Tuesday, April 01, 2008

Checkout time 11 AM!

Busy hospitals around the country have put in place bed control initiatives to improve efficiency, reduce patient diversion, reduce ER wait times and reduce ER crowding. One such measure involves setting an early morning discharge time, analogous to check out time at the Hilton as Bob Wachter recently put it.

Pressure to discharge by a certain time of day is driven largely by administrators. Busy doctors struggle with it. Though conceptually flawed, difficult and loaded with unintended consequences (read Wachter’s post and comment thread) the idea has surface appeal. Clearing out the hospital in the morning opens up beds to alleviate the mid day crunch. That, in turn, reduces ER crowding and ambulance diversion. In some cases there are discharge planning advantages. Nursing homes and other long term facilities may not accept patients late in the day, and trying to arrange follow up appointments and obtain medical equipment presents difficulties when it’s 4 PM.

Vanderbilt University Medical Center (VUMC), where I attended medical school back in the days of the House of God, has become a model institution for systems improvements and efficient resource utilization. I’ve followed developments there through the years and read with interest about their discharge timing initiative, launched a few years ago:

VUMC faculty and staff are launching a patient discharge initiative to reduce midday patient access problems at Vanderbilt University Hospital. As recommended by the project team, the Clinical Enterprise Group (academic department chairs and senior administrators) endorsed two new requirements.
• Doctors enter “anticipate discharge” orders at least 24 hours ahead of discharge.
• Doctors enter discharge orders before 9 a.m. on the day of discharge.

On a typical busy morning those requirements could turn a doctor’s work flow upside down. According to project leader and professor of medicine Allen Kaiser:

He said writing of discharge orders before 9 a.m. will be a major change for faculty and house staff. As morning rounds get underway, doctors have always tended to visit the sickest patients first, so that for the less sick patient who is ready to go home, writing of discharge orders is typically delayed until later in the day. “It’s natural and very understandable for doctors to start the day attending to the sickest patients,” Kaiser said. “Switching to round first on the least sick patients is a gigantic culture change.”

And easier said than done. The notion of “rounds” (starting in one area and working your way from unit to unit) may be obsolete in this era of high acuity and much sicker patients. Hospitalists on busy medical services, constantly pulled in different directions, don’t often have the luxury of orderly rounds. Deteriorating patients in the ICU, rapid response calls and families demanding to see the hospitalist now (and threatening to go to administration) demand immediate attention. The wheel that squeaks the loudest at any given time gets the grease and it’s not optional. It’s too bad such events can’t be scheduled for the afternoon after discharges are complete.

When I read about the Vanderbilt initiative I thought it was onerous. Wachter’s post suggests that initiatives of this sort are popping up everywhere. Doctors at his institution (UCSF) are feeling the pressure and a similar program is underway at Stanford, where an administrator said:

Given these benefits, the hospital is launching an initiative to set our discharge time at or before 11 a.m. What can we do to help bring about this change? First, we need to make discharge decisions earlier in the day. This may require some process changes, such as conducting our attending rounds earlier.

Next, physicians need to plan ahead the night or the day before discharge

If it’s 3 PM and you realize your patient is stable for discharge why not discharge then rather than wait until the next morning? It may blow your time of discharge stats but it would help the hospital’s bottom line if the patient’s insurance plan (e.g. Medicare) doesn’t reimburse on a per diem basis.

Because setting an early discharge time may require keeping the patient an extra night hospitalists, also under pressure to cut the length of stay, find themselves under competing demands. Again, from Wachter’s post:

So when I am pressured to “improve” my time of discharge, I usually respond, “If you’d like, I can move the average discharge time up to 8 am. It’ll just be one day later than I had planned.” CFOs don’t like to hear that.Which brings me to my final plea: I believe it should be illegal to report Time of Discharge without also – in the same document – reporting adjusted average length of stay (or LOS against appropriate benchmarks). Time of discharge and ALOS are inextricably linked. The service that has a long length of stay AND a late discharge time might really have a problem. But the service with a short length of stay and a late discharge time is probably doing very good work, and harassing it over its TOD is annoying and counterproductive.

Finally, I chuckled at this from the Vanderbilt initiative:

Leutgens said plaques will be mounted on every hospital room door frame to inform patients of the VUH 10 a.m. discharge time.

Just like the Hilton.

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