput for patients waiting in the emergency department, the operating rooms and procedural areas, along with referrals from other facilities, has provided the impetus for hospitals to make beds available for the next patient (Baim, 2012; Mayer, & Jensen, 2012). Across the U.S., hospitals continue to face the challenges of severe capacity constraints that contribute to bottlenecks in patient flow (Kane et al., 2016).

Wasted capacity
Several factors contribute to the unavailability of hospital beds (Rees, Houlahan, & Lavrenz, 2014; Tortorella, Ukanowicz, & Douglas-Ntagha, 2013; Walker, Kappus, & Hall, 2016). Bottlenecks are caused by various reasons – staffing shortages, delays in discharges, longer LOS. Avoidable days – defined as those delays related to barriers that prolong the stays of patients who are otherwise medically cleared and ready for discharge – may be due to missed tests and appointments, insurance authorization or lack of care coordination (Shelerud & Esden, 2017). The Institute for Healthcare Improvement has published the work of healthcare institutions that have successfully optimized bed capacity. A wasted capacity management tool determines the amount of time whereby beds are not used for patient care, especially when a patient is waiting to be discharged without a need for medical care but continues to occupy the bed (IHI, 2019).

To go or not to go: That is the question
Patients who are discharged from the hospitals to their homes have reached a milestone in their illness-wellness continuum and the transition of care represents a major step in their medical care and management. This change in the venue of care poses potential health problems after the patients have left the hospital (Couturier, Carrat, & Hejblum, 2016). It has been estimated that about 20 percent of patients have experienced adverse outcomes two weeks after leaving a general medicine service of the hospital (Forster et al., 2003; Forster et al., 2004). Several factors have been studied to identify the deficiencies related to the discharge process of patients from the inpatient setting to the outpatient setting. These gaps in the transition of care process have been attributed to hospital readmissions, visits to the emergency department and mortality (Hernandez et al., 2010; Weiss, Yakusheva, & Bobay, 2010).

Failed processes. There are many hospital inefficiencies that prevent a provider from discharging the patient early and timely. These broken processes may include cumbersome medication reconciliation processes, increasing clerical work for providers such as looking for laboratory and diagnostic results, searching for patient schedules for surgery or procedures, or waiting for the recommendations of consultants. There may be work-arounds and lack of prioritization to discharging patients because of the multiple activities, including medication administration, treatments and documentation. There are also cumbersome discharge paper works, multiple calls or pages to providers to obtain discharge orders and competing demands between discharges and admissions. Certain social factors such as lack of transportation or ride, unavailability of a family member to accompany the patient or absence of relatives to receive the patient at home may delay the discharge of the patient (Johnson, Sensei, & Capasso, 2012; Mustafa, & Mahgoub, 2016).

In the dark. When patients leave the hospital late in the day, the patient and family members are faced with the challenges related to after-business-hours issues. Patients wanting to speak with their providers may have problems reaching the physicians because the physician office has closed. Questions about prescriptions may remain unanswered and medications may be missed or delayed. Durable medical equipment (DME) companies, such as those providing oxygen and other devices, may not be able to deliver the required equipment on time. These dark-hour issues increase the patient’s risk for complications or harm and may lead to readmissions (El-Eid et al., 2015; Wertheimer et al., 2014).

Failed discharges: A patient safety conundrum. There are situations where the patient suffers as a result of early discharge – referred to as failed discharge (Forster et al., 2003; Forster et al., 2004). When patients leave the hospital unprepared and feel that they have not fully recovered, they become dissatisfied with care. The patient may be readmitted due to their worsening medical condition. When the condition is not averted, the patient and family will experience the inconvenience of returning to the ER or to the hospital (Nowak, Rimmasch, Kirby, & Kellog, 2012).

Pressed for time
Some providers may feel that they are being pushed to discharge patients early (Shine, 2015). They believe that patients are not ready to be discharged and that the patients feel pressed or rushed. Patients and families may have questions for the physicians about their new home medications, their medical care at home or their follow-up clinic visits. However, the providers may not be available because they may be tied up in the OR, in a middle of a procedure or busy taking care of more acute patients who need their attention (Johnson et al., 2012). Discharging patients may not be a priority of the providers because they may not be incentivized to receive more patients or due to their workload (Shine, 2015).

Early discharge: What is the evidence saying?  
The focus on the transition of care questions compel hospital leaders to come up with strategies to address the preferences of the patient and family members in their decisions on the patient’s healthcare needs when the patient has left the hospital, the patient understanding of the things for which the patient is responsible in managing their health, and the patient’s clear understanding of the purpose of each of the medications (Center for Medicare and Medicaid Services, 2015). Unfortunately, although the notion of DBN has become popular among hospital leaders, there is paucity in evidence that early discharge increases the patient satisfaction scores. Most literature on the impact of DBNs has been focused on the throughput in the emergency department. The results of observational studies on DBNs are mixed (Shine, 2015).

Discharge before noon initiatives have been associated with positive patient care outcomes, increased patient experience, improved bed capacity, decreased wait times in the ER and increased staff and provider experience (Resar, 2011). There is also evidence to show that DBN increases productivity and has positive financial performance of the hospitals. There is some evidence that points out the negative results due to early discharges including increased readmissions (Kane et al., 2016; Wertheimer et al., 2014).

Shifting the paradigm of early discharge to a patient-centered approach
A patient-centered approach to discharging patients before noon is founded on a paradigm shift from a reactive to a proactive mindset. Events surrounding the discharge are changed from random episodes to planned events. The encounters of the patients with the providers and healthcare staff are transformed from being rushed to becoming prepared. A patient who is unprepared and unaware of the discharge planning process may feel the experience as a rout, rather than being a personalized approach. Taking the preferences of the patients is key to an individualized, patient-centered discharge planning process. Ultimately, no member of the nursing staff should experience a rash of unexpected discharges within their assignment. Knowing which patients are anticipated to leave the hospital will allow for a programmatic patient assignment. Taking these paradigms into consideration when planning a discharge before noon performance improvement activity would ensure safe and timely transition in care of the patient (Goodson, DeGuzman, Honeycutt, Summy, & Manly, 2014; Gray, Santiago, Dimalanta, Maxton, & Aronow, 2016; Kane et al., 2016; Wertheimer et al., 2014).

Table 1. Discharge before noon: From traditional to patient-centered approach

Traditional	Patient-Centered
Reactive	Proactive
Random	Planned
Rushed	Prepared
Rout	Personalized
Rash	Programmatic

Final takeaways
Early discharge allows the patient to be at home early and to be comfortable and settled. They have time to call the pharmacy or call their physicians if they have any questions. The patient and the family are also able to observe the patient before it gets too late, after dark. Collaboration and communication are key to effective patient-centered discharge planning (Walker et al., 2016; Wertheimer, Jacobs, Iturate, Bailey, & Hochman, 2015).

Overcommunicate. Keep every member of the team informed of any barriers to discharge. Anticipate the needs of the patient from the medical standpoint, nursing care requirements, care coordination and care transition, and from the vantage points of the ancillary services including physical therapy and pharmacy. Ensure adequate and appropriate redundancy in communication, particularly during hand-off or handover to other healthcare facilities.

Use checklists. Identify specific tasks and activities that the patient may need. Assign responsibility and accountability to the various milestones that must be met to safely discharge the patients. Develop and design checklists that the patient and family could use to prepare them for the discharge, including medications, activity of daily living, follow-up doctor’s visit and transportation or ride.

Leverage technology. Utilize and optimize available technology, including iPods, iPads, patient movement and tracking systems, personal devices or computer-on-wheels. Explore electronic white boards to promote just-in-time tracking of the patient movement (Tortorella et al., 2013). The use of technology should encompass providers, the frontline staff, environmental service staff and internal patient transport. Using “low level” technology such as dry-erase boards with magnets may be an alternative as you launch your pilot program.

Make the discharge process visual and visible. Many organizations have utilized visual aids and toolkits to signal the team on the progress of the patients. Printing discharge instructions or checklists in different colors may serve as cues for the team members. Patient tracking systems have functionalities that use different colors for tabs or screens. Use the traffic lights system as a point of reference, using red as a category for a patient who is not ready for discharge, yellow for patients who may be ready to be discharged within 24 hours and green for patients who do not have a barrier for discharge for today.

Anticipating the needs of the patients results in effective and efficient discharge planning. When the staff and the providers feel unrushed and believe that they did what needed to be done to discharge the patient safely, the discharge planning process becomes a positive experience for all. The final Ps: Remember that prior (discharge) planning promotes a positive, patient-centered experience.

References
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