#DBN: Discharge Before Noon Structuring Interdisciplinary Rounds to Expedite Early Discharges Lisa Bednarz, LCSW, ACM-SW Background & Current State
Process
Current State: • Most discharges across NYP happen in the late afternoon and early evening. 2018
DBN
12-2 PM 2-4 PM
4-6 PM
6-8 PM
8 PM+
All NYP
11.1%
20.6%
24.2%
22.0%
15.7%
6.4%
CUIMC
6.1%
11.7%
22.4%
28.3%
23.1%
8.4%
WC
9.0%
19.6%
26.9%
22.5%
15.4%
7.0%
• Average transportation delays were > 2.5 hours when discharges occurred after 2 PM. • 4.4% of patients left the ED without being seen in 2018; the benchmark average is 2.0%. • 17.8 median hours in ED for admitted patients; cumulative average of 22,455 boarding hours per month. • Patients admitted through the ED provided “top box” HCAHPS ratings 3.6% less often than direct admits. • Most room turnover and admissions to unit happening on evening shift, when there are less employees and a shift differential. • NYC does not have enough non-emergency transportation available to support simultaneous later-afternoon discharges from all area hospitals. Recent Evidence: • Late afternoon discharges create admission bottlenecks in the ED.1 • Increased boarding time in the ED is detrimental to quality, length of stay, and patient satisfaction.2, 3, 4 • ED boarding times decrease with earlier discharges.5 • Structured communication is positively correlated with improved interdisciplinary collaboration, efficiency, and patient safety.6,7
Barriers to Early Discharge
Objective • This project was developed to increase the rate of patients discharged before 12 PM, which we believed would have a positive impact on wait times for discharge transportation and ED boarding times. • Structured communication was used in interdisciplinary rounds to identify patients appropriate for early discharge and to ensure all disciplines were mobilized to act on this goal.
RESEARCH POSTER PRESENTATION DESIGN © 2015
www.PosterPresentations.com
Mark Levey, MBA, RT(T)
I. Day Prior to Discharge A. Structured Interdisciplinary Rounds Communications i. Discuss estimated date of discharge on every patient and enter information into electronic rounds board that connects with medical record. ii. Interdisciplinary team must agree on and record a status for all patients discussed: “medically active,” “pending discharge,” “confirmed discharge,” or “discharge before noon.” iii. Confirm any labs or diagnostics needed to meet criteria for discharge. iv. Enter method of discharge transportation on interdisciplinary rounds board. a. Transportation list auto-populates to EMS dispatch board to ensure early access to vehicles. v. Automatic distribution of DBN list to interdisciplinary leadership for oversight.
B. Medical Team i. Order labs or diagnostics ahead of time to meet criteria for discharge. ii. Complete discharge summary and medication reconciliation. iii. Schedule all outpatient appointments and e-prescribe medication. iv. Notify patient and/or family of the planned discharge. v. Campus-specific: place conditional discharge order. C. Case Management/Social Work i. Inform patients of the plans for discharge and ensure that all potential delays are addressed. ii. Confirm post-acute care is arranged and authorization is obtained. iii. Arrange necessary transport. D. EMS i. Review Discharge Before Noon list on electronic board. ii. Confirm trip in EMR. iii. Arrange pickup with appropriate vendor for requested date/time. iv. Stay in contact with CC/SW team if additional information is needed to book trip with vendor. E. Nursing i. Night charge nurse to ensure that all conditional requirements have been met (i.e. lab draws, diagnostic exams, patient tolerating diet, patient weaned off oxygen, pain control, Foley/IV lines discontinued, etc.). ii. Night nurse to start necessary discharge paper work night prior to discharge. II. Day of Discharge A. Structured Interdisciplinary Rounds Communications i. Confirm all contingencies have been met to move forward with discharge. B. Medical Team i. Place discharge order by 10 AM. C. Case Management/Social Work i. Complete all documentation by 10 AM. D. EMS i. Confirm timely arrival of discharge transportation. E. Nursing i. Review discharge instructions with patient after morning medication administration.
Results
Scalability & Sustainability
The Discharge Before Noon program began on 10/1/2018 at NYP/Weill Cornell. The first units to go live: Unit
Campus
Go Live Date
Pre Intervention DBN Rate
Post Intervention DBN Rate
Change
G5C
Cornell
10/1/18
2.0%
10.0%
8.0%
M6HN
Columbia
11/28/18
7.0%
14.0%
7.0%
M6G
Columbia
1/1/19
3.0%
3.0%
0.0%*
*In the first phase of implementation on M6G, we saw no increase in discharge before 12 PM. However, discharges between 12-1 PM increased by 3.0% and discharges between 1-2 PM increased by 5.0%, indicating progress towards the DBN goal.
• Implementing a successful DBN program on multiple medicine units at NewYork-Presbyterian was due to the collaboration and commitment by the medical team, nurses, care coordinators, social workers, and EMS staff. • This was supported by the use of our electronic interdisciplinary rounds boards, which structure conversation and align plan of care. • We were able to scale the project quickly to other units by standardizing roles and IDR scripts and showing a quick return on investment. • The project continues to grow throughout the NYP systems. To sustain this enterprise-wide, efforts will be made to incorporate conditional discharge orders into standard of care and to frontload transportation so that ambulances and ambulettes are on site awaiting patient pickup each morning. • While we have evidence that this intervention increases early discharges, further investigation is needed into additional metrics impacted by this program, including HCAHPS scores, time of admission to unit, ED boarding times, ED patients leaving without being seen, and transportation delays. • With this information, additional resources from senior leadership can be requested to continue to scale and sustain the DBN initiative.
Conclusions
Total Discharges
NYP/WC - G05C Discharges Before Noon
180 160 140 120 100 80 60 40 20 0
18 16 14 12 10 8 6 4 2 0
Total Discharges
Total Discharges
DBN
DBN
Intervention
NYP/CUIMC - M6HN Discharges Before Noon
160 140 120 100 80 60 40 20 0
DBN
Intervention
Acknowledgements Thank you to the social workers, care coordinators, nurses, and physicians “in the trenches” who made this project a success, including: Yvonne Francis-Heaven, RN, Aurelia Pemberton, RN, Montegomery Fishoff, LCSW, Liza Goldberg, LCSW, Denise Henry, RN Bernice Cobbs, RN Jane McGrath, RN, Nasya Moise, RN, Ciby Thomas, LMSW, Lisa Thomas, LCSW, Nicole Ratto, LMSW, & Lauren Caballero, LMSW
References DBN
20 18 16 14 12 10 8 6 4 2 0
Total Discharges
• Structuring interdisciplinary rounds to identify patients that are able to be discharged before noon and standardizing the roles of the interdisciplinary team resulted in an increase in early discharges on two of our units. • Early discharges improve patient flow and access and EMS availability. • Further investigation is needed into impact on HCAHPS and ED metrics.
Khanna S, Boyle J, Good N, Ling J. Impact of admission and discharge peak times on hospital overcrowding. Stud Health Technol Inform. 2001;168:82-88. 2 Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009;16:1–10. 3 Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008;52: 126–36. 4 Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med 2009;54:381–5. 5 Emilie S. Powell, Rahul K. Khare, Arjun K. Venkatesh, Ben D. Van Roo, James G. Adams, Gilles Reinhardt. The Relationship between Inpatient Discharge Timing and Emergency Department Boarding, Journal of Emerg Med 2012; 42; 2: 186-196. 6 O’Leary, K. J., Wayne, D. B., Haviley, C., Slade, M. E., Lee, J., & Williams, M. V. (2010). Improving Teamwork: Impact of Structured Interdisciplinary Rounds on a Medical Teaching Unit. Journal of General Internal Medicine, 25(8), 826-832. 7 Townsend-Gervis, M., Cornell, P., & Vardaman, J. M. (2014). Interdisciplinary Rounds and Structured Communication Reduce Re-Admissions and Improve Some Patient Outcomes. Western Journal of Nursing Research,36(7), 917-928. 1