Improving Timely Discharges Through Nurse-Initiated Conditional Discharge Orders

Area of Science:

• Healthcare Management
• Quality Improvement
• Patient Flow Optimization

Background:

• Hospitalized patients frequently experience discharge delays due to multifactorial issues including workflow, knowledge, culture, and system inefficiencies.
• Identifying clear discharge criteria via nurse-initiated conditional discharge (NICD) orders can streamline the process.
• NICD orders foster a shared understanding of discharge readiness, potentially reducing workflow bottlenecks.

Purpose of the Study:

• To increase the percentage of morning discharges (6:00 am-12:00 pm) from 6% to 11% within the hospitalist intervention team.
• To sustain the target of 11% morning discharges for a minimum of six months.
• To improve overall patient flow through earlier discharges.

Main Methods:

• A quality improvement methodology, including Plan-Do-Study-Act (PDSA) cycles, was employed from July 2018 to March 2020.
• Interventions included the implementation and education of NICD orders, dissemination of written tools, and regular email reminders (PDSA1).
• Further education, an instructional module, and a resident champion were introduced to address hesitancy and promote adoption (PDSA2).

Main Results:

• A positive shift in early discharges, indicating special cause variation, was observed following the implementation of PDSA2.
• The process measure demonstrated special cause variation after PDSA1, with six points exceeding the mean.
• These results suggest the interventions were effective in increasing the rate of morning discharges.

Conclusions:

• Nurse-initiated conditional discharge orders, coupled with tool dissemination and a resident champion, facilitate earlier patient discharges.
• These strategies contribute to a system-wide culture change, ultimately improving patient flow.
• The initiative successfully demonstrated a method for increasing early hospital discharges.