Increasing and sustaining discharges by noon - a multi-year process improvement project.

Area of Science:

• Healthcare Management
• Process Improvement
• Hospital Operations

Background:

• High hospital occupancy negatively impacts emergency department (ED) performance, leading to increased wait times and adverse patient outcomes.
• Late patient discharges are a significant contributor to prolonged hospital occupancy and ED overcrowding.
• Optimizing discharge timing is crucial for enhancing hospital efficiency and patient care.

Purpose of the Study:

• To describe a process improvement initiative aimed at increasing and sustaining early hospital discharges at a large academic medical center.
• To evaluate the impact of interventions on the proportion of early discharges and key hospital performance metrics.
• To provide a scalable roadmap for other academic facilities seeking to improve discharge timeliness.

Main Methods:

• Implementation of iterative Plan-Do-Study-Act (PDSA) cycles over 41 months, following the Institute of Medicine Model for Improvement.
• Introduction of multiple, evolving interventions designed to facilitate earlier patient discharges.
• Continuous monitoring of performance metrics, including discharge timing, Risk-Adjusted Length of Stay (RA-LOS), mortality, and readmissions.

Main Results:

• The proportion of discharge orders before 10 am significantly increased from 8.7% to 22.2% (p < 0.001).
• The proportion of discharges by noon (DBN) rose substantially from 9.5% to 26.8% (p < 0.001).
• Key balancing metrics showed no negative impact; RA-LOS decreased (1.16 to 1.09, p=0.01), and RA-Readmissions decreased (0.92 to 0.74, p < 0.001).

Conclusions:

• Sustained increases in early discharges are achievable in large academic medical centers through systematic process improvement.
• The implemented strategies enhanced hospital efficiency without compromising patient safety or increasing readmissions.
• Multidisciplinary engagement, adaptability, and institutional support are vital for successful implementation and sustainability.