Many hospitals in the country operate at capacity, and many patients are boarded in the emergency department. Although there are many ED-based flow initiatives, virtually none of these address the most significant impediment to flow: boarding of admitted patients in the emergency department due to lack of inpatient beds. Only a few interventions really have any lasting and significant impact on boarding and capacity.
Explore This IssueACEP Now: Vol 35 – No 12 – December 2016
This is one of a series of interviews that highlight dramatically effective interventions to reduce boarding and crowding. Early-morning discharges can have a strong impact on capacity, virtually eliminate boarding, and also decrease the length of stay. I recently sat down with Katherine Hochman, MD, to discuss NYU Langone Medical Center’s efforts to increase capacity by discharging patients earlier in the day.
- Peter Viccellio, MD, FACEP, is vice chairman of the department of emergency medicine and associate chief medical officer for the Health Sciences Center at Stony Brook University in New York.
- Katherine Hochman, MD, is assistant professor and associate chair for quality of care in department of medicine at NYU Langone Medical Center in New York City.
PV: Welcome and thank you for joining me to discuss another issue related to hospital overcrowding and flow. As you know, this is a major issue for emergency medicine, hospitals, and patient safety. Previous literature has suggested that early discharge could really have a dramatic impact on hospital capacity and on hospital flow. You have been a leader in some major initiatives at NYU in order to improve early discharge.
KH: Thanks very much for having me. The major metric that changed how we viewed early discharge was the fact that patients who came up to the floor after 1 p.m. stayed an average of 0.6 days longer even after you adjusted for all the different diagnoses compared with those patients who physically arrived on the floor before 1 p.m. This was a major eye-opener for us; the metric that really changed it all was that 0.6 increase in length of stay.
PV: There are five or six articles that looked at length of stay as a function of boarding, and the punchline was that there was roughly a day increase in stay if you boarded patients in the emergency department. When we initiated the full-capacity protocol, we reversed that. We were always curious as to why. If you admit and board a patient in the emergency department, they are going to get their antibiotics and their CT scans, but they’re not going to get care management, social work, and other inpatient services. If you don’t get them up in the morning, they lose that day.
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.
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.
PV: To what degree was the physician workday impacted by this process? In many places, they’re not finished with rounds until 11 a.m. or noon, and they don’t do discharges until after that.
“At 9 a.m., nurses and doctors, social workers, and care managers all get together and talk about the issues for the day. One of these issues is early discharge. The team identified the three to six patients on their unit that are being discharged home, and the doctors have already rounded on them; those people could be discharged early.” —Katherine Hochman, MD
KH: We tried to work smarter instead of harder. It meant adjusting the resident conferences from the morning conferences to the afternoon. We also created a daily safety huddle in the morning. At 9 a.m., nurses and doctors, social workers, and care managers all get together and talk about the issues for the day. One of these issues is early discharge. The team identified the three to six patients on their unit that are being discharged home, and since the doctors have already rounded on them, those people could be discharged early.
PV: Before we get to the nitty-gritty details of the obstacles, what was the overall end result?
KH: The effort was started in March 2012. We quickly rose from the single-digit percentage of discharge before noon to over our target, which was 30 percent. We’ve sustained that over the years, and our most recent discharge-before-noon rate has been over 40 percent.
PV: What did it take to accomplish this?
KH: I think it is important to note that this effort did not cost the institution any money except for some pizzas, cupcakes, and a few gift cards. In terms of our process improvement, everything we did was one big, giant PDSA cycle [Plan Do Study Act]. On occasions when we missed a target discharge, we did a mini root-cause analysis with the medical director and nurse manager to determine why. Some issues were very actionable. Other times, we understood that, for example, a patient waiting for dialysis really should never have been put on the discharge-before-noon list, but we did work with hemodialysis staffing, and sometimes those nurses would come in early to accommodate a discharge-before-noon patient.
PV: Did you have to extend more hours for care managers or social workers?
KH: No. Everybody, the care management and social workers, stayed during their current hours.
PV: What was the afternoon like before this process?
KH: Our interdisciplinary rounds were critical. Currently, between 1 p.m. and 2 p.m., the teams will round at the bedside. The hospitalist, the resident, the care manager, the social worker, and the nurse participate. We go around at the patient’s bedside to answer four key questions. The first question is, why is this patient here? The second is, why is this patient still here? The third is, what has to happen for this patient to leave the hospital? The last question is, where and when will this patient be discharged safely?
PV: How self-sustaining is this? Does this still need to be prodded and pushed or has it become automatic now?
KH: It’s definitely ingrained into our culture. When the care managers and social workers identify, along with the team, a discharge the day before, we put that in a computer program, and an email goes out to pretty much the entire medicine service and other services on a twice daily basis.
PV: Any pockets of opposition?
KH: The house staff had a small pocket. I think that we could have done a better job, perhaps, explaining the “why” to the house staff. The house staff constantly is rotating.
PV: Any steps going forward to further your progress?
KH: We’re moving to a slightly different metric to capture our early discharges. We’re gravitating to a median discharge time number. We’ve found that there’s sort of a flurry of activity that occurs between 9:30 a.m. and noon where people are really trying to rally to get patients out, but we want to level the load a little bit. We want to avoid the dichotomy of 11:59 a.m. is a good discharge time, but 12:01 p.m. is a bad discharge time, so we’re making a new metric called the median discharge time. The thrust of this new metric is, it’s OK if you didn’t make the 12:01 p.m. cutoff, but try and make every discharge as early as it can be. That’s really the message.