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In the what-have-you-done-for-me-lately category, many hospitalists are expected to really ramp up their efforts to improve their hospital’s throughput. So many hospital executives, who not long ago were dazzled by impressive reductions in lengths of stay and cost per case attributable to hospitalists, seem to have turned their attention to discharging patients early in the day. To some hospitalists who still expect gratitude for things done in the past, it seems terribly unfair that administrators now expect us to attend to this new metric. And, by the way, don’t let discharging patients early in the day interfere with improvements in quality metrics, patient satisfaction, and documentation.

Because of these increasing demands on hospitalists, we might feel sorry for ourselves. I do sometimes. But I also know that if we became hospital executives—and some of us have—we would expect the same of hospitalists in our institutions.

I’m struck by how often hospitalists, particularly those not in leadership positions, fail to understand why it matters so much to the execs that discharge orders are written early in the day. For them, I’ll try to provide a brief explanation.

Why It Matters

In nearly every hospital, the biggest bed crunch occurs in the afternoon. This is the time patients are ready to leave the post-anesthesia care unit or ED and move to their “floor” bed.

An increasing number of hospitals are operating with all of their staffed beds fully occupied. Many end up with patients boarding in the ED or ICU because no “regular” beds are available. And hospitals really suffer financially when they have to cancel elective admissions, such as surgeries, because no beds are available for the patient postop.

Hospitals could build more beds to increase their capacity, but that requires a long time and something along the lines of $1 million per bed. Where could they get the financing in today’s market? The other option is to shorten the length of time a patient occupies a bed so that more patients can be served using the existing inventory.

In nearly every hospital, the biggest bed crunch occurs in the afternoon. This is the time patients are ready to leave the post-anesthesia care unit or ED and move to their “floor” bed. If patients being discharged that day haven’t left yet, gridlock occurs. Costs of the gridlock are spread throughout the hospital, notably in the ED, which suffers because of the resulting increased lengths of stay and reduced throughput. This isn’t just an economic issue for the hospital; patients are adversely affected, too.

Even if your hospital has spare beds, early discharge still matters. If the discharge day isn’t managed well and patients routinely leave late in the afternoon, the hospital will have to spend more on evening-shift nursing staff.

It makes sense to look at every step that must occur prior to a patient vacating their room on the day of discharge. The time that the doctor actually writes the discharge order is one of the most critical, rate-limiting steps in the discharge process, so helpful executives suggest we organize our rounds to see the potential discharges first, then get around to seeing the patients who are really sick. I think most hospitalists, including me, find it really difficult to do this. If you’re in this category, you might consider starting your rounds earlier in the day.

Consider Rounding Earlier

Starting rounds earlier is usually an unpopular idea. Many groups refuse to consider it. If you are in a group that works day (rounding) shifts with specified start and stop times, coming in before the start of your shift to begin rounding is just donating uncompensated time to the practice. That is one of many reasons I think it is best for most practices to avoid specified start and stop times for their day shifts. Instead, I think it is reasonable for each doctor to decide when to start and stop work each day depending on the workload. So on days you have a higher-than-usual number of expected discharges or sick patients, you would probably choose to start earlier. And when patient volumes are low, you might choose to start later. The same is true of when you choose to leave for the day. Choosing to start earlier in the day should mean that you can wrap things up earlier on most days.

For a lot of hospitalists, routinely starting rounds earlier would be OK as long as they can finish earlier. But there are some for whom this is really tough or impossible, such as those who need to take their kids to school before work each morning. Rounding early won’t do any good if the hospital doesn’t ensure test results and other information is available early.

A practice could choose to undertake an initiative as simple as the following steps to support improvements in writing most discharge orders early in the day:

  • Encourage starting rounds earlier (e.g., 7 a.m.) on most days;
  • Whenever possible, prepare discharge summaries the day before;
  • As often as possible, write in the order section “probable discharge tomorrow” one day before planned discharges;
  • Keep routine morning conferences, such as signout, as short as possible; move it to later in the day, or eliminate it entirely, if feasible; and
  • If you have routine, sit-down rounds with case managers each morning, think about whether they get in the way of early-in-the-day discharges. If so, consider moving them to the afternoons, and focus on discussing the next day’s potential discharges rather than discharges for the current day.

Consider establishing targets for each of these metrics and audit performance compared with a historical baseline. For example, the goal might be that the “probable discharge tomorrow” order appears the day before discharge in 50% of hospitalist patients, and the discharge summary is prepared the day before in 30%. These things help ensure other hospital staff members realize discharge is possible or likely and can significantly reduce discharges that are a surprise to nurses and others.

There is nothing magic about the bulleted protocol above. I’m offering it as only one potential idea to improve throughput, and you might want to pursue an entirely different strategy.

The Flip Side

Two closely related issues come up when working on getting discharge orders written early in the day. The first is that some late-afternoon discharges are in reality very early discharges that might have otherwise waited until the next day. It is important to stress that not all discharge orders are written early, and that hospitalists should not hold on to patients who could be discharged late in the day and instead release them the next morning to make their statistics look better.

The other related point is that a declining length of stay and discharging early in the day begin to compete with each other at some point. From a bed management perspective, the theoretical optimal length of stay means discharging patients the moment they are ready and not waiting until the next morning. This means discharging around the clock without regard to the time of day, and that would look terrible when analyzed from the perspective of the portion of discharge orders written early in the day—not to mention it would be very unpleasant for patients asked to leave at night. So I’m not suggesting that we should be discharging patients around the clock, but I just want to point out the tension between length of stay and writing discharge orders early in the day. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospital practice management consulting firm. He is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official SHM position.

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