KH: Discharge planning should be started on the day of arrival. You absolutely lose the efficiencies that you have with the team if a patient is in the emergency department and they don’t have that team surrounding them. We started this discharge-before-noon initiative, and it absolutely was a multidisciplinary team effort. We knew that we were only as strong as the weakest link. If housekeeping didn’t come up and clean the room, you could have a whole floor of rooms almost ready to go. We had a major kickoff event in which anybody who touched a patient or had anything to do with patient care was included. We jam-packed everybody into one of the conference rooms and discussed this before-noon initiative. We wanted to really hammer home the point that it’s better patient care if the patient is able to safely leave the hospital—the earlier, the better. We don’t want patients acquiring hospital-acquired illnesses, infections, or complications because they are hanging around waiting for lunch or for dinner. If a patient left before noon, the patient could get their medications from the pharmacy. If there was trouble with a pharmacy, someone would be around to field the phone call, and patients would be able to make their follow-up visits in the light of day. Not only was it important for the patient to be discharged, but never sacrificing safety meant that the patient in the emergency department could come up to the floor, the patients in the ICUs could come down to the floor, and also the post-anesthesia care units could become decompressed.
Explore This IssueACEP Now: Vol 35 – No 12 – December 2016
PV: Was this something that you started on medicine?
KH: There had been a goal set by the administration for a 30 percent discharge-before-noon rate. It hadn’t been achieved for several quarters. I would say it was definitely a combined effort of administration and frontline staff and key medicine and nursing leadership.
PV: Usually when you get such a group together, there’s a cacophony of voices explaining why you can’t. How did you deal with all that?
KH: It certainly was an issue. Right before we did the kickoff, I had one of our administrative fellows at the time, Martha Bailey, come around with me while I was on the wards, and I asked Martha to write down the reasons why patients were not being discharged before noon. For 30 patients that we discharged, there might have been 40 different reasons why the patients did not go before noon. They included, “I wanted to stay for lunch,” “I didn’t know that I was being discharged,” “I don’t have a ride,” “I don’t have any clothing,” “My family doesn’t know.” We realized very quickly that there wasn’t a single answer that was going to fix this problem. That’s why we involved every member of the interdisciplinary team, so that everyone knew the plan for the patient. We even had a way of prioritizing patients who needed a specific study or specific lab tests. Those patients would get prioritized first to get their study done so that we could make a decision on the day of discharge.