ACUTE CARE MEDICAL CENTERS across the United States are facing increasing financial pressure from changes in the regulatory environment and patient demand for high-value care. Patient care is shifting from the acute care environment to the outpatient setting and curbing revenue growth for acute care medical centers. As health care continues its trend toward value-based care, leaders must be proficient at controlling cost and effective clinical operations, both which are critical to an effective capacity management strategy. Effective patient flow is a bellwether for systemic clinical operations effectiveness and timely delivery of patient care.1 Many sophisticated cardiac surgery units have established evidence-based clinical pathways such as Enhanced Recovery After Surgery (ERAS) to improve patient care, reduce cost, and improve patient throughput. ERAS has been shown to be an effective tool for clinical excellence and operational efficiency within cardiac surgery programs through reduced variation in the clinical care processes.2
Effective capacity management programs may utilize evidence-based clinical pathways such as ERAS to provide safe patient care in addition to clinical operational tools including efficient day of discharge routines. Discharge timeliness is an important clinical operational indicator that leaders must be able to leverage and the downstream positive financial effects of effective patient flow, including reduced length of stay (LOS). Previous research has shown the inclusion of advanced practice providers (APPs) can positively impact both LOS and cost within surgical units.3 The effects of early discharge are immediately palpable and include efficient and clinically appropriate transfer of patient care from intensive care units to surgical step-down units where utilization of precious resources can be optimized.4 Further, when patient discharges are earlier in the day, admissions from outside facilities and the emergency department can be accepted more timely enhancing optimal care for the patient.1 This discharge timeliness project explores how APPs on a surgical step-down unit can balance the complexities of patient care and clinical operations through enhanced communication using huddles and electronic medical record (EMR) to improve patient discharge timeliness.
It is well documented that poor communication between providers and patients and among interdisciplinary health care teams is a leading cause of delay in discharge.5,6 Discharging a patient from the hospital is a complex endeavor and requires open communication across interdisciplinary teams to safely and efficiently transition care to the home or postacute care setting. Given the complex and dynamic nature of patient flow, a high-tech, APP-led, interdisciplinary approach to optimize early patient discharges through improved communication on a cardiac surgery step-down unit was deployed. APPs have been identified as key leaders of innovation within complex health care systems that can lead to improved patient and operational outcomes.6
This discharge timeliness project took place at a large, level 1 trauma center, quaternary care academic medical center in the Southeastern United States. The population consisted of adult patients discharged from the cardiac surgery service (Department of Cardiothoracic Surgery) from November 2018 to January 2020. The Department of Cardiothoracic Surgery consisted of 6 cardiothoracic surgeons who perform approximately 1500 cases annually. An APP team of 6 nurse practitioners and 1 physician assistant provided care for patients on the surgical step-down unit where most of the patient discharges occurred. These patients underwent a range of cardiothoracic surgical procedures including, but not limited to, coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral valve replacement or repair (MVR/r), CABG/AVR, tricuspid valve replacement or repair (TVR/r), transcatheter aortic valve replacement (TAVR), septal myectomy, pulmonary endarterectomy, and complex thoracic ascending aortic aneurysm repair.
REDESIGNING THE DISCHARGE PROCESS
Design thinking methodology was used as the foundation of this discharge timeliness project. This is an iterative process engineering method of generating innovative solutions to difficult problems through use of technology and an interdisciplinary team approach.7 Popularized by IDEO,8 a global design company, design thinking has been applied to address a wide range of organizational changes as a means to bridge what is humanistically desired with what is technologically possible while generating the best possible business solution. Design thinking was the chosen methodology to redesign the discharge process due to its ability to foster innovation through extensive end user engagement (interdisciplinary health care team) through an iterative process that challenged the current assumptions about the day of discharge processes.
Deploying design thinking can take different forms, but it is essential to understand the 3 pillars of empathy, ideation, and experimentation from a health care perspective and should guide the design thinking process. Empathy refers to having a deep understanding of the needs of both patients and the interdisciplinary health care team when designing a new discharge process. Patient safety was at the core of every decision point. Ideation is the process of generating creative ideas from unique perspectives. This can be accomplished through group brainstorming sessions, one-on-one interviews with members of the health care team, or focus groups that involve patients and families in addition to the health care teams. Experimentation involves the iterative testing of creative ideas that are generated.8 It is important to understand that the process of design thinking does not move forward in a linear fashion. When adhering to the pillars of empathy, ideation, and experimentation, new ideas may be discussed that will require the team to formulate new experimentation, and possibly better outcomes. Table 1 outlines a design thinking approach to improving discharge times.
Table 1. -
Approach to Improving Discharge Timelinessa
|(re) Define the problem
||Empathy—iterative process where design never ends
||A human-centric approach to understanding the problem and user. The APP is the locus of change and serves to translate clinical practice to sound business decisions. Nonclinical professionals' shadowing, tracer events, and storytelling provide insight into the daily feedback loops where APPs critically evaluate the design and implement new practices based on real-time data.
|Need finding and benchmarking
||Ideation—understand the user and design space
||Data are distributed to interdisciplinary health care team via dashboards on progress and communicated during morning rounds.
||Ideation—brainstorm and trial solutions
||Initial and ongoing evaluation of the significance of the problem by interdisciplinary health care team.
||Experimentation—innovation takes place through cocreation among interdisciplinary team
||Focus on transformation of conceptual ideas into tangible solutions that can be implemented at the point of care by APPs.
||Experimentation—iterative investigation of value of current prototype
||Small tests of change by APPs that take place in real time with feedback loops provided through data on performance daily. Use of unit-based electronic boards with metrics, EMR dashboard, or Tableau data for feedback on effectiveness of prototype.
Abbreviations: APP, advanced practice provider; EMR, electronic medical record.
Based on design thinking
model by Plattner et al.9
The design thinking process was commenced through a design workshop that included the interdisciplinary team of health care professionals, including but not limited to, APPs, physical/occupational therapy (PT/OT), pharmacy, social work, case management, unit-level nursing leaders, patient flow nurse (PFN), medical receptionist, and attending MD. Critical strategies to facilitate the discharge process were identified and were focus areas for improved discharge timeliness with a common theme of improved interdisciplinary communication. The outcome of this design workshop was a 90-day action plan that was intended to facilitate iterative improvement through weekly discharge prototype evaluation and improvement. At the end of 90 days, a prototype for a redesigned discharge framework was in place and included 6 key strategies for efficient patient discharge. The discharge prototype included identification of early discharge patients, morning stand-up bed management huddle, prioritization of early discharges, interdisciplinary transition management huddle, PFN, and electronic shared discharge plan. Strategies to improved discharge timeliness can be seen in Table 2.
Table 2. -
Strategies to Improve Discharge Timeliness
Identify early discharge patients. APP teams in conjunction with attending MD identify patients who could potentially discharge early (prior to 11 am) the day before on morning rounds. These early discharge patients are communicated to the larger health care teama via electronic medical record and on nightly handoff. This identification and communication ensure that ancillary staff can work toward efficient early discharges the next morning.
Morning stand-up bed management huddle. Surgery clinical teamb meets for 10 min at 6:50 am to discuss logistics of patient flow for the day inclusive of: operating room schedule, pending transfers from outside hospitals, potential transfers from ICU to surgical step-down unit, and potential discharges. Barriers are discussed and acted upon if identified.
Prioritize early discharges. APP team works on entering discharge orders by 9:30 am on patients who have been targeted as early discharge.
Interdisciplinary transition management huddle. APPs participate in interdisciplinaryc team huddle focused on case review of every patient on service and their clinical status, potential discharge needs, predicted date of discharge, and anticipated barriers. All information is available for every member of the health care team to view via EMR as dashboard.
Patient flow nurse. Registered nurse assigned to specific unit(s) who coordinates the admissions, transfers, and discharges of patients in a safe and efficient manner.
Shared discharge plan. Fully integrated visual tracking of 15 critical discharge elements visible through the patient EMR designed to promote discharge coordination across multiple health care providers and teams.a
Abbreviations: APP, advanced practice provider; EMR, electronic medical record; ICU, intensive care unit.
aHealth care team consists of ancillary health care professionals including but not limited to: physical/occupational therapy (PT/OT), pharmacy, social work, case management, unit-level nursing leaders, patient flow nurse, medical receptionist, and attending MD.
bSurgery clinical team consists of surgeon, APP (surgical step-down and ICU), patient flow nurse, unit-level nurse leader, perioperative nursing leader, medical intensivist from ICU, and access center nurse.
cInterdisciplinary case management huddle included APP team members, RN case managers, social work, discharge planners (members of case management team), patient flow nurse, liaisons from inpatient rehab, and home health.
Patient discharge times were measured for 3 periods: before 11 am, 11 am to 2 pm, and after 2 pm. All discharge times reflect patients who were discharged home from the cardiac surgery step-down service. This data excluded patients who were discharged to skilled nursing facilities or inpatient rehab facilities. Discharge before 11 am was the main outcome variable. The target goal for discharge by 11 am was 25% of patients who are discharged home. Discharge order entered by 9:30 am was a secondary outcome variable with a target goal of 30% of discharge orders by 9:30 am. Additional data collected included average and median LOS, discharge before noon, number of discharges between 11 am and noon, total number of minutes from discharge order to patient discharge, and total number of minutes from discharge order to medication delivery (meds to beds).
Baseline data were collected for 4 months from July 2018 to October 2018 from 284 patient discharges. The average discharge time before 11 am was 9% and 19% discharged before noon. Of those patients discharging home, 12% had a discharge order placed by 9:30 am. Lastly, the time from discharge order to the patient leaving the hospital was 151 minutes (goal is <120 minutes).
The discharge timeliness project data were collected from November 2018 to January 2020 (14-month project period). The discharge timeliness project data were collected from 1287 patient discharges. The results in Table 3 show improvements in all metrics, though the main goal of discharging 25% of patients before 11 am was not achieved. Additionally, the secondary goal of 30% of discharge orders entered by 9:30 am was not achieved. The discharge timeliness project showed the average discharge time before 11 am was 14% and 26% discharged before noon. Of those patients discharging home, 16% had a discharge order placed by 9:30 am. The time from discharge order to patient leaving the hospital was 143 minutes (goal is <120 minutes). Notably, the average LOS decreased from 8.10 (baseline) to 7.83 days during the discharge timeliness project. The median LOS decreased from 6.41 (baseline) to 6.22 days. While the goal of discharge 25% before 11 am was not met, it is organizationally significant that discharge time improved and patient LOS decreased by 6.48 hours.
Table 3. -
for Patients Discharging Homea
||Baseline Data July 2018 to October 2018
||Pilot November 2018 to January 2020
|Total discharge home
|11 am to 2 pm
|Discharge order by 9:30 am
|Time to discharge, min
Abbreviation: LOS, length of stay.
aFrom April 2019 to September 2019 discharge <11 am was 9% related to staffing challenges.
Optimizing the patient discharge process is complicated and is best viewed as part of a larger capacity management plan that balances patient safety with efficient clinical operations. The patient discharge process is complicated due to the multiple disciplines involved, patient preferences, clinical indicators, and external factors (insurance and postacute care). As previously mentioned, this discharge timeliness project identified 6 key strategies to improve discharge timeliness that have been discussed in greater detail.
Shared discharge plan
While one team or provider is responsible for entering the discharge order, that order is dependent on the aforementioned factors that may delay the discharge. Access to real-time data is critical in improving patient flow and achieving early discharges. Key to improved discharge coordination was a shared discharge plan that enhanced communication across teams and was embedded in the EMR. This was a critical strategy to improve communication around patient discharge readiness. There were 15 critical discharge elements that were included in the electronic shared discharge plan broken down by profession: APP, nursing, case management.
- APP—estimated date of discharge, physical and occupational therapy evaluation, medication reconciliation, postoperative appointment scheduled, discharge order.
- Nursing—identified discharge barriers, patient education, meds to beds requested from pharmacy, after-visit summary printed, transport requested.
- Case management—identified planned disposition, predicted score for postacute care, case management assessment completed, durable medical equipment needs, ride confirmed.
This dashboard is a visible queue to all teams involved and resides within the EMR. The discharge elements were color coded with green, yellow, and red to indicate the progress on each task. The shared discharge plan was updated daily at the interdisciplinary transition management huddle discussed next.
Interdisciplinary transition management huddle
The interdisciplinary transition management huddle serves as a means to communicate across multiple disciplines including APP team members, registered nurse (RN) case manager, social work, discharge planner (members of case management team), PFN, liaison from inpatient rehab, and home health. Case managers within this academic medical center are RNs (many who are master's-prepared RNs) and serve as the primary team responsible for coordination of care and steward of effective discharge planning. According to the Case Management Society of America,10 case management is defined as:
Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes.
The interdisciplinary transition management huddle, moderated by the RN case manager, is a mechanism for updates regarding daily patient progress and clinical status updated within the shared discharge plan located in the EMR. The RN case manager completes a standard evaluation on every patient and facilitates communication among health care teams, patients, and family members related to the patient discharge status and barriers to discharge. The APP is present at the Interdisciplinary transition management huddle and discusses each patients anticipated date of discharge and associated barriers to discharge. This first hand information from the provider allows for immediate action on addressing barriers to discharge.
Identify early-discharge patients
The impact of frequent and accurate communication across multiple teams on discharge timeliness cannot be understated. Patient care is shared across multiple interdisciplinary teams, all of whom play an important role in the plan of care. The need for improved communication among team members regarding patient discharge readiness was a main theme in brainstorming sessions. APP teams in conjunction with attending MDs identify patients who could potentially discharge early (prior to 11 am) the day before on morning rounds. These early discharge patients are communicated to the larger health care team via the shared discharge plan in the EMR and on nightly handoff. This high-tech solution allows for all members of the interdisciplinary health care team to be informed in real time and can work toward efficient early discharges the next morning.
Morning stand-up bed management huddle
The morning stand-up bed management huddle is a mechanism for brief communication among key clinical and administrative team members regarding the operational state of the cardiac intensive care unit (CVICU), surgical step-down unit, and cardiac surgery operating rooms. The group meets for 10 minutes at 6:50 am to discuss logistics of patient flow for the day inclusive of: operating room schedule, pending transfers from outside hospitals, anticipated direct admissions, potential transfers from CVICU to surgical step-down unit, and potential discharges. Barriers are discussed and acted upon if identified. Morning rounds are conducted at 7 am immediately following the stand-up bed management huddle as to prioritize early discharges that have been identified.
Prioritize early discharges
The main outcome of this discharge timeliness project was increase discharges by 11 am. The target was 25% of patients to be discharged by 11 am. To achieve this target, it was identified that patients who are discharging need an order to discharge by 9:30 am. The motto of “just one discharge” was adopted by the APP team to identify one patient on the service who could be discharged early the next day. This was communicated via the EMR and in the interdisciplinary transition management huddle the day prior to the patient's projected discharge. The next day during morning rounds, the patient's clinical status was reviewed and, if stable overnight, discharge orders were entered prior to 9:30 am.
This identification of just one early discharge was a shift in behavior and clinical reasoning for many APPs. As health care providers, APPs are focused on the patient's safety above all else. Prioritizing what on the surface can be perceived as a purely operational metric, early discharge can be off putting to many providers. However, the engagement of the APP team to lead the project was identified early as the most effective path to sustainability. Once the APP team was engaged, it became clear that when patient flow improves from the step-down unit to home, there are fewer delays in transfers from the CVICU, more predictable timing of transfers from outside hospitals, and available beds for critically ill patients in the emergency department. As a quaternary care academic medical center our mission is to treat high-acuity patients, and this is what resonates the most with providers. Having available beds to accept high-acuity patients is critical to achieving this mission.
Patient flow nurse
In high-performing acute care medical centers, discharge planning starts from the time of admission and progresses throughout the patient's hospital course. As part of a larger effort to improve patient flow and LOS, an RN was assigned to specific unit(s) to coordinate admissions, transfers, and discharges of patients in a safe and efficient manner. These PFNs were in place prior to the discharge redesign project and were key members of the health care team and responsible for the coordination of high-quality transitional care planning. Table 4 describes the responsibilities of the PFN.
Table 4. -
Description of Patient Flow Nurse Responsibilities
Intent: The PFN role was designed to encourage patient throughput by supporting the roles below.
Increased time with primary nurse
Enhanced patient and family education
Provides a single point of contact regarding discharge needs
Increased time with patients
Improved response time to patient needs
Provides seamless handover for newly admitted patients and transfers
Responsibilities: The PFN collaborates with the health care team to facilitate:
Discharges—Prioritize early discharges at the beginning of the shift. Act as a liaison between the interdisciplinary health care teams to efficiently discharge patients and improve patient satisfaction
Admissions—-PFN will “pull” patients from admitting or transfers from CVICU. Complete admission documentation including history, full nursing assessment, and communicate to primary nurse patient needs
Abbreviations: CVICU, cardiovascular intensive care unit; LOS, length of stay; PFN, patient flow nurse.
The PFN was designed to support throughput and provide a single point of contact to the provider, primary nurse, and patient to impact patient flow safely and efficiently. They are also responsible for incoming admissions, transfers, and discharges and often perform those duties independent of the primary nurse. As nurses, PFNs provide support to the primary nurse and patient by providing comprehensive discharge education regarding incisional care, medication management, and signs and symptoms of postoperative complications that are imperative to high-quality transitions. The PFN coordinates with the pharmacy for bedside medication delivery and teaching. Medication access education has been shown to improve patient outcomes, particularly readmission related to medication error or adherence.11
While this discharge timeliness project saw improvements in the key measure of discharge before 11 am, there were several limitations. First, this discharge timeliness project was a department-specific project and may not be applicable to other medical units. The cardiac surgery step-down service was staffed by an APP team that afforded the project a high level of engagement and buy-in to the redesign process. Many medical units in academic medical centers are staffed by residents who are often engaged in teaching rounds throughout the morning and may not be amenable to entering discharge orders by 9:30 am. Entering the discharge order by 9:30 am was an effective tool to improve discharge by 11 am.
Second, APP staffing on the cardiac surgery step-down was found to have a major impact on discharge before 11 am. The service is typically staffed with 3 APPs. However, from April 2019 to September 2019, the service was staffed daily with 2 APPs due to unforeseen circumstances. This causes an increase in the number of patients cared for by a single APP team member. The byproduct is more clinical work to be completed in the morning (patient review and attending to critical patient care issues) prior to discharging patients. As seen in Table 3, baseline discharge time before 11 am was 9%, which was same percent of discharges prior to 11 am from April 2019 to September 2019.
Third, hospitals must not only look at the financial benefit in reducing the LOS, but also consider how unnecessary hospital days may negatively impact patient safety. Reducing LOS has been shown to improve hospital finances through decreased variable costs (reduced resource utilization) and opportunity to gain additional volume.12 Additionally, by reducing LOS, hospitals may also realize additional cost savings from improved patient safety through reduced infections or other hospital-acquired conditions.13 Future research is needed to quantify the financial and patient safety synergy to patients undergoing cardiac surgery to fully understand these outcomes.
Lastly, discharge timeliness programs must be integrated into larger programs of care coordination and strategic capacity management programs that optimize LOS. Key to the success of this discharge timeliness program was the integration of the shared discharge plan into the EMR. This ensured consistent and accurate clinical communication across multiple disciplines all working toward the goal of safely and efficiently transitioning the patient to the next level of care. While discharge efficiency metrics were included in the EMR discharge dashboard, there is currently a lack of understanding on how to blend both quality and efficiency metrics in an electronic dashboard. Therefore, it is critical that balancing quality improvement measures are reported and may include LOS, readmission rate, surgical volume, case mix index, mortality and morbidity rates, outside hospital transfer rate acceptance, among other service-specific quality metrics. A holistic approach to measuring capacity management can add context to interpretation of the complexities that encompass patient throughput.5
Cardiac surgery programs have a responsibility to ensure that patients progress in the safest and most efficient way possible to ensure the highest quality of care is provided. Discharging patients efficiently supports smooth patient transitions from the operating room to the intensive care unit and from the intensive care unit to the step-down units. Discharge timeliness is a complex metric of throughput efficiency that is best tackled with an interdisciplinary approach led by the clinicians who are at the frontline of patient care. Information technology provides a platform for effective communication across multiple disciplines through EMR integration and real-time dashboard solutions associated with patient discharge metrics. This increased flow of information allows APPs at the point of care to codevelop unique solutions to effective patient discharge and incorporate supplementary throughput initiatives into a concise and successful discharge timeliness prototype. Patient discharge timeliness should not be addressed in isolation, but one of several patient throughput efficiency metrics that is part of a larger capacity management strategy.
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