JOHN NELSON: Morning Discharges and Length of Stay
Last month, I discussed ED, or “front end,” throughput. This month I will focus on what can be thought of as the two components of “back end” throughput: effective management of length of stay (LOS) and patient discharge in the morning rather than late in the day.
How many times have you heard a well-intentioned administrator ask: “We can’t get patients from the ED to ward more quickly unless we can discharge patients earlier in the day to make beds available. So please round on your potential discharges and get the D/C order written early”?
Easier said than done. But not impossible, if you’re willing to make some adjustments in how you organize your work.
Strategies Re-examined
I provided a list of strategies in my April 2009 column (see “Early-Day Discharge Strategies,” p. 48), and in May 2010 I described in greater detail two ideas that can help with early-morning discharge. The easiest of these is to increase the portion of patients who discharge early in the day. To do this, hospitalists should write in the order section of the chart (not just the progress notes where it can be missed by nursing staff) an order like “possible disch tomorrow” or “Probably discharge Thurs or Fri.” That will help hospital staff anticipate and prepare for discharge, and there is little cost if the patient isn’t ready on the day forecast.
More difficult, but more effective, is fully preparing a patient’s discharge a day ahead of time. I do this on about half or more of my patients and, despite having no rigorous data to prove it, I’m convinced that it makes for better discharges and transitions, and it’s a real stress-reliever for me. My mornings are much less hectic, as I rarely have to devote 30-60 minutes to a discharge while other patients are waiting to be rounded on. And it helps me uncover loose ends like the need to get additional chest imaging to evaluate a possible lung lesion early enough that I can order the additional test without delaying discharge (it can be done the night before).
Note that when billing the discharge visit only, the time spent on the day of discharge counts as billable time. So preparing everything the day before will mean that nearly all discharges will be billed at the lower level: 99238 rather than 99239. You will have to decide for yourself whether losing the ability to bill some discharges at the higher level is worth it. Most hospitals probably will be willing to make up the lost professional fee revenue if it led to a meaningful improvement in the portion of patients with discharge orders early in the day.
One CMS administrator told my consulting partner, Leslie Flores, that discharge summaries can’t be dictated on a day prior to discharge because they have to include all information related to the hospital stay, including any relevant information from the night before discharge. The administrator said that CMS would view this as a surgeon dictating an operative report before performing the operation. (Are there surgeons who are actually doing that?) I think care is better when I do a discharge summary unhurried and with few interruptions in the evening before discharge rather than the busy morning of the discharge day. And I can always add an addendum (and often do) at the time of actual discharge. So you might want to ask your hospital compliance expert about dictating a D/C summary the day before discharge.
