Top o’ the Morning
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
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.
