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discharge process

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  • #25398

    sixsigmadeewana
    Member

    i know this is an old question but we are currently doing a project to reduce the discharge times. Our discharge time is defined as time from care conference to actual discharge.and defect is any discharge that takes more than 200 mins from care conference.
    Is there anyone working on similar projects? I would like to talk and exchange ideas…  I can post my email if anyone is interested.

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    #61210

    Brit
    Participant

    The reason to be concerned with discharge time is to ensure that a bed is available for a waiting patient.  So the actual discharge time might be one measure, but when the room is freed for turnover is another, maybe more important number. A patient can be moved to a discharge area/lounge if they are waiting for their conference or a final IV, et al.  This allows for the room to become available more quickly.  If patient satisfaction is a concern, take care to make the discharge area very patient and family friendly, else they will think you are just trying to get rid of them.

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    #61211

    sixsigmadeewana
    Member

    Brit
    I agree with the discharge lounge. But I think for our setting that might not solve the problem.
    On the same issue……. Is there a way to get around waiting for depart order to be put in? Is there a way to put a “dummy depart order” one day earlier. If the pt. is stable the next day, the nurses dont have to wait for the depart order to be put in and the dummy order can somehow be converted into the final depart order. Has anyone done this? this would mean that the nurse dont have to wait for physician to round or wait till they are free to put the depart order.
     

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    #61212

    Brit
    Participant

    Are you in the U.S.?  If not, you might have different requirements.  U.S. patients cannot be discharged without a signed order from the physician. We do implement something called Hospitalists who can discharge a patinet and make selected rounds when the primary physician is unavailable or late.  Usually there is a phone conference between the primary and hositalist before discharge.  Other than that, a dummy order would be akin to a standing order, and that can’t be done in the U.S. for discharges – primarily becuase of the variability of patients, even with the same diagnosis.

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    #61213

    sixsigmadeewana
    Member

    I am in the US and our hospital does not have a hospitalist program. There has to be something that can be done !!!

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    #61215

    Brit
    Participant

    I would look into the hospitalist process.  Saved us about $1M a year in reduced LOS and increased capacity (filled).  Without that or gettign the docs to round earlier, the best bet is to move them from the floor once able – if not discharged, then to a different location for final paperwork or waiting.  Not many more options given JCAHO standards (if that’s what you folow).
    There are a couple of other strategies to consider for relieving room pressure:

    Eliminate bed holds for surgery patients (or reducing occurrences where nurses hold beds)
    Reduce internal transfers (have people go to patients instead of other way around)
    Synchronize admissions, transfers and discharges
    Schedule nursing home discharges earlier in the day
    Use multidisciplinary rounds in units other than the ICU’s
    Make sure utilization criteria is set AND FOLLOWED for tele, ICU, PACU beds
    Work with extended care facilities to increase their abilities to reduce ED visits
    Decrease use of inpatient beds by outpatients (we had this issue with surgeries)

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    #61217

    sixsigmadeewana
    Member

    Brit
    Thats really helpful. I think we definitely need to look at our case management issues so that we can relieve some of the pressure on beds.
    I just cant believe that there is no way to work around this discharge order.
    Its amazinz how no one else on this forum has this issue or is working on this issue except you. What hospital do you work for, Brit?
     

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    #61218

    Brit
    Participant

    You’re right – there have to be others.  If yo upass along an email address I’ll send information and hope you do the same.  I work at
    Bay Medicl Center in Panama City, FL

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    #61220

    sixsigmadeewana
    Member

    [email protected]
     
    Thats my email address. Please pass it on to appropriate people and also email me so that I can have your email address.
    Thanks
    Anoop

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    #61222

    John Evans
    Participant

    You guys are not alone.  We have been working on this for over a year and with some success and failure.  Our big hangup is getting the physician to round and write the order early.  No early order, no early D/C.  We have hospitalists who act like independent practitioners not our employee.  I have been trying to get them to shift their traditional thinking regarding the rounding of patients on a floor or unit.  Instead of the traditional, see my sickest patients, see my routine, then see my D/C’s, I want them to see the unstable patient’s first, then D/C’s, sick, and rountine in that order on each floor or unit as they round through the day.  This, in my opinion, is a much better work pattern than is currently practiced.  Priority of work tasks for nurses is likewise an issue.  Today, nurses put D/C last on their list of tasks.  A couple of organizations that have had success in early D/C have moved the D/C higher on the list of things to do right after assessment and giving meds
    Our program is an Out By 11:00 effort and certain criteria must be met in order to make the OB 11 D/C.  i.e.  Order written prior to 10:00am with nothing such as last med round after lunch, or D/C in afternoon/after tolerating lunch, stuff still hanging.  Our goal is to have 40% of all D/C’s eligible and 75% of those eligible D/C’d by 11:00.  We are currently 35% eligible with 74% making it out by 11:00.  Two areas are killing the eligibility, 1. Physician rounding times, 2. Transportation from the building to home, rehab, nursing home, etc. 
    We are working on scripting and a nice wall plaque with our OB 11 committment for check out.  Lots of resistence and unless the CEO and COO says to do it, you will have lots of frustration.

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    #61223

    sixsigmadeewana
    Member

    John
    I almost thought that you worked for our hospital. The scene here is very similar to  what you describe with the exception that we dont have a  hospitalist program.
    When dealing with such an issue, you have 2 groups, nurses and physicians and unless physicians change their attitudes the nurses are reluctant to change. So a lot of effort is wasted in team building, and trying to explain these things instead of focusing on the actual issue.
    No wonder we have such high healthcare costs in this country.
    Imagine the amount of money that can be saved if everyone worked together. This should drive the healthcare costs down and insurance down and maybe solve some of the issues that companies like GM and Ford is facing….rising health cost…. thats my wish for today …any angels around???? :))
     

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    #61224

    Brit
    Participant

    John & Anoop:
    We have the same issues that John posted and have similar goals.  In addition to the physician issue, we also had an issue with lab/radiology results ready in a timely manner.  If we are asking the docs to round earlier, the tools have to be there for them to make it happen.  If they have to wait on results, then that pushes the DC time out as well.

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    #61227

    Tierradentro
    Participant

    Our lab, pharmacy, and radiology depts have 3 levels of orders, STAT, D/C pending, and routine.  STAT orders obviously have top priority, D/C pending is next in line, and routines lastly.  These areas know that if we have a D/C pending and we are waiting on their work and response then they move quickly to fullfill the order unless a STAT is in the queue first. 
    As with most hospitals, almost everything was STAT (and we want it right now) when we first started and we still have a lot of abuse of that priority.  We did have some success in moving the number of STAT orders to a lower percent but there’s more work to be done there.
    If you haven’t learned this yet, you will.  This whole issue of early discharge has a lot of pieces to discover and deal with.  It is not easy to change people, one person at a time.  I could write a book on just this one area but it wouldn’t matter unless you have the support and people truely want to do better.  It is team but I am most important and I do it my way.  I don’t mean to be so cynical but reality is where you live.

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    #61228

    sixsigmadeewana
    Member

    You are right. Its not easy to change unless some senior management guy wakes up and says something or there is a hospital 30 miles away which does a better job than you. (We have 4 hospitals within 40 mile radius). I think its a matter of time until one or the other happens.

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    #61230

    Tierradentro
    Participant

    In looking at your first post on this subject, I have thought about what you said and would suggest that you might want to expand your view a little.  It may be a huge eye opener for your administration to see.  To me at least, a D/C process starts when the order is written.  What is your timeframe from order written to order entered into your HIS system, to nurse D/C conference with patient, to notify transportation to pickup patient, to their arrival and take patient out of building or next location for them (ICU, surgery, etc.), to notify housekeeping to clean the room, to their arrival, to room clean status, to notify bedboard room is clean, to room assignment for next patient, to notify transportation to take new patient to room, to their arrival.  Some of this cycle may really be out of scope such as from notify that room is clean and ready for next patient on. 
    I believe the last time I looked at the time from D/C order entered into the HIS to patient leaving was about 1 to 2 hours depending on time of day, number of D/C’s and admits, and other factors. It can be done in 30-45 minutes if things are going very, very well (case mgt/soc. services work all done) but ususally it’s 1 to 2 hours and it used to be 4-6 hours too often.  We are talking about med/surg units with 6-7 patients per nurse.  We don’t have a dedicated D/C nurse because if we do ever have one, he/she is pulled to do regular nursing duties because we are short staffed somewhere.  We don’t have a D/C unit or lounge–once upon a time I’m told we did that and it didn’t work. 

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    #61231

    sixsigmadeewana
    Member

    The process for us works this way…
    1. nursing care conference—>
    2. nurse identify discharge—>
    3. call doc and confirm dis—>
    4. order in system—>
    5. med. recon. and other stuff—?
    6.pt. goes home.
    before we started working on this issue, we were looking at times from point 4 to 6.This looked okay !!! about 1.5 to 2 hours… But we knew that the pt. is fit to be discharged in the care conference which was about 4-6 hours ago!!! Also, we can predict discharge as early as 24 hours prior. So we started looking at times from 1 to 6 and surely those were bad. That was an eye opener. from 1 to 6, we average 6 hours with variation of 3 hours. Thats huge !!!…..all that time counts in the LOS… puts pressure on the beds etc etc etc.
    So the approach is, to identify dis. early, get the depart order as early as possible (24 hours prior) so that nurses know exactly what to do and when to do. It helps them schedule themselves and makes sure they are not running around wasting their time.
    I would suggest that you go back and find out the time when you actually knew that the pt. will be discharged. For us its usually care conf. Your clock starts at the moment you know that the pt. is fit to be discharged. Measure from that point to actual exit and compare results.
    I heard the same stuff about dis. lounge from people here but for me that is one of the final steps.

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    #61237

    mark palmer
    Participant

    You are messing with a JCAHO standard with this idea. It would seem like you are creating the summary notes prior to actual discharge.
    What we have done is forecast the estimated discharge by using Best Practice historical data on our “common” patients.  This way, we can anticipate services and coordinate clinicians more effectively, as they are aware of the anticipated discharge date ahead of time.

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    #61241

    sixsigmadeewana
    Member

    how much time does it take for you to discharge a patient?
     

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    #61554

    Sandy Kowalski
    Member

    For anyone who has completed a project on the Discharge Process-How did you go about calculating financial gain (or cost avoidance) for your project.?
    Our organization is working on improving the Discharge Process-looking at “Time  Discharge Order Given” to Time Patient Out the Door”
    Any help or suggestions would be greatly appreciated.

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