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'Express discharge' alerts team to pending discharge
Sheet sets out responsibilities of each discipline
Faced with a shortage of hospital beds that extends throughout the state of Washington, St. Joseph's Medical Center in Tacoma has embarked on an "express discharge" initiative, which alerts the treatment team a day in advance when physicians anticipate the patient is almost ready for discharge.
The aim of the initiative is to discharge patients who are ready for discharge as quickly as possible to free up badly needed beds, says Jan Balaban, RN, manager, care management services for Franciscan Health System.
"To improve quality and efficiency of the discharge process, it really takes time and commitment from the entire clinical team," she adds.
Components of the discharge initiative include a bright-yellow express discharge sheet that gives the treatment team 24-hours notice of a pending discharge and reminds all members of the team of their responsibility in ensuring a timely discharge with a newly created position of access nurse who rotates among units to help expedite discharge and a punch card system that rewards staff for timely discharges.
The throughput initiative is the result of a pilot project during which two care managers worked with a hospitalist and a physician assistant to come up with ways to ensure that patients are ready for discharge when they are medically cleared for release.
Based on the input of the care managers, a multidisciplinary team set standards with specific time frames for discharge orders, hand-offs of patients, and when the patient is actually discharged.
"We want to make the staff aware that when a discharge is scheduled, it should happen in a timely manner and not be the last thing that someone takes care of in their day," Balaban says.
Reminders in place
The team created an express discharge document, a laminated piece of paper that goes into the patient record but is offset on one side.
The document alerts staff to anticipate that the patient may be discharged within 24 hours and includes a list of tasks that each discipline can do to speed the discharge.
The express discharge form includes ticklers for all members of the treatment team to remind them what needs to be done before the patient can be discharged. There is a section for the physicians, another for the RNs, and another for the health unit coordinator.
For instance, one of the nursing tasks is to make sure that whatever labs have been ordered are completed and the results are on the chart. The RN section also reminds the nurses to explain the plan to the patient, continue the discharge teaching, encourage the patient to make transportation arrangements, make sure all test results are in the chart the day of the anticipated discharge, as well as alerting all shifts to begin the discharge paperwork.
"When they see the yellow document, the treatment team is reminded to alert the family that the patient will probably go home the next day so they can arrange for transportation," says Laureen Tomich, RN, BSN, one of the care managers who worked on the pilot project.
Once the physician determines that the patient may be discharged the next day, the yellow express discharge sheet goes into the chart. Clinicians usually are able to predict the day of discharge with some degree of accuracy, Balaban says.
"It's a common occurrence that if we document that we expect a discharge to happen, it usually does. We know that it's not always going to work and that every patient is not necessarily going to be discharged just because there is an express discharge sheet in his or her chart. The majority of the time, however, the patient is discharged when it is predicted," she adds.
The hospital system's express discharge initiative aims to raise the staff's awareness of discharge and to make it a priority. "We also want to alert the patients in time for them to process everything that is in the discharge instructions, rather than telling them in the last hours when everyone is throwing information at them," Balaban says.
Once the discharge order is written and given to the health unit coordinator, the nursing staff have a goal of getting paperwork in order and discharge instructions complete within 60 minutes. This means that the orders must be processed and given to the nurse so that patient education can be completed and the patient can get ready for discharge.
Discharge within an hour
"This is our goal. We want to get them ready earlier and better. We want the paperwork to be done and the patient leave within that hour. We know it can't happen every time but we hope it can happen some of the time," Balaban says.
The hospital alerts the patient's family members as early as possible when a discharge is anticipated and negotiates with the family on discharge time.
The staff offer to provide transportation if the patients don't need assistance but do need a ride home.
"We absorb the cost of a cab if we can safely discharge the patient and free up a bed. In specific instances it's very effective. The patients would rather take a cab home than stay and wait," Balaban says.
The hospital has hired an access nurse, who is based out of the bed control department and floats between the units taking care of whatever is necessary to make a discharge happen and assists with new admissions coming to the hospital. The bed control staff have the big picture of what types of beds are needed and can deploy the access nurse to help free up a bed, Balaban points out.
"We have five med-surg units, two critical care units, and a short stay unit. She could be pulled anywhere by any nurse who needs help in expediting a discharge," she says.
For instance, if there is a male patient who is out of surgery and waiting for a bed, the access nurse may be sent to one of the med-surg units where a discharge is pending.
"The access nurse additionally can begin admitting new patients coming in. This is helpful for the staff nurse who may have just discharged two patients and now needs to spend her time with her other patients," Balaban says.
The access nurse component was rolled out incrementally throughout the hospital system. It worked very well at two smaller hospitals in the system. The access nurse started work at St. Joseph's in mid-April.
St. Clare Hospital in Lakewood and St. Francis Hospital in Federal Way, both in Washington, were the first sites to implement the role of access nurse.
"At St. Joseph's, one nurse for a 320-bed hospital is a drop in the bucket. If we can correlate her admission and discharge activities with an increase in available beds when and where we need them, we may be able to hire other nurses for the job," Balaban says.
The team created punch cards that reward staff members who complete a discharge by 11 a.m.
Those members can get their card punched. A completed punch card entitles them to a $5 gift certificate at the hospital gift shop or café. Punched cards are eligible for a once-a-month drawing for a prize.
The entire team, the unit health coordinators, nurses, and nursing assistants are included in the rewards program. When some physicians indicated they would like to participate, the team created a punch card for them.
"We try to include the off-shifts for the nurses so if they are able to do a transfer, they get a punch. We want to encourage the entire team to share the work and make sure that everything is handled as early as possible," she says.
The project is part of the health system's leadership's emphasis on creating access to the hospital so that patients will stay in the community.
"They realize that there is some cost associated with the project but they also realize that facilitating a timely discharge is not just about saving money but it's about providing better care for the patient," she says.
Like all hospitals in the state, St. Joseph's frequently has patients waiting for beds.
Staff members encouraged
Staff members have been affected personally by the bed shortage, which makes them more determined to move patients through the continuum as safely and quickly as possible, Balaban says.
"One staff member whose husband has heart disease and who lives three minutes from the hospital drove him to Seattle because she knew we had no beds. A case manager's mother was in the emergency department with chest pains and couldn't get a bed for several hours. This makes it real to our staff and gives them the motivation to meet patient needs as quickly as possible," she says.
During the throughput pilot project, the care managers consulted with the physicians first thing every morning to determine which patients were likely to be discharged the next day and stayed in touch throughout the day to determine what needed to be done prior to discharge, Tomich says.
"The other care manager and I found out which patients could potentially be discharged and started working to make sure everything was in place. We also piloted a system by which the treatment team can text-message each other instead of wasting time waiting for a telephone call to be returned," Tomich says.
(For more information, contact Jan Balaban, RN, manager, care management services for Franciscan Health System, e-mail: email@example.com.)