The Art and Science of Patient Discharge

Intro: On today’s episode of the Patient Flow Podcast, we welcome Deb Kaczynski, Managing Consultant for TeleTracking’s Consulting Team. Deb works with organizations to help support and guide them to optimally use the TeleTracking technology. She does this by helping influence how they adopt the technology to change management and process redesign. Let’s listen in as Deb sheds light on this critical step in the process.

Deb: I'm in my fourth year now with TeleTracking. I came to Tele after spending over 20 years with the University of Pittsburgh Medical Center. I live in Pittsburgh, Pennsylvania, which is the headquarters of TeleTracking. So I spent many years in patient flow with UPMC. Probably 15 years ago I began all of my patient flow work. And we were TeleTracking clients. So it gave me an opportunity to understand the company and the technology, and I've had experiences with the Toyota production system, I have a black belt, and I have also done work with the Institute for Healthcare Improvement out of Boston, and patient around the country, and actually some international work.

With UPMC, oversaw a lot of the patient flow activities. For at that time, UPMC had 17 hospitals. So, we utilized our technology and tried to put best practices in place across our system.

Susan: Deb, as you know, always have the challenge of making sure they're creating enough capacity. And one way to do that is through efficient discharge processes. You have to get the patients out in order to get the new patients in. And often times, people think it's important to get as many patients as possible out as early as possible. But could you talk about the benefits of staggering those discharge times and working on more of a 24 hour cycle?

Deb: Absolutely. Just about every client we begin work with, and over the years in the past 10 to 15 years, there's always been this drive, let's get as many people out by 11 as we can. Hospitals would comment, "Hotels have those signs on the door that you have to leave by 11. Can't we put a sign on the door?" What we've realized over time though is when we try to do that, we're just putting undue stressors on our system. When we say, "Everybody out by 11," everybody's focus then becomes let's try to get the patients who are going be discharged today out as fast as possible, as soon as possible. That ups the workload of the nurse who's discharging the patient. It uploads the work of the transporters who have to take those patients out, and ultimately, the environmental services team that has to turn and clean those rooms. And they just don't have the amount of resources available early in the day to accomplish those things.

The other thing that it does is it puts undue stress on your system for getting test results, for having physicians write discharge orders, having PT see patients early. Really, we've found that it's not everybody that you have to get out by 11. You really only have to get a small portion of them out by 11. And by preparing that small portion 24 hours in advance, you can be much more successful in getting your smaller amount of patients that needed to go out by 11 by that time.

Susan: Can you talk about how techniques such as queuing theory and implementing the utilization curve can help effectively manage this type of discharge process?

Deb: Sure. You know, I can most ... The basic way to explain this is everyone's familiar with the line at Starbucks and the queuing system. And the line begins when you don't have enough folks there to serve ... Baristas to serve the coffee. And so we found out through queuing that when you put stress on a system, when the demand is great, if you don't have enough folks to support that demand, lines are created. There's a wait line. Every hospital has fixed capacity. You're a 200 bed hospital and 200 beds in all you have. But then you have unscheduled demand coming into your ED every day. The doors are open, and patients are coming in. And so what happens is as those patients come in, if you can't meet that demand by providing additional empty beds or in the Starbucks world, baristas, those folks are going to line up and form a queue in the emergency room, or in the PACU.

We found that by reducing the capacity by just a small amount, you don't have to reduce the capacity by 100 percent. If you just get about 25 percent of the discharges for the day out by 11 o'clock, you can drop that utilization curve enough so that you can bring the patients in from the emergency room as they're arriving. So in queuing theory, we say with relatively fixed capacity and unscheduled demand, high utilization results in long queues. That's the bad part about queuing. But the positive effect is at times when your utilization is high, and for us in hospitals, that means when we're near capacity, like every hospital is today, planning for the timely transition of just a few appropriate patients an increase the available capacity and then have a substantial effect on your delays.

Susan: What are some tactics that people can do to increase the level of accuracy when it comes to these things? When they're looking at the patients in their unit, how can they accurately predict who's going to be ready to go home versus who is probably going to need a longer stay?

Deb: The greatest advice we can give is begin this planning 24 hours in advance. If you are discussing this morning today's discharges, you are behind the curve. You're probably not gonna have an early discharge, if a discharge at all. So probably the most important thing that we can do to increase accuracy is through your multi disciplinary rounds, your discharge huddles that almost every hospital now has almost every morning, is to begin discussing tomorrows discharges at that huddle in the morning. You can finalize today's discharges. But you really want to be concentrating on who do we think will go home tomorrow? Who's gonna be medically stable by tomorrow? Who do we think we can have all the discharge arrangements made by, by tomorrow?

And usually, probably in the morning when you have your discharge huddle, you can probably be about 50 percent accurate in who you think may go home tomorrow. You still have doctors around. There's still test results to be read. But the next key point in the day comes around mid afternoon when case managers and charge nurses can, once again, look at that list of discharges for tomorrow, doctors have rounded, tests have been completed, patients have been up and about for the day. And now you can continue to fine tune that list and say, "You know what, we felt this morning Mrs. Jones was going to go, but it doesn't look like it today. So let's take her off this list." Or at three o'clock we can say, "Mr. Smith had a really good morning and the physician feels he can go tomorrow. So let's put him on the list."

So mid afternoon, refining that list of discharges is very helpful. And then the final step is the handover of charge nurses at seven pm, and again at seven am, if that handover includes a quick review of the list of the discharges that we've anticipated for tomorrow when you have your handover tonight, and what can the evening and night shift do to help support that discharge? Let's get that work done so that in the morning, when the night shift nurse is handing over to the day shift nurse, those discharges that you predicted yesterday for today, you've now worked on those for 24 hours. And the chances of getting a couple of those patients out by 11 o'clock are greatly increased.

Susan: What are some of the other challenges that are involved when occupancy at the hospital is high as the staff is being forced to focus solely on the discharge process versus some of the care issues that they need to manage.

Deb: Sure. This is really an important point that sometimes we really don't realize. That period of time. Traditionally, if we let things happen in hospitals without proactively managing them, we will have a lot of discharges occurring about the same time a lot of admissions bed requests that they made for admissions in the ED and the PACU. We call that churn in a hospital. Churn is when a nurse, who might have a five patient assignment, has three patients going home. And when those three go home, three new patients come in. So they may really have taken care of eight different patients on that day.

By spreading out that work a little bit, that allows the nurse to have a little bit of a breathing time to take a look at the patients who aren't going home today. And what do I need to do to keep them on their path? If the patient was just admitted yesterday and is probably goning be here for three days, what do I need to do today to make sure that our patient stays on track to be discharge in three days? Because if my total focus is on today's discharges, I may miss an important thing I should've done this morning for my patient who's going nowhere to make sure that they stay on that continuum to be discharged in a timely manner. And when those patients aren't discharged on a timely manner, length of stay goes up. And when length of stay goes up, we know that that costs hospitals money.

And the other issue is the longer a patient stays in a hospital, unfortunately, the greater chance there is something bad happening to them beyond the point where they need our care. They can get an infection. They can fall. There's a few other things that can happen when they're there longer than they should be. So the challenges of sliding some of those discharges to early, but not all of those discharges to early, makes you understand that I have time to look at my patients who are going nowhere today, and keeping them on track to have a safe discharge in their expected length of stay.

And that's so important to the financial wellbeing of the hospital and the physical wellbeing of the patients.

Susan: What would you say the key best practice is that health systems should follow when it comes to a discharge?

Deb: I think the key best practice we talked about in pieces throughout this whole discussion is that discharge is a 24 hour cycle. The discharge process is not something that the daylight nurse or the care manager takes care of on daylight shift. It's a 24 hour process. And that 24 hour process really is comprised of probably four key events. The first being some type of multi disciplinary huddle in the morning that will allow us to review all the patients on the unit, making sure that those who are not going home are on the path for a successful discharge when expected, but also beginning to predict who may go home tomorrow to set the stage for us to begin that work 24 hours in advance.

The next key tactic then is that mid to late afternoon discussion just between a case manager and a charge nurse. It doesn't have to be a huddle. We call it running the board. And it's really a list of all of the little d's, the lowercase d's that have been entered into TeleTracking for potential discharge tomorrow, and are we still on track with those? Do we need to take some off? Should we add some? This next step improves your accuracy. And then the handovers between charge nurses at seven at night, when the daylight charge nurse is handing over to the evening charge nurse, making sure, again, we're reviewing that list of potential discharges for tomorrow, and what can evenings and nights do to contribute to that discharge process?

And then by morning, when the night nurse is handing over to the daylight nurse, we're really handing that daylight charge nurse a list of who we feel are pretty strong candidates for discharge for discharge today. And we've identified one or two of those patients. That's all we need is one or two patients to go by 11 to successfully drop that wait line in the ED.

So here are one or two patients we focus on for this morning's discharge by 11. And this is the last thing you need to do for those. So those four items, the multi disciplinary rounding in the morning, the mid afternoon huddle between a case manager and a charge nurse, and the handover of charge nurses at seven p and seven a, probably the key to having a successful 24 hour cycle for discharge.

And I'm happy to be supporting this initiative to ensure that no patient ever waits for the care they need.

Outro: Thank you for listening to the Patient Flow podcast powered by TeleTracking. We take pride in bringing you insightful conversations with the leading experts in patient flow, as well as tips on industry best practices to help ensure patients get the right care in the right place at the right time.